Who Heals the Healer? The Junior Doctor Circle

Who heals the healer?

How might we equip and support Junior Doctors to start conversations about their mental health and not feel alone?

CL ARE SUMMERFIELD R OYA L C O L L E G E O F A R T M R E S H E A LT H C A R E & D E S I G N THESIS M AY 2 0 2 0 WORD COUNT 14,721

C O N T A C T: hello@thejuniordoc torcirlce.com thejuniordoc torcircle.com

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Who heals the healer?

How might we equip and support Junior Doctors to start conversations about their mental health and not feel alone?

CL ARE SUMMERFIELD R OYA L C O L L E G E O F A R T M R E S H E A LT H C A R E & D E S I G N THESIS M AY 2 0 2 0 WORD COUNT 14,721

C O N T A C T: hello@thejuniordoc torcirlce.com thejuniordoc torcircle.com

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Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

Junior Doctors today are suffering high rates of burn out and negative mental health.

This spotlights a cohort within a professional group already known to have the highest suicide rate and who paradoxically, have the poorest access to mental health support.

We know that the health and well-being of our doctors is directly linked to a reduction in medical errors, good quality patient outcomes and satisfaction. Crucially, poor health leads to low staff retention, contributing to the biggest crisis facing the NHS today – workforce attrition.

Who heals the healer? Stigma and shame hinders clinicians from seeking support and when they do, their only option is to access help from their own medical colleagues.

A culture of blame and ‘resilience’ at all cost means many doctors suffer in silence and asking for help can be the hardest words to find. How can we support Junior Doctors to prevent them becoming unwell?, Based on Qualitative Research, Co-design Workshops and Quantitative User Testing with Junior Doctors, this research presents The Junior Doctor Circle, an app specifically designed for Junior Doctors to share their stories and begin a conversation about their mental health privately with their professional peers.

This online community can help Junior Doctors to develop the confidence and vocabulary needed to start a conversation in real life. The user testing results indicate that by sharing and relating to others, Junior Doctors can take a first private step towards finding words to ask for help. This research advocates the need for ongoing, active mental health support for Junior Doctors to acknowledge, track and be signposted to support services before they present with serious mental health issues. We should aim to support doctors before they burn out or are forced to take sick leave. We must appreciate that by supporting doctors’ physical and mental well-being that we are strengthening the very backbone of the NHS.

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CONTENTS 5-6 Executive Summary 7

Terminology

8

Acknowledgements

9

Introduction

.

137 Figures & References 143 Appendices

The Research Context, Urgency & Audience The Research Problem, Aim & Process

19 Methodology Process, Methods & Adaptation

27 Setting the scene Literature Review

35 Qualitative Research: Interviews & Insights Interview Methodology Thematic Analysis Key Insights

55 Designing Cultural Probes: Three Concepts The Key Insights Three Junior Doctor Personas Three Hypotheses & Three Concepts Co-Design Workshops: Clinical and Design Voices 1. The Virtual Doctors’ Mess 2. Share my Story 3. The Work Emotion Diary

81 User Testing & Feedback Analysis Designing the Test : Remote Participant Preparation & Test Criteria User Feedback: Interaction Analysis Key Validation & Insights to Iterate

95 Final Design: The Junior Doctor Circle The Why, The How, The What UX Co-Design Workshop How it works: Features & User Walk Through Three User Journeys Building the Circle: Advertising & The Business Model Future Circles: Other User Segments & The Gifting Community

125 Conclusion & Reflections

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Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

For Lauren & all Junior Doctors

“If we can only equip them, [Junior Doctors] to make that approach and ask that vital question, then nobody need die believing they are worthless, beyond help, a burden, or that no one cares. We are the caring profession and we can do this.�

Dr Jonathan Phillips

A senior doctor, whose daughter Lauren committed suicide at the age of 26 after an A&E shift. Lauren was in her third year of training and at the beginning of her medical career. Described as a talented young doctor, Lauren had not shown any signs to her colleagues, friends or family that she was feeling so low.

(Phillips, 2019)

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EXECUTIVE SUMMARY

Who heals the healer?

How might we equip and support Junior Doctors to start conversations about their mental health and not feel alone?

Aim: To empower Junior Doctors to track, vocalise and feel supported in their mental health

(BMA, 2019)

80%

• Junior Doctors do not know where to access mental health and of doctors reported being well-being support. Support varies greatly across NHS Hospital Trusts at risk of burnout and Insight: 1, 3 Insight: 2,3,4,5,6 Insight: 1,2,5,6 Junior Doctors were the • Fear of reflecting honestly and speaking up. Juniors said they had ‘played down’ Insight: 1, 3 Insight: 2,3,4,5,6 Insight: 1,2,5,6 their feelings when talking about their mental health to supervisors out of fear of most vulnerable Persona Persona 2: Jenny Persona 3: Melissa Insight: 1, 31: Guy Insight: 2,3,4,5,6 Insight: 1,2,5,6 being labelled as not resilient or incompetent

(Copeland, 2019)

Psychiatry Trainee, 29

25%

O&G Trainee, 31

F1 placement in A&E, 25

Persona 1: Guy Persona 2: Jenny Persona 3: Melissa Persona 1: Guy Persona 2: Jenny Persona Melissa • Female Doctors are particularly susceptible to negative mental health.

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Trainee, 29 the O&G Trainee, F1 placement inmust A&E,urgently 25 training rotation forced him London.

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3,000,000

peers are hard to cultivate

Hypothesis 01

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Insight: 1,2,5,6

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It is crucial to have an appreciation of when you are so down that you need to speak up

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DEPRESSION

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Key Recommendations •

Abolish Resilience Training and Remove the Culture of Blame Resilience culture perpetuates the cycle of shame and secrecy surrounding a doctors mental health. It shifts the blame on to the shoulders of the Junior Doctor and leads Junior Doctors to feel unworthy if they cannot cope

•

Focus on Prevention and Monitoring not Intervention Junior Doctors need a continuous support tool. Ongoing, active mental health support is crucial, to acknowledge, track and signpost to support before doctors present with serious mental health issues. We must pre-emptively support doctors before they burn out or are forced to take sick leave

•

Prepare Doctors at Medical School – Mental Health and Well-being Curriculum is a must Many Junior doctors described arriving at their first post and feeling overwhelmed and unprepared for the realities of being a doctor. By preparing them, we can equip and empower them

•

Create spaces for Junior Doctors to come together at work Hospitals must provide physical spaces for Juniors to come together to build commeraderie, support eachother and combat social isolation.

•

“Medicine would be transformed if doctors were able to admit freely to vulnerabilities, fears and failings. Yet no one does, despite the terrible costs.

If even one of my peers had taken me aside and encouraged me to seek help, or even just let me know they were concerned and cared for me, I might have been able to halt the march of my depression before it became utterly devastating.�

Senior colleagues sharing their experiences is a key factor prompting Doctors to seek help

The Proposed Design Intervention Nancy, Junior Doctor

“The final straw came when I worked 17 days in a row including five 25-hour shifts. [‌] Never had I experienced such darkness and hopelessness.

I found myself angry at the patients for being sick, and another night wishing that a sick patient would die so I could close my eyes for 10 minutes because I was so desperately tired. ‘I did not feel like myself on the inside anymore.�

The Junior Doctor Circle

An app for Junior Doctors to share ‘I’ve seen Junior Doctors their stories with a community of other Junior desperate to tell these stories.

Doctors. They are unable to identify you and And it’s completely eating them Doctor to your employer areGreta, not Junior affiliated By realising you are not alone you learn Junior Doctor, 27 “Medicine would be transformed if doctors and support others were able to admit freely to vulnerabilities, fears and failings. Yet no one does, despite the terrible costs.

If even one of my peers had taken me aside and encouraged me to seek help, or even just let me know they were concerned and cared for me, I might have been able to halt the march of my depression before it became utterly devastating.�

Key Insights

 �

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DEPRESSION

by Clem, Junior Doctor, 29

The Specialty Today, this Traineehappened...

Circle

The Junior Doctor Circle

Stress

Has this story resonated with you?

a story of life on the wards

Disclosing privately and safely with professional peers motivated Junior Doctors to seek support more than talking to friends and family. Resonating with people who ‘really understood’ or ‘had been there’ facilated opening up.

The knowledge that another in the community could relate to your disclosure provides an emotionally safe space to be vulnerable.

•

You are not alone

Nancy, Junior Doctor

This story resonated with 32 others in the community

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Inspiration & Success

Why I love being a doctor

“Inside it was so far from what I had been feeling.�

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

Depression

“The final straw came when I worked 17 days in a row including five 25-hour shifts. [‌] Never had I experienced such darkness and hopelessness.

I found myself angry at the patients for being sick, and another night wishing that a sick patient would die so I could close my eyes for 10 minutes because I was so desperately tired. ‘I did not feel like myself on the inside anymore.�

May we show you coping strategies that others in the community are using who have resonnated with this story?

Anxiety

SUPPORT SERVICES EXTERNAL T H E PAT I E N T I C A N T FORGET

by Lesley, O&G Consultant, 63

Taking it home most resonated Most resonnated

T H E PAT I E N T I C A N T FORGET

T H E PAT I E N T I C A N T FORGET

by Lesley, O&G Consultant, 63

by Lesley, O&G Consultant, 63

“I can still see her face... and it’s thirty years ago.� a story of remembering and questioning

ou become an F1 and like shit hits the fan�

56

a story of feeling out of control

“Its been thirty years and I can still see her face� a story of remembering and questioning

o t he rs re s o n n a t e d

INTERNAL

THE BRI TI S H MED I CAL ASS OC I ATI ON

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

“Actually no, this has gone a bit too far, I need to speak to someone about this.� a story of developing clinical ability to acknowledge my mental health

“I didn’t want to let my guard down.

I guess for anyone to know that I felt I wasn’t competent at my job.� a story of bottling it up

32

o t he rs re s o n n a t e d

28

o t he rs re s o n n a t e d

WEBS I TE L I NK

The BMA wellbeing services are available to all doctors and their spouses and chilldren, 24/7 and free of charge

P EER S U P P OR T / COU N S ELLI N G / P SYCH OT H ER AP Y / GM C I N V EST I GAT I ON S U P P OR T /

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

you go throughout your entire you know, from like secondary school, you’re the best in your class and you always get A’s in your GCSEs. You study, you get your A levels you study, get your A’s and get into university, you go through medical school, you pass every exam, you’ve done really well. You’re on sports teams, you’re just doing you know, you are acing life. You

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

AD V I CE FOR YOU R S LEF OR A COLLEAGU E

THE PRAC TI C I ONER HEALTH PROGRAMME

Practitioner Health is a free, confidential NHS service for doctors and dentists across England with mental illness and addiction problems, who are working or looking to return to clinical practice.

The service can help with issues relating to a mental health concern, including stress or depression or an addiction problem.

Greta, Junior Doctor

COU N S ELLI N G / P SYCH OT H ER AP Y / AD D I CT I ON T R EAT M EN T/ CB T /

I N D I V I DAU LI S ED CLI N I CI AN LED CAS E M AN AGEEN T / GR OU P S U P P OR T

“It’s incredibly distressing and when things go wrong you do take it very personally.� a story of remembering and questioning

ACAD EMY OF MED I CAL ROYAL COL L EGES

19

o t he rs re s o n n a t e d

The Junior Doctor Circle is an app for Junior Doctors to share their stories with a community of other Junior Doctors. No one using the app can be identified and the app is not affiliated in any way to your employer

up inside.’

•

An online community gives Juniors the space to take a first step to track and understand their mental health and well-being privately, without fear of judgement.

 �

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DEPRESSION

by Clem, Junior Doctor, 29

The Specialty Today, this Traineehappened...

Circle

The Junior Doctor Circle

Stress

You are not alone

This story resonated with 32 others in the community

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Inspiration & Success

By realising you are not alone you learn and support others

Has this story resonated with you?

a story of life on the wards

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

Depression

Why I love being a doctor

“Inside it was so far from what I had been feeling.�

May we show you coping strategies that others in the community are using who have resonnated with this story?

Anxiety

•

The Junior Doctor Circle can help Junior Doctors to develop the confidence and vocabulary needed to start a conversation in real life.

SUPPORT SERVICES

EXTERNAL

T H E PAT I E N T I C A N T FORGET

by Lesley, O&G Consultant, 63

T H E PAT I E N T I C A N T FORGET

Taking it home most Most resonated resonnated

by Lesley, O&G Consultant, 63

“I can still see her face... and it’s thirty years ago.� a story of remembering and questioning

ou become an F1 and like shit hits the fan�

56

a story of feeling out of control

o thers res o nna ted

INTERNAL

T H E PAT I E N T I C A N T FORGET

by Lesley, O&G Consultant, 63

“Its been thirty years and I can still see her face�

a story of remembering and questioning

T H E B R I T I S H M E D I CA L ASS O C I AT I O N

WEBSITE LINK

The BMA wellbeing services are available to all doctors and their spouses and chilldren, 24/7 and free of charge

PEER SUPPOR T / COUNSEL L I NG / PSYCHOTHER APY / GM C I NVESTI GATI ON SUPPOR T /

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

“Actually no, this has gone a bit too far, I need to speak to someone about this.� a story of developing clinical ability to acknowledge my mental health

“I didn’t want to let my guard down.

I guess for anyone to know that I felt I wasn’t competent at my job.� a story of bottling it up

32

o thers res o nna ted

28

o thers res o nna ted

you go throughout your entire you know, from like secondary school, you’re the best in your class and you always get A’s in your GCSEs. You study, you get your A levels you study, get your A’s and get into university, you go through medical school, you pass every exam, you’ve done really well. You’re on sports teams, you’re just doing you know, you are acing life. You

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

ADVI CE FOR YOUR SL EF OR A COL L EAGUE

T H E P R AC T I C I O N E R H E A LT H P R O G R A M M E

Practitioner Health is a free, confidential NHS service for doctors and dentists across England with mental illness and addiction problems, who are working or looking to return to clinical practice.

The service can help with issues relating to a mental health concern, including stress or depression or an addiction problem.

COUNSEL L I NG / PSYCHOTHER APY / ADDI CTI ON TR EATM ENT/ CB T /

I NDI VI DAUL I SED CL I NI CI AN L ED CASE M ANAGEENT / GR OUP SUPPOR T

“It’s incredibly distressing and when things go wrong you do take it very personally.� a story of remembering and questioning

ACA D E MY OF M E D I CA L R OYA L CO L L E G E S

19

o thers res o nna ted

By sharing and relating to others, you can find the words to ask for help.

The Junior Doctor Circle is an app for Junior Doctors to share their stories with a community of other Junior Doctors. No one using the app can be identified and the app is not affiliated in any way to your employer By realising you are not alone you learn and support others

6

Acknowledgements Firstly, I would like to thank Professor Ashley Hall and Anna Wojdecka for their continuous support and inspirational teaching throughout the two years of my masters of research degree and thesis. Thank you also to Rachel McDonagh and Raleigh Mangsat for facilitating this masters course and their patience and kindness to us all.

I must thank The Royal College of Art and the wider RCA community of staff and students. I have gained and shared skills, knowledge and friendships and have had the pleasure of working with them over the last two years.

I am indebted to Lord Naren Patel, Professor Dame Lesley Regan, Dr Clare Gerada, Ms Lucy Holmes, Mr Bertie Leigh and Dr Guy Ansah-Palmer for their encouragement, contributions and insights to this piece of research.

A huge thank you must go to all the Junior Doctors I have had the privilege of working with throughout this research process. Their dedication and motivation to do their job in the face of sometimes very difficult working environments was awe inspiring and humbling. They have given me so much hope for the future of the NHS. Thank you to Guy, Clemmie, Jaz, Ola, Olivia, Anne, Melissa, Akash and Jenny.

Thank you to my family for their unwavering support and love throughout this masters course.

7

Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

TERMINOLOGY

E X P L A N AT I O N

Junior Doctor

A qualified doctor practising at any stage between graduation and completion of specialist postgraduate training

Locum Doctor

A locum doctor is a doctor who works in the place of the regular doctor when that doctor is absent, or when a hospital/practice is short-staffed

The Firm Structure

‘The Firm Structure’ is a historical term denoting a past training model for doctors. Although criticised for its pyramidical structure leading to favouritism and paternalism, the loss of the firm has made a significant contribution to the isolation and low morale experienced by many Junior Doctors today

‘The Doctors Mess’

A euphemism to describe a communal space at work where doctors gather and converse

The Practitioner Health Programme (PHP)

Practitioner Health is a free, confidential NHS service for doctors and dentists across England with mental illness and addiction problems, who are working or looking to return to clinical practice. The service can help with issues relating to a mental health concern, including stress or depression or an addiction problem, in particular where these might affect work. The service is provided by health professionals specialising in mental health support to doctors and is available in various locations across England

The British Medical Association (BMA)

The BMA is the professional association and registered trade union for doctors in the United Kingdom. The association supports doctors in their professional lives, advocates for fairness and equality in the medical profession, and negotiates for better pay and working conditions. The BMA does not regulate or certify doctors, a responsibility which lies with the General Medical Council

The General Medical Council (GMC)

The GMC is the regulator and public body that maintains the official register of medical practitioners within the United Kingdom. Its chief responsibility is to “protect, promote and maintain the health and safety of the public” by controlling entry to the register, and suspending or removing members when necessary. It also sets the standards for medical schools in the UK

Figure 2: Table of Useful Terminology 8

CHAPTER 1

Introduction Who heals the healer?

How might we equip and support Junior Doctors to start conversations about their mental health and not feel alone?

9

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The Research Context Mental Health : An NHS Workforce Crisis The National Health Service (NHS) workforce is its most valuable resource. Employing over 1.7 million people, the NHS is the UK’s largest employer and the fifth largest globally (BMA, 2019). In 2018, an NHS Staff survey reported that 47% of staff were thinking of leaving the NHS organisation they worked in, with further analysis showing that mental health and stress were by far the biggest contributing factors to staff dissatisfaction (Copeland, 2019; GMC, 2019). Over 25% of all sick days taken in the NHS are due to mental health issues caused by work factors. This amounts to over 3,000,000 full time days lost to anxiety, stress and depression in 2018–2019 alone (Copeland, 2019) This represents a huge financial pressure on the NHS, with staff absences necessitating costly locum appointments to fill empty positions, which further exacerbates the stressful environment and adversely affects the ability to deliver high quality care to patients for those staff who remain at work, (Gerada, 2018b; West, 2019).

A Doctor’s Last Taboo The mental health and well-being of the workforce underpins the ability of the NHS to deliver high quality care and long term sustainability of the NHS. Extensive data identifies that staff well-being is a key indicator for high quality patient care (GMC, 2019). Despite this knowledge the NHS has dragged its feet in acknowledging the growing mental health crisis amongst its’ workforce. Medical doctors have one of the highest suicide rates amongst professional groups and yet have some of the poorest access to mental health services (Gerada, 2018b) and some 80% of doctors working today in this country are at risk of burnout (BMA, 2019).

Doctors are the only profession to be treated by their colleagues when they become physically or mentally unwell. Research has shown us repeatedly that doctors and medical students are reluctant to disclose and seek support for their mental health problems (Sykes, Borthwick & Baker, 2019; Brooks et al. 2011). A culture of ‘you must develop

10

resilience’ at all costs has reigned in healthcare, amplifying the shame and stigma attached to those who speak up. Mental Health remains the last medical taboo for doctors.

The Research Urgency A Worsening Problem 1. Demand and the NHS The NHS today can provide more treatments and interventions than ever before.

An expanding and ageing population has exacerbated the demand faced by the health service. This has necessitated more complex, costly care in managing multiple chronic conditions, intensifying the pressures on an under-resourced service. This disproportionately pressurises Junior Doctors, who cite persistent rota gaps placing impossible demands on them at work, leading to a negative mental effect on their professional life.

Over the last five years, mental health has become part of the national conversation in a way that it never has before, bringing with it more awareness and acceptance of the problem. Mental Health is the biggest disease burden in the UK and demand for services is set to increase by 111% by 2030 (McCrone et al., 2008). I believe we owe it to young, inexperienced doctors working in stressful and demanding environments to equip them with the tools they need to cope with these pressures.

2. The Changing Demographic of Medicine Sadly, female doctors are four times more likely to end their own life than their counterparts in the general population (Hemmings, 2018). This is particularly pertinent when the gender balance of the NHS workforce is examined. Some specialties such as Obstetrics and Gynaecology are currently made up of 80% female trainees (RCOG, 2019).

11

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Junior Doctors are Uniquely Disadvantaged Junior Doctors have the highest rates of reported mental health and wellbeing issues and alarmingly they are also the least likely to know where to seek help (Gerada, 2018b; Sykes, Borthwick & Baker, 2019). Heavy workloads, rota gaps and rigid training structures result in many Junior Doctors feeling socially isolated at work. The lack of a close team structure and provision of communal rest facilities to unwind or debrief, such as the Doctors’ Mess can make Junior Doctors feel more alone.

The Target Audience of this Research Project Junior Doctors and their age range – 22-33 I am defining Junior Doctors as doctors who have qualified from medical school and are early in their medical career, completing their two years of Foundation Training and then embarking on their speciality training in their chosen area of medicine (Figure 3. p.13). Depending on whether they entered medical school as an undergraduate or a graduate, they are usually aged between 23 - 33 years.

Mature Junior Doctors are highly valued within their cohort for their previous experience, different perspectives and maturity. Doctors entering medical training as graduates are more likely to have coping strategies in place. Their earlier experiences make them more likely to speak up to a senior member of their team.

12

Figure 3: Definition of a Junior Doctor. Source:‘Journey through medical training’, (BDI Resourcing, 2016)

The Research Problem to Address The Lack of Mental Health Support In the UK, Junior Doctors have two main routes to access mental health support, internally and externally. All NHS Hospital Trusts are mandated to provide mental health and well-being support for their Junior Doctors and are expected to adhere to recommendations and best practice guidelines. In reality, mental health support for Junior Doctors varies greatly between different NHS Hospital Trusts.

This inconsistency in the internal support offered to Juniors is compounded by personal factors such as the quality of relationships and rapport with, peers, clinical supervisors and seniors within that NHS Trust. Research shows that good relationships with colleagues and a culture of openness within a hospital are key to Junior Doctors being able to access support. And that these services they differ widely across the NHS. Even where the support services on offer are of high quality, Junior Doctors are frequently unaware of them.

There are a few exemplary external support services available to Junior Doctors in

13

Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

the UK, however, only a minority of Junior Doctors I spoke to could name one.

The Practitioner Health Programme specialises in treating sick doctors and does great work challenging the stigma around mental health and addiction issues. Over the last eleven years, they have treated and helped return to work thousands of doctors. Yet less than 5% of Doctors I spoke to knew of this service. PHP are limited by funding and are not available to all doctors; many doctors having to take annual leave and travel hundreds of miles away to access help from PHP.

The Research Aim The Support Gap This research is aimed at addressing the gap in mental health support available to Junior Doctors. Current services are designed to intervene after a Doctor has become unwell. This research is designed to establish how we can better support and equip doctors mental health and well-being before they present with serious pathology. I think Junior Doctors need consistent support tools which can track their progress, grow and adapt with them rather than a safety net to catch the most seriously unwell after they have fallen off the cliff. I hope this piece of research will help to improve Junior Doctors lives, by equipping them to deal more easily with the physical and mental demands of their job.

Researching how we can pre-emptively and consistently support the well-being and mental health of our Doctors requires an understanding of the root causes of why they develop mental ill health. Hopefully, it should also help to tackle the downward spiral that occurs when we wait for doctors to become unwell before intervening.

14

Junior Doctors could be the Change-Makers The NHS has set out its plans to move from a disease intervention service to a disease prevention service, shifting the emphasis upstream in order to prevent patients becoming ill in the first place. This paradigm shift should be mirrored in how the NHS treats its doctors in order to achieve the vision of better health for the nation. We know that healthy doctors make for better patient outcomes (GMC, 2019) and hence the need to take action is both clear and urgent.

There is a moral imperative for our society to care well for those whom we ask to care for others. Our NHS leaders need to appreciate that by supporting doctors physical and mental well-being that they are strengthening the very backbone of the NHS. Reforming how we care for doctors will result in positive changes on a scale that no other health intervention has been able to achieve, for the simple reason that it focuses on the NHS’s most crucial resource, its workforce.

Of course, this is a massive task but is more vital today than ever before. Doctors deserve to be treated with empathy and understanding, in the same way that we expect them to treat us as their patients.

Empowering Junior Doctors with the right tools, could ensure they become future change-makers and ambassadors, creating a new culture in healthcare that is open to talking about mental health in the years ahead. Promisingly research shows that Junior Doctors, regardless of age, point to good mental health and well-being as a key issue to their ability to achieve a successful career in medicine (Sykes, Borthwick & Baker, 2019).

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The Present Research Context The Covid-19 Pandemic This research will be especially pertinent following the damaging impact of Covid-19 on NHS healthcare workers. Reports have shown that the pressure on healthcare workers has negatively affected mental health and well-being, with a global rise in suicides among healthcare workers (Orr, 2020). Promisingly Covid-19 has also seen clinicians mental health brought into a national conversation in a way that has not been heard before. The British Medical Association has introduced a national hotline for all doctors and commissioned new services to deal with the mental health fallout (BMA, 2020). These new resources for doctors, coupled with the overt public appreciation for our healthcare workers (seen in initiatives such as ‘clap for our carers’ every week to thank them) have the potential to frame conversations around doctors mental health with compassion and free from stigma.

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Overview of The Research Process Figure 4 illustrates the research process to develop a support tool for Junior Doctors

1. Semi-Structured formal and informal

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Figure 4: Overview of my Research Process. The Research Jo 17

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ourney is Mapped in Four Stages – Highlighting Key Methods, Themes & Insights which led to the Design Solution 18

CHAPTER 2

Methodology: Process, Methods & Adaptation

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Design Research Methodology Mapping the Design Research Process Figure 5 maps my design research process. The research process led the research journey and the outcome followed to ensure that Junior Doctors voices were kept at the heart of this complex research subject area.

Figure 5: Mapping the Research Process. Map of the Research Journey and Framework of Thesis

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Research through Design This is a piece of Design practice-based research to develop a process for Junior Doctors to begin to vocalise their feelings of mental health and well-being within their professional lives. Mental Health and well-being is a universal and inescapable experience of all human beings. However, I have been acutely aware of my role as designer who has no previous clinical knowledge or practical experience of the realities of mental health in Junior Doctors. This design process aims to focus on listening and empathy, giving voices to the men and women who would benefit from the results of this research the most. Trying to mitigate for this experience gap has been one of my greatest concerns during this process.

Methods 1. Grounded Theory I have used Grounded Theory to balance qualitative and quantitative research methods. Strauss focuses on the richness and breadth of qualitative research, acknowledging the infinite and varied complexities of social interactions, together with Glaser’s categorised and scientific analysis, (Aldiabat & Le Navenec, 2011).

I have endeavoured to design a research process that shed lights on ‘human behaviour as a social process among actors in their interactional context’.

Investigating the nature of mental health in healthcare settings needs this duality in approach to capture on one hand, the depth of social experience, (from the future of social customs, to mapping emotional responses to taboos) to on the other hand, scientifically rating these results to extrapolate to future scenarios. In conjunction with Grounded Theory I aim to use Symbolic Interactionism to compliment it.

Symbolic Interactionism aims to yield a hypothesis to explore human behaviour by focusing on communication and relationships between people, (Boyd, 1989; Aldiabat & Le Navenec, 2011).

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2. Interviews, Hypotheses and Personas I conducted a series of in semi structured formal and informal interviews to gain insights from a wide diversity of views and stakeholders. From Junior Doctors to medical students and retired or senior doctors. I am keenly aware of my role as an observer in these contexts, so I used hypotheses and Personas to keep clinical voices at the heart of this research project.

3. Co-design I ran four separate co-design workshops though out the research process. The first two co-design workshops were conducted separately with a Senior Consultant and a Junior Doctor to align insights and embed clinical voices within the cultural probes.

The last two were with a UX and Graphic designers to explore storytelling and communication within the probe. All co-design workshops were designed to enrich the cultural probes with insights from multiple perspectives and ensure that the probes responded to my research question.

4. Cultural Probes Cultural probes are an important method in this research as they have the potential to disrupt assumptions around a subject area. Rather than focusing solely on methods such as interviews which aim to be objective and remove the personality of the interviewer, cultural probes are likely to produce results that are subjective and hard to interpret. This subject areas is one that treads across many areas of sensitivity and opinion. A method which does not end in ‘comfortable conclusions’ should be embraced in the subject area of taboo, ‘responding empathetically, not intellectually’ to my research findings, (Gaver et al., 2004). Insights gained from the probe which are biased, ambiguous and unexpected will provide a richness to my research which is necessary to the match the sensitivity of a taboo in healthcare.

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Method adaptation for Covid-19 Unexpected Benefits of New Method Adapting the research methods to align with social distancing measures required me to develop online interview tools added to the research. Co-design and User Testing were adapted by simulating and storyboarding, with presession briefings for my participants. Preparing participants before the sessions elevated the productivity of online sessions and resulted in more unified and repeatable testing. In co-designing sessions, drawing as documentation with my participants garnered more insights as the process required a deeper level of collaboration. The degree of separation created by conducting the session over Zoom, mirrored the concepts more truthfully than face to face testing.

Ethics Board Approval Before I began my research I submitted an ethics assessment to the Royal College of Art Ethics board, detailing my research plans and participant risk assessment, which was approved. I paid great attention to designing participant involvement; understanding that the subject area for some was potentially upsetting and revealing. I have endeavoured to ensure that all my participants, who have so kindly contributed to this research process felt they were safe and represented with integrity.

My Research Journal Reflection, Interrogation and Iteration I kept a detailed journal to note and reflect as I progressed through my research project. This proved valuable in acknowledging my role as a researcher and analysing my hypothesis and design decisions throughout the process (Figure 6).

Figure 6: M 25

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My Reflective Research Journal 26

CHAPTER 3

Setting the scene: Literature Review

Figure 5: Mapping the Research Process. Map of the Research Journey and Framework of Thesis 27 Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

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Literature Review:

Who heals the healer?

How might we equip and support Junior Doctors to start conversations about their mental health and not feel alone?

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Doctors and Mental Health Prevelance In 2019 the The British Medical Association (BMA) published a survey entitled ‘Caring for the mental health of the medical workforce’. In this survey of 4,300 UK doctors and medical students they found that as many of 80% were at high risk of burnout and that Junior Doctors were the most vulnerable group, (BMA, 2019). Of course survey respondants are often self seleciting if the topic is one that they feel is particularly relevant to themsleves. Nevertheless, we already knew that doctors suffer the highest suicide rate of any professional group (Gerada, 2018a) and experience greater rates of mental illness and poorer access to mental health support services than the general population, (Brooks, Chalder & Gerada, 2011).

The nature of being a doctor frequently involves listening and empathising with a patient at its most burdensome it has been described in The Reflective Practicioner by Schon as entering the ‘swampy lowland’, the fact that there may not be a solution to the problem, can weigh heavily on a doctor’s mind (Schon, 1983).

Junior Doctors may be no more predisposed to negative mental health than the rest of the population (Cantopher, 2012), but when they enter their demanding work enviroments they are subjected to extreme stress which exacerbate their chances of devloping mental ill health (Roycroft, 2020). Research suggests that personality traits such as altruism, concientiousness, perfectionism and obsessive behaviour (Gerada, 2018b) are highly prevalent amongst doctors and may need to be considered as potential risk factors for them developing future mental ill health.

Risk Factors The Michael West Report for the The General Medical Council, ‘Caring for doctors Caring for patients’ (2019), emphasises the importance of good mental health and well-being for working doctors, which directly correlates with the quality of care they deliver to their patients and the doctors own health (Dawson, 2014, 2018). Research studies have shown that high levels of stress and burnout increase the chances of medical errors (GMC, 30

2019; West et al., 2009) and that workload intensity and stress exacerbate poor mental health (Gerada, 2018b). When a medical error results in a doctor becoming the subject of an investigation into their clinical practice, the risk of their mental health deteriorating escalates dramatically (Gerada, 2018b; Horsfal, 2014). A report by the Royal College of Physicians published in 2016 found that seven in ten Junior Doctors are working on a rota with a permanent staff gap and four in five junior doctors regularly experience excessive stress because of their job (Royal College of Physicians, 2016). Stress, anxiety and depression account for one quarter of all sickleave in the NHS (Copeland, 2019) and in the financial year spanning 2017 - 2018 the NHS spent £5.5 billion in employing temprary staff to cover many of these abscences (The Health Foundation, 2018).

It is well established that supportive work environments and professional relationships are critcal to positive mental well-being. However, risk factors such as the disintegration of the old firm structure coupled with poor staffing levels and high workload intensity all contribute to placing relationships under strain, (Health Education England, 2019) Added to which is the reality of the Junior Doctor training model, where many are forced to move jobs frequenlty. This hinders their ability to forge stable and close peer relationships and iolating them from family and friends (Roycroft, 2020). Spaces that used to facilate doctors meeting informally together have been stripped away (Raw, 2003).

Institutional Culture – Stigma, Shame & Blame Personal, professional and institutional stigma exacerbate mental health problems amongst doctors. Many suffer in silence because they fear they will experience stigma if they speak out (Gerada, 2018b). As a result doctors are reluctant to acknowledge their vulnerability and consequently fail to seek help (Henderson et al., 2012). When they do seek help they are forced to confide in their colleagues, which inevitably leads to self diagnosis and treatment (Gerada, 2018b). Research from the Univeristy of Swansea has convincingly argued for our NHS leadership to take action to reduce the stigma and shame (Rimmer, 2019).

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Working in an envrionment with a blame culture negatively affects mental health and well-being (Health Education England, 2019). Junior Doctors are significantly impacted by this during their training years and can experience stigma and anxiety after being involved in a medical event with an adverse outcome. This culture is detrimental to Junior Doctors being able to admit mistakes, reflect and learn. Furthermore they are less likely to speak up if they have concerns about the culture fo their workplace for fear of being labelled a ‘whistleblower’ (Royal College of Physicians, 2016). This culture also hinders Junior Doctors disclosing they are struggling to cope at work to a colleague. Because they fear it will harm their career or that a ‘transgression might lead to a referal to the regulator’ (Gerada, 2018b. p 11;

Support Mental health support services should be available to all Junior Doctors in their place of work. The NHS Health and Wellbeing Framework, (NHS Employers, 2019) mandates that all Trusts provide training for managers and mental health support interventions for staff.

However, the framework consists of structural and cultural leadership recommendations which may be easy to propose but require implementation and local commitment to be effective. Consequently internal support services can vary dramatcially between NHS Trusts.

There are some excellent external support service for doctors to access. The Practitioner Health Program (PHP) is the largest physician health service in Europe and has treated over 11,000 doctors, with over half of their patients being Junior Doctors. The service is very successful in both treating doctors and returning them to work. Consistently scoring highly in satifaction suveys. However, services such as PHP usually see Doctors after their mental health has deteriorated to a worrying degree, ‘Many have reached the end of their ability to self-scrifice and to care, and thier professional, personal ad social lives are often in tatters.’

(Gerada, 2018b. pg. 3)

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Peer to Peer Support Evidence points to peer to peer support methods as having a positive impact on doctors mental health (Health Education England, 2019; Royal College of Physicians 2016). Sharing experiences with peers is important to unburden the ‘emotional load’ clincians carry around with them (The Health Foundation, 2018).

Schwartz Rounds are an example of ‘peer to peer support’ where multidisciplinary hospital teams come together to share personal and professional stories. Schwartz Rounds are not designed to acknowldge issues rather than solve them, reducing social isolation, offer compassion and understanding to the emotional burdens associated with healthcare work (The Point of Care Foundation, 2018). The poor psychological health has been reported to reduce from 25% to 12% of hospital staff who regularly attended these Schwartz Rounds (Maben et al., 2018).

Attrition A recent survey revealed that 47% of staff were thinking of leaving the organisation they work in and one in five debating whether to leave the NHS completely (NHS Staff Survey, 2018). Research shows a lack of well-being and work satisfaction as major factors in poor staff retention (GMC, 2019; Lambert, Smith & Goldacre, 2018). The NHS will not be sustainable if we fail to rectify these high levels of attrition. The current cost of training a doctor in the UK is approximately £500,000. If we then place young doctors in environments that negatively affects their mental health, we seriously undermine their ability to provide quality care to patients (GMC, 2019)

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Future Workforce Planning – Fit for Purpose?

The NHS Five Year Forward View commits to spending £2.3 billion annually for mental health services and yet only briefly mentions NHS staff (NHS, 2017). Furthermore, The Mental Health Implementation Plan (NHS, 2019) makes no mention of workforce mental health services only referring to the additional numbers that need to be deployed to work in mental health services to serve the general population. Even if the BMA’s survey results are inaccurate by a factor of 10, meaning that 8% rather than 80% of doctors are at high risk of burnout, we still have a massve problem to tackle.

We know that good staff health and well-being reduces sick leave which is crucial to ensuring the NHS can deliver high quality services and fulfill ever incresing demands (Boorman, 2009). We need to start by acknowledging the high prevelance of mental health problems amongst Junior Doctors (Roycroft, 2020) and determine effective methods to remove some of the trigger factors in their working environment.

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CHAPTER 4

Qualitative Research: Interviews & Insights

Figure 5: Mapping the Research Process. Map of the Research Journey and Framework of Thesis 35 Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

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Understanding the problem Qualitative Interviews Methodology The Research Question Who heals the healer?: How might we equip and support Junior Doctors to begin a conversation about their mental health and not feel alone?

Exploratory Interviews with Multiple Stakeholders Over the last year I have interviewed a range of doctors, nurses, regulators and policy makers, both formally and informally The aim of this qualitative research was to paint a fuller picture of how the NHS treats, perceives and deals with mental health and well-being among its workforce.

Interview Construction Semi structured one hour Interviews were conducted. All were one-on-one unobserved interviews to preserve privacy, which allowed for participants to share their stories frankly and honestly in a sensitive subject area.

Qualitative Interview Research Limitations Medical Speciality Specific This research did not have the time or scope to separate themes by medical speciality. For example, thematically cross referencing risk factors with different medical specialities, such as Gastroenterology or Obstetrics and Gynaecology. I acknowledge that more research is needed to build further on the excellent research conducted by The Practitioner Health Programme in ‘The Wounded Healer’ (Gerada, 2018b) and ‘Mental Health and Well-being in the Profession’ (Sykes, Borthwick & Baker, 2019).

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The Primary and Secondary Care Distinction This research focuses on the experience of secondary care doctors. While I have included and interviewed primary care doctors, through interviews and user testing with GP’s, more research is needed to account of the nuances in primary care.

Recruitment Strategy Due to the nature and sensitivity of my research topics, candidates who had undergone mental health and well-being issues were recruited through my own network. Initially I had developed a strategy to deal with not being able to recruit enough participants with relevant experience. However participant recruitment was not difficult as the issue is highly prevalent among Junior Doctors.

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Interview Objectives 1. Understand the prevalence and causation of mental health and well-being amongst Junior doctors working today.

Identify specific factors that contribute to negative mental health and well-being. Including the perception of mental health and well-being within the profession.

2. Understand how generational factors have impacted the profession and the perception of mental health and well-being in the healthcare system.

Have the realities of being a Junior doctor changed over the last 40 years?

3. Understand the barriers to speaking up about mental health and well-being within the profession.

How aware are Junior Doctors of any types of support available?

Participant Selection Criteria I aimed to be speaking to medical professionals who had: 1. Issues with their mental health and well-being and had a) sought professional support or b) not spoken up 2. Junior Doctors who had experiences with their mental health or well-being at work 3. Senior Doctors who managed Junior Doctors and had a perspective on how mental health and well-being as an issue was perceived over the last 40 years 4. Doctors who had no negative experiences with their mental health or well-being

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Participants I interviewed Medical Students, Junior Doctors, Consultants, Retired Doctors and a Medical Lawyer (Figure 7), the breadth of experience was key to gaining insights which contextualised the changing landscape of the NHS.

Participant

Semi-Structured Interviews

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Medical Lawyer

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Synthesis of Qualitative Data Reflective Journal and Miro I used two processes to synthesise my interviews. All interviews were recorded and then transcribed by hand. Although time consuming it allowed for greater absorption and reflection of the content collected. In my Research Journal (Figure 8), I spent time reflecting and dissecting interviews. I then collated my insights using the software Miro, an online collaborative whiteboard (Figure 9). Miro allowed me to record insights immediately after an interview and cross reference them with others easily to see emerging trends as I conducted the research.

Figure 8: My Reflective Research Journal. Interview Analysis

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Figure 9: Interview Analysis on Miro – A Virtual Whiteboard

Thematic Analysis A thematic analysis approach has been used to extract insights from my interviews. Insights were themed by prevalence in the qualitative data collected and relevance to the research question.

Themes from the Interviews Interview insights have been grouped into four major themes (Figure 10).

N MEN

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Figure 10: Insight Themes from Semi-Structured Interviews

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Systemic Insights Relating to the Whole Health System Systemic factors, such as a lack of resources within the NHS were the backbone of the causes for negative mental health and well-being for Junior Doctors. Pressures presented by impossible workloads and understaffed shifts contributed to Junior Doctors feeling isolated and demotivated because their ‘best was never good enough’. Senior doctors talked with nostalgia at how the service had changed and expressed regret at how the current demand on the NHS negatively affected Junior Doctors. There was a persistent lack of knowledge of internal and external mental health and well-being support services. Junior Doctors are particularly susceptible to not knowing about support services due to moving jobs often. This causes frustration as many describe these services as being extremely helpful after accessing them.

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Figure 10: Insight Themes from Semi-Structured Interviews

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R TE

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Insights relating to relationships or communication between people

1. An Impossible Expectation Workload Intensity Negatively Effect Mental Health ‘I was literally at the breaking point, I was in tears most days.

After her [a Junior Doctor colleague] shift finished at five, she would come and help me. Even then, we didn’t get through it, if it’s not even doable by 2 people, how is it ever going to be achievable for one!?”

Junior Doctor ‘It’s not the fact that what they are asking you to do is hard, It’s they expect you to do a million things. They just say, ‘oh just do your best’.

But that’s not good enough.’

Junior Doctor

Many expressed the feeling that they were not doing their job to the best of their ability. Emotions such as guilt, shame and feeling overwhelmed were reported often. Furthermore, these pressures added to Junior Doctors not wanting to speak up as they felt guilty for taking time off work as it meant increasing the already impossible workload of a colleague.

2. The Junior Doctor Training Model ‘The old game of caring is gone’ ‘It feels quite isolated and fragmented and you might be working with a different consultant every week or constantly being asked to go and step in for rota gaps on different wards so you feel like no one has ever quite got your back.’

Junior Doctor

Junior Doctors cited the new training system added stress and anxiety at work, as it led to the, having to move jobs frequently, sometimes every six months.

This constant upheaval when coupled with rota gaps and under-staffing added to feeling isolated and a lack of consistent training from senior colleagues. This meant they often felt unsupported from consultants and registrars when dealing

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with complex cases. Contributing to ongoing stress and anxiety about cases after they had gone home. Senior Doctors expressed sympathy and acknowledged that the new training models gave Junior Doctors a ‘bad crack at the whip’.

3. Little knowledge of Mental Health Support Services “I don’t know why when we had so much teaching on resilience and how to deal with stress, complaints and to make sure you don’t burn out, yet PHP (The Practitioner Health Program) had never been raised as an option… no one seemed to know that service existed, even though it worked really well.’

Junior Doctor “I think there is zero [mental health and well-being] in the curriculum. Which is pretty bad. I definitely think there needs to be an improvement on that. Because, if you prepare medical students in how to mentally prepare themselves for what is going to happen in F1, then I think it will completely change the way you are able to cope with it.”

Final Year Medical Student

Junior Doctors are particularly unaware of mental health support. Which contributed to a general unease about speaking up, assuming they should be able to manage it themselves as there was no capacity to deal with it.

Senior doctors were slightly more likely to know of support services as they were more likely to have accessed services themselves or have been signposted to by a colleague. Or had developed through experience personal coping strategies so that only more severe cases were referred. Junior Doctors described forging their own path to find support services, usually outside their professional lives.

One interviewee described finding out about the Practitioner Health Programme through a friend’s mum after she had reached breaking point and her family and friends were worried about her.

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4. Junior Doctors are prepared for the realities of being a doctor when they begin work ‘You become an F1 and shit hits the fan. You can’t get all the bloods out on time.

You can’t do this or that. The system doesn’t always allow it, and then someone dies on you. Did you check this thing properly? Did you do this? If you’ve always been the perfect, best one, and suddenly you’re in an environment where someone is shouting at you, you’re not doing it right, and you’re not keeping up...

I think that can affect someone’s mental health. You need to be told earlier that this is going to happen.’

Junior Doctor

Medical students and Junior doctors were particularly concerned about a lack of preparation for the messy realities of being a doctor. Citing that this knowledge could aid coping with mental distress caused by the job if it was an expected outcome. Statistically the first years of medical training are when Junior doctors are most a risk of negative mental health.

5. Contempt for Resilience Training ‘It feels like you are a bit of a failure as you are not able to cope.

It feels like it’s saying we aren’t doing a good enough job already.’

Junior Doctor

There was a consistent contempt for resilience training within the NHS amongst Junior Doctors. It was cited as actively causing feelings of inadequacy and insecurity which made their mental health worse. These feelings meant they were less likely to speak out as they should ‘just be better’.

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Fear of reflecting honestly and speaking up Inauthentic reflections and defensive medicine Juniors said they had ‘played down’ their feelings when talking about their mental health to supervisors out of fear of being labelled as not resilient or incompetent. Juniors reported that their mandatory portfolio reflections were ‘inauthentic and box ticky’.They were scared to reflect honestly because of fear of the regulator. Many cited the case of Dr Bawa Garba (a Junior Paediatric Doctor who was convinced of gross negligence manslaughter by her reflection notes, the conviction was later overturned) as the reason why they did not want to reflect honestly about their practice. This impacted their mental health and well-being by making them not able to decompress and open up about issues at work and that they were unsupported by the profession and public, who were ready to make an example out of them at the smallest opportunity.

Environmental Insights Relating to Practical and Physical Aspects of the Workplace Many Junior Doctors described with dismay how non-conducive the place they work in could be to their mental health and well-being. Citing the fact there was nowhere they could sit and informally chat with colleagues, a space to have the conversations that they desperately wanted to have to feel normal and share experiences. Many described that after working up the courage to speak to a supervisor about their struggles, that there was no where to discuss privately.

For example, trying to disclose something highly personal in a busy hospital corridor, which further added to a sense of hostility in the workplace towards acknowledging and empathising with mental health struggles.

‘We didn’t have a proper functioning mess where all doctors gathered and you could sit down and share those kinds of ideas.’

Junior Doctor

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Figure 10: Insight Themes from Semi-Structured Interviews

Endemic Insights Relating to the realities of being a doctor Endemic factors were particularly felt to impact Junior Doctors mental health and well-being. Distressing events, the perception of mental health within medicine and the fact that doctors are the only profession to be treated by their colleagues were cited as negatively impacting mental health and act as barriers to self disclosure.

1. Distressing Events ‘I’ve seen Junior Doctors desperate to tell those stories.

And it’s completely eating them up inside.’

Junior Doctor

Junior Doctors were more comfortable citing stresses caused by systemic challenges rather than endemic challenges, such as a distressing clinical event.

Juniors spoke about wanting to share their clinically distressing stories but they were too fearful to in case they were blamed for it. In many cases a lack of clinical guidance and support to deal with distressing cases left Junior Doctors to feel inadequate. Junior Doctors desperately wanted to know whether a colleague would have handled a clinical case in the same way they would have.

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R PER S O N AL

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Insights relating to relationships or communication between people

2. Experience Matters ‘When things go wrong, and things can go badly wrong in medicine....It’s incredibly distressing and you do take it very personally. In my case, if a baby dies during a delivery or a woman loses another pregnancy, no, it may not be your fault, but you do feel it very acutely.‘ Senior Consultant ‘The more senior you get, you are more quick to say it, but when you are junior you just don’t want anyone to think you are incompetent.’

Junior Doctor

Junior Doctors were distinctly disadvantaged in dealing with endemic factors due to a lack of clinical experience. On the other hand, Senior Doctors were much more likely to have learnt through experience to transform negative experiences into meaningful personal coping strategies. Whereas Junior were more likely to view endemic factors as negatively impacting their professional and private lives as they were exacerbated by systemic factors. The more senior a doctor the more likely they would express distress experienced at work.

3. Doctors, like all of us, have little insight into their health Many of us are bad at recognising patterns in our own mental health until a crisis point is reached. Doctors are no different. Doctors expressed disbelief that they had in the past got to such a breaking point and not spoken up sooner. They felt they should have recognised the signs and acted on them. Junior doctors cited their training in clinical diagnostic vocabulary resulted in finding the words to talk about their emotions and mental health concerns proved difficult.

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Figure 10: Insight Themes from Semi-Structured Interviews

Interpersonal Insights Relating to relationships or communication between people Many interviewees who had sought help for their mental health were prompted to by a close colleague. Close friendships and rapport are key to disclosing and encouraging doctors to access help. And crucially are fundamental to identifying those in need of help.

1. Mental Health Problems are Seen as Weakness ‘If you say the medical profession are unforgiving of each other, I would agree with you. But I think the medical profession reflects society.

I think we are unforgiving of doctors.’

Medico-legal lawyer

The stigma attached to mental health among doctors was one the most prevalent insights gathered. There seemed to be a perfect image of what a doctor should be, propagating the idea that they should be ‘made of stronger stuff’ if they experienced mental health struggles, further propagating shame and isolation.

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R PER S O N AL

SY

Insights relating to relationships or communication between people

2. Generational Tension ‘It’s so rare a consultant actually listens to you. If you try to tell a consultant what you are going through, they are like, ‘yeah, it is rubbish, but you know, when I was a junior…’

Junior Doctor

‘I thought a work life balance was something I would just do in my 70’s.’

Senior Consultant

Senior colleagues expressed dismay that their junior colleagues saw medicine as a job rather than a vocation. Whereas Junior colleagues felt these attitudes were dismissive and that their personal lives played an important role in coping with their mental health and well-being at work.

3. Sharing your Experience Helps Many doctors I interviewed, who had experienced negative mental health have become advocates among their colleagues. Identifying and signposting peers to professional support was seen as a duty and ensuring that no one had to go through what they had. Doctors may not have empathy for themselves at difficult moments but had great compassion for their colleagues. This community knowledge transmission was a safety net in place of a lack of systemic support.

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Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

Interview Findings Key Insights • Junior Doctors are uniquely disadvantaged.

Representing the highest burden of mental health amongst workforce.

• Support Services vary across Hospital Trusts and many have no knowledge of how or where to access support.

Juniors cited resilience training as actively making them feel worse as it made them feel unworthy or up to the job. Citing senior colleagues as the main proponents of this culture who could at times be dismissive and compare and say, ‘back in their day…’.

• Relationships Matter. A close and candid relationship with colleagues, especially seniors or supervisors is crucial to speaking up. How can we provide the benefits of meaningful connections with colleagues to all Junior Doctors?

• Interventions must start as early as possible. Medical students and Junior Doctors felt they were unprepared for the realities of their job and this amplified the distress they felt.

• Experience Matters – Consultants were more likely to have developed individual coping strategies.

Senior doctors had develop coping strategies over time and represent a self selecting group as peers that had not been able to cope usually did not make it to their level. Junior doctors felt able to speak only after they gained significant clinical experience. There is a culture of suffering in silence as they think that they are the only one not coping.

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• Life events vs Traumatic Events – Must prepare for both There must be consideration to prepare and support Junior doctors to manage both the inevitable distressing events that arise from practicing medicine as well as distressing life events that might impact their professional lives.

• Junior Doctors are the Change Makers. There current generation of Junior Doctors have a great deal of awareness and see mental health as a crucial issue. They want to engage in these conversations and represent the base to change culture within their organisation from the bottom up.

• Female Doctors are particularly susceptible to negative mental health. As the profession moves to a higher proportion of women, we must urgently address this.

This Research Project’s Aim To give Doctors the tools to speak up about their mental health and wellbeing at the beginning of their careers so that they will be equipped to speak up throughout their clinical life. Doctors who have had mental illnesses described feeling alienated from their peer group, how might we connect them meaningfully together?

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Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

54

CHAPTER 5

Designing: Cultural Probes & Three Concepts

Figure 5: Mapping the Research Process. Map of the Research Journey and Framework of Thesis 55 Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

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Three Cultural Probes Overview of the design process Research Synthesis To design the cultural probes, I defined the six key insights from my qualitative research (Figure 11. p. 59), to create three Junior Doctor personas. Based on these personas, I defined three hypotheses to synthesise the key problem areas experienced by Junior Doctors which my research had identified.

Hypotheses Transformed into Opportunity Areas I then defined three opportunity areas to design probes for. By transforming a hypothesis, into an opportunity area with a ‘How might we...?’ statement, turned the synthesis of my research into an actionable design brief. The resulting three probes are designed to test these hypotheses to gain further insights into my research question.

Three Cultural Probes I have designed three cultural probes , which I refer to as concepts, to gain a deeper understanding of the many levels of interactions, (Grand, 2012), involved in Junior Doctors and mental health and well-being. As described by Pfeifer and Bongard as a design research strategy as ‘analysing, understanding and explaining by building’, (2006).

Co-design Workshops Through three co-design workshops the concepts were refined with a Senior Obstetrics and Gynaecology Consultant, a Junior Doctor and a Designer. Leading to further iterations, ready to test with Junior Doctors and other participants for the testing stage.

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Junior Doctor voices at the heart of the design process Each concept has been created through the collation and synthesis of the Junior Doctors I have had the privilege to interview and work with. The complexity and nuance of this subject matter necessitates this careful consideration if it will serve the very people it wishes to. I have strived to retain their voices as the spine of each concept that will be presented.

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1

The Key Insights (Figure 11)

E IN T R PE R S

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Figure 11. Key Insights from Semi-Structured Interviews

5

1. Junior doctors are often isolated, often since they are frequently expected to move jobs. This makes forging close relationships with either peers or senior colleagues

E

difficult and results in the loss of potential informal support networks

2. There is a culture of fear about speaking up. There is a perception that mental health issues are seen as a weakness by colleagues and seniors and admitting a

3. Many Junior doctors feel that they are the only one not coping 4. Many Junior Doctors just want to know that what they are feeling is normal and reassurance that someone else would handle a similar situation in the same way

AL

problem could lead to being penalised

5. Juniors don’t know where to access support. There is inconsistent support offerings amongst different trusts

6. A private first step is needed, encouraging the Junior Doctor to start a conversation with themselves, thereby acknowledging a problem, before they can usefully go and talk to someone else

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F

Three Junior Doctor Personas I developed individual personas (Figure 12), reflecting the beliefs of the wonderful Junior Doctors I have had the privilege to meet through this research process. Their unwavering devotion to their job, their passion for the importance of mental health and well-being became an integral part of the process of persona building.

Insight: 1, 3

Insight: 2,3,4,5,6

Insight: 1,2,5,6

Persona 1: Guy

Persona 2: Jenny

Persona 3: Melissa

Guy, 29, Junior Doctor from Essex. Guy recently moved to Basildon for a new placement.

When he goes into work at this new hospital he doesn’t know anyone and feels isolated at work and at home

Jenny, 31, Junior Doctor from London. Normally outgoing and bubbly, recently Jenny has become anxious and stressed due to back to back night shifts and being involved in a patient incident at work

Guy feels lonely and unsupported as he has no work friends to confide in. He wishes to build a sense of team spirit with his new colleagues

Jenny is uneasy about speaking up to her colleagues as she doesn’t want them to think she can’t cope. She desperately wants to be reassured that another Junior Doctor would have acted in the same way she did. She feels alone and doesn’t know who to turn to

Melissa, 25, Junior Doctor from Birmingham. Recently qualified and finding her job in a hospital can be overwhelming at times.

She feels her work negatively impacts her mental health but is unsure whether this is a normal feeling

Figure 12. Three Junior Doctor Personas 60

Melissa tries not to think about her mental well-being and to just push through. She does not want to be labelled as the only one that cannot cope

Three Hypotheses The three personas became a set of hypotheses to create opportunity areas to design for (Figure 13).

Insight: 1, 3

Insight: 2,3,4,5,6

Insight: 1,2,5,6

Persona 1: Guy

Persona 2: Jenny

Persona 3: Melissa

Guy, a Junior Doctor whose training rotation forced him to move to Basildon for a new placement, far removed from friends and family. When he goes into work at this new hospital he doesn’t know anyone and feels isolated at work and at home

Jenny, a Junior Doctor from London. Normally outgoing and bubbly, recently Jenny has become anxious and stressed due to back to back night shifts and being involved in a patient incident at work

Melissa, a Junior Doctor from Birmingham. Recently qualified and finding her job in a hospital can be overwhelming at times.

She feels her work negatively impacts her mental health but is unsure whether this is a normal feeling

Psychiatry Trainee, 29

Guy feels lonely and unsupported as he has no work friends to confide in. He really wants to build a sense of team spirit with his new colleagues

Hypothesis 01 Junior Doctors are increasingly isolated when they are forced to move job every six months.

Close relationships, support and rapport with seniors and peers are hard to cultivate This places them at a significant disadvantage for seeking help and advice

O&G Trainee, 31

Jenny is uneasy about speaking up to her colleagues as she doesn’t want them to think she can’t cope. She desperately wants to be reassured that another Junior Doctor would have acted in the same way she did. She feels alone and doesn’t know who to turn to

Hypothesis 02 Junior Doctors often feel they are the only one not coping.

They are less likely to speak up, for fear of being labelled as weak or not resilient. Many do not know where to access help A private first step to vocalise their own feelings is crucial to building the confidence to start a conversation with someone else

F1 placement in A&E, 25

Melissa tries not to think about her mental well-being and to just push through. She does not want to be labelled as the only one that cannot cope

Hypothesis 03 Junior Doctors may have limited insight into their own mental health or well-being due to the fast paced, high stress environment they work in. Mental health and well-being ebbs and flows over time. It is hard to keep track of mental health over a period of time in this environment It is crucial to have an appreciation of when you are so down that you need to speak up

Figure 13. Three Hypotheses 61 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

Three Opportunity Areas Defining the brief The three personas became a set of hypotheses to create opportunity areas.

These Opportunity Areas (Figure 14), became the brief for three separate concepts to test the hypothesis and explore the research question.

Insight: 1, 3

Insight: 2,3,4,5,6

Insight: 1,2,5,6

Hypothesis 01

Hypothesis 02

Hypothesis 03

Junior Doctors are increasingly isolated when they are forced to move job every six months.

Close relationships, support and rapport with seniors and peers are hard to cultivate

Junior Doctors often feel they are the only one not coping.

They are less likely to speak up, for fear of being labelled as weak or not resilient. Many do not know where to access help

This places them at a significant disadvantage for seeking help and advice

A private first step to vocalise their own feelings is crucial to building the confidence to start a conversation with someone else

Junior Doctors may have limited insight into their own mental health or well-being due to the fast paced, high stress environment they work in. Mental health and well-being ebbs and flows over time. It is hard to keep track of mental health over a period of time in this environment

Persona: Guy, 29, Junior Doctor

Opportunity Area How might we create a working environment which fosters supportive relationships and camaraderie?

Persona: Jenny, 31, Junior Doctor

It is crucial to have an appreciation of when you are so down that you need to speak up

Opportunity Area How might we show them they are not alone in feeling this way and facilitate a private first step towards speaking up?

Figure 14. Three Opportunity Areas. Three Design Briefs

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Persona: Melissa, 25, Junior Doctor

Opportunity Area How might we encourage Junior Doctors to vocalise and track their well-being?

And leverage the data set so that it becomes a meaningful personal and transformational metric?

Three Concepts I designed three concepts (Figure 15), to answer my ‘How might we..?’ statements utilising a process of personal and co-design sessions. Before I explain each concept I will explain the co-design process.

Opportunity Area

Opportunity Area

Opportunity Area

How might we create a working environment which fosters supportive relationships and camaraderie?

How might we show them they are not alone in feeling this way and facilitate a private first step towards speaking up?

How might we encourage Junior Doctors to vocalise and track their well-being? And leverage the data set so that it becomes a meaningful personal and transformative metric?

Concept 01

Concept 02

Concept 02

The Virtual Doctors’ Mess

Share Your Story

The Work Emotion Diary

‘That story resonates with

Record and confidentially tell your employer how to improve your work experience. Find ways to leverage the power of the data set generated by the Junior Doctor community to affect change

An online Slack* community to simulate a virtual Doctor’s Mess through a platform that is sensitive and responsive to your realities of working life as a Junior Doctor

me’. Share your stories with a community of Junior Doctors who are unable to identify you and are not affiliated to your employer. By realising you are not alone you learn and also support others

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

DEPRESSION good evening, share your stories and support others you are not alone

Today I feel RECENTLY RESONATED

STRESS

ANXIETY

ELATION

STORIES FROM OUR COMMUNIT Y T H E PAT I E N T I CANT FORGET

LONELINESS

TAKING IT HOME

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

dread

about going to work

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Today I feel

excited

about going to work

On one of the days when I was

feeling the lowest, if anyone asked

HOW YOU HAVE FELT ABOUT GOING TO WORK

me a question I would go red and get really flustered. I couldn’t get home without stopping on the way home

*Slack is an online messaging service. Its workspaces allow you to organize communications by channels for group discussions and allows for private messages to share information, files, and more all in one place

Jan

and crying. One of my F1 colleagues SHARE YOUR STORY

it might be the key to helping someone else

turned to me and said ‘you literally

Mar

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Inside it was so far from what I had been feeling. Maybe everyone had been feeling the same but no one was letting the cracks show.

Has this story resonated with you?

Inside it was so far from what I had been feeling. Maybe everyone had been feeling the same but no one was letting the cracks show.

Has this story resonated with you?

This story resonated with 32 others in the community

Your story might resonate with other members in the community Would you like to share it?

HOW YOU HAVE FELT ABOUT GOING TO WORK Week

Month

This story resonated with 32 others in the community

You have resonated with 5 other stories of experiencing anxiety and depression at work

Jan

Feb

Mar

Today I feel

nervous

about going to work Apr

May

Jun

Have you considered discussing your feelings with someone at work?

You’ve been feeling less positive about going into work over the last few months Not sure who to talk to in your Trust?

Can we direct you to someone?

(Don’t worry it’s confidential to access our directory) Have you thought about external support services?

The Practitioner Health Program?

Its confidential and they can offer immediate support

What could your employer do to improve your feelings about going to work? provide us with a doctors mess

Did anything change in April?

May we share with you experiences of others in the community who have talked to someone?

Figure 15. Three Concepts. The Three Cultural Probes

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

Year 2020

You are not alone

You are not alone

63

Feb

always look so happy, is there ever a day where you aren’t happy?!’

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

May we share this feedback anonymously with your employer?

If enough us speak up, together we can make a change.

Co-Design Workshops Clinical and Design Voices

64

Co-design Workshops Clinical and Design Voices Aims I ran three co-design workshops to expand the perspectives that informed the cultural probes. The aim of these workshops was to enrich the probes I had designed with insights from different fields of experience within the NHS.

Participants This was gained by three different perspectives, a Senior Consultant, a Junior Doctor and a Designer (Figure 16). The first, Professor Dame Lesley Regan, a senior O&G consultant, who with forty years of experience in the NHS has seen how the experience of Junior Doctors has evolved. Crucially, Regan still manages and trains numerous Juniors, providing a unique perspective on the concerns and needs of this cohort. In addition, her seniority and experience provided a perspective on the potential viability of an intervention within the NHS system. The second co-design workshop, I ran was with Dr Guy Ansah-Palmer, a Junior Specialty Trainee in Psychiatry. Guy’s perspective as a current Junior Doctor was crucial to ensuring these concepts served the current needs of Junior Doctors. The final co-design workshop was with Lucy Holmes, a designer who specialises in designing for people and places through storytelling.

Method adaptation: Covid–19 I had planned to conduct all of the co-design workshops in person. However, due to social distancing and lockdown restrictions, I only managed to conduct one in person workshop with Professor Dame Lesley Regan. I adapted the other two workshops to Zoom. All were given a pre-workshop briefing, which set out the background to the research project. As I simulated to three concepts through storyboarding them and sharing my screen, I draw the session to capture the design and clinical inputs from Lucy Holmes and Dr Guy Ansah-Palmer.

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Figure

Unexpected Benefits of New Method Adapting the workshop to an online setting added to the co-design experience.

The constraints of using Zoom became a strength. I documented the interviews by drawing. I found that I gained more insights through drawing, as the process required a deeper level of collaboration. As I drew and interpreted their input we continually discussed my interpretation of their meaning which facilitated a more in-depth conversation (see Figure 16). The space created between the researcher and the participant added a dimension to process that was unexpectedly beneficial.

Co-design 01 Professor Dame Lesley Regan, Senior Consultant

Co-design 02 Lucy Holmes, Designer

e 16. Three Co-design Workshops. Documentation Through Drawing.

66

Co-design 02 Dr Guy Ansah-Palmer, Psychiatry Trainee (Junior Doctor)

Three Cultural Probes

1. The Virtual Doctors’ Mess 2. Share my Story 3. The Work Emotion Diary

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CONCEPT 01

The Virtual Doctors’ Mess

“We don’t have a proper functioning mess where all doctors gather and you can sit down and share those kinds of ideas.

There is very much this attitude that you will turn up everyday and support your team, even though that concept of a team has disintegrated because the firm structure has dissolved.

Junior Doctor, 28

”

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The Virtual Doctors’ Mess Bring camaraderie back Implementing this concept would require nominating a Junior Doctor to create an online ‘Slack’ community (online messaging service), for the Junior Doctors in that hospital. It is designed to utilise contemporary technology to simulate the advantages of a supportive firm structure ‘of the old days’, the value of which has been highlighted by senior doctors. This would help to reduce social isolation and build camaraderie amongst a team, as outlined in Figure 17. Adopting multiple and bespoke ‘channels’ will create the feeling of belonging to a dynamic group. The Slack platform would be more sensitive to the nuances of life of Juniors than WhatsApp. Slack allows for simultaneous multiple conversations rather than one binary conversation often on conducted on traditional messaging apps.

For example, Slack could alleviative isolation on a lonely night shift by setting up a ‘channel’ for all the weekend night shifters. This in turn encourages social engagement and opportunities to meet face

Insight: 1, 3

Insigh

Guy, a Junior Doctor whose training rotation forced him to move to Basildon for a new placement, far removed from friends and family. When he goes into work at this new hospital he doesn’t know anyone and feels isolated at work and at home

Jenny Londo and b becom due to and b incide

Persona 1: Guy Psychiatry Trainee, 29

Guy feels lonely and unsupported as he has no work friends to confide in. He really wants to build a sense of team spirit with his new colleagues Opportunity Area How might we create a working environment which fosters supportive relationships and camaraderie?

The Virtual Doctors’ Mess

Perso O&G

Jenny up to doesn can’t c wants anoth have a she d doesn

Oppo

How m they a way an step to

Shar

to face to support one another, whilst not worrying that you might

good evening

share your stories an you are not alone

be sending a message to colleagues trying to sleep!

RECENTLY RESON

STRESS

STORIES FROM O T H E PAT I E N T I CANT FORGET

Benefit

SHARE YOUR ST

it might be the key to

On one of feeling th asked me go red an I couldn’t stopping and cryin

Effective, simple and low cost

One of m to me and always lo ever a da happy?!’

Motivation

Inside it w I had bee everyone same but cracks sh

Minimal effort required to build relationships and forge

H w

Yo

Thi 32

community spirit and responsibility for each other

Yo wi the W

Reward The feeling of belonging to a dynamic and supportive team 69

Figure 17. Guy: Persona 1.

Concept Inspiration

Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

The Virtual Doctors’ Mess Bring camaraderie back

The Virtual Doctors’ Mess An online slack community to simulate a virtual Doctor’s Mess through a platform that is sensitive and responsive to your realities of working life as a Junior Doctor

Channels are chosen by the group of doctors to create a space which is meaningful and supportive to them

Figure 18. Storyboard of ‘The Virtual Doctors’ Mess’ 70

CONCEPT 02

Share Your Story

“I’ve seen Junior Doctors desperate to tell those stories.

And it’s completely eating them up inside.”

Junior Doctor, 25

“If someone had just said, ‘Oh don’t worry I do that kind of thing all the time’ it would have been reassuring.”

Junior Doctor, 29

“Hearing somebody else say this thing the other day really stressed me out, lets talk about it, would have been so helpful.”

Junior Doctor, 29

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Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

Share Your Story By sharing my story, I give you permission to share yours and hopefully act upon it This app community would encourage Juniors to share their stories Insight: 1, 3

about experiencing stress, anxiety and themes that impact their

Persona 1: Guy Psychiatry Trainee, 29

mental health and well-being. All stories would be anonymous so Guy, a Junior Doctor whose

users could contribute freely without fear and judgement. training rotation forced him

to move to Basildon for a new

placement, far removed Affirmation from peers and senior colleagues was pointed to as from friends and family. When he goes into work at this new having the biggest impact on Junior Doctors throughout the hospital he doesn’t know and feels isolated research. Helping them realise that no one anyone else was ‘perfect’ and at work and at home

they were good enough was particularly important. induced Guy feels Anxiety lonely and unsupported as he has no work

by a quest for perfection hinders Junior Doctors todework friendsability to confi in. He really

wants to build a sense of team new colleagues effectively (Gerada, 2018b). Understandingspirit that with theyhis and others, Opportunity Area

are not perfect, can empower them to not blame themselves and How might we create a working which assume they have a lack of resilience, for their low environment mood. fosters supportive relationships and camaraderie?

Junior doctors reported not knowing of support services they could

access (Figure 19). Many cited long and difficult routes to accessing.

The Virtual Doctors’ Mess services; dismayed they had never been informed of support during

Insight: 2,3,4,5,6

Insigh

Jenny is a Junior Doctor from London. Normally outgoing and bubbly, recently Jenny has become anxious and stressed due to back to back night shifts and being involved in a patient incident at work

Meliss Birmin and fi can b She fe impac but is norma

Perso F1 pla

Persona 2: Jenny O&G Trainee, 31

Jenny is uneasy about speaking up to her colleagues as she doesn’t want them to think she can’t cope. She desperately wants to be reassured that another Junior Doctor would have acted in the same way she did. She feels alone and doesn’t know who to turn to Opportunity Area How might we show them they are not alone in feeling this way and facilitate a private first step towards speaking up?

Share Your Story

Meliss her m just p not w only o

Oppo

How m Docto well-b set so person metric

The

HOW ARE YOU FEE ABOUT GOING TO

their medical education. This app would provide them with a DEPRESSION

directory of support services and contact details.

good evening,

RECENTLY RESONATED

Benefit Providing Junior Doctors with the permission and personal freedom

STRESS

ANXIETY

ELATION

STORIES FROM OUR COMMUNIT Y T H E PAT I E N T I CANT FORGET

Today I fe

about goi

share your stories and support others you are not alone

LONELINESS

TAKING IT HOME

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

On one of the days when I was

feeling the lowest, if anyone asked

me a question I would go red and get really flustered. I couldn’t get home without stopping on the way home and crying. One of my F1 colleagues SHARE YOUR STORY

it might be the key to helping someone else

to reflect honestly, without fear or judgement

Motivation A space to offload and vocalise your feelings

Reward To feel that you are not alone and find comfort in knowing that someone else might know how you feel 72

turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Inside it was so far from what I had been feeling. Maybe everyone had been feeling the same but no one was letting the cracks show.

Has this story resonated with you?

HOW YOU HAVE ABOUT GOING T

Inside it was so far from what I had been feeling. Maybe everyone had

Week

Month

been feeling the same but no one was letting the cracks show.

Has this story resonated with you?

You are not alone

Jan

F

Apr

M

This story resonated with 32 others in the community

You have resonated with 5 other stories of experiencing anxiety and depression at work Have you considered discussing your feelings with someone at work?

You’ve been feeling less about going into work o few months

Did anything change in April?

You are not alone This story resonated with 32 others in the community

Your story might resonate with other members in the community Would you like to share it?

Not sure who to talk to in your Trust?

Can we direct you to someone?

(Don’t worry it’s confidential to access our directory) Have you thought about external support services?

The Practitioner Health Program?

Its confidential and they can offer immediate support May we share with you experiences of others in the community who have talked to someone?

Figure 19. Jenny: Persona 2.

Concept Inspiration

Share Your Story By sharing my story, I give you permission to share yours

Share Your Story

1/4

‘‘That story resonates with me.’ Share your story with a community of Junior Doctors who are unable to identify you and are not affiliated to your employer. By realising you are not alone, you learn and also support others

T H E PAT I E N T I C A N T FORGET

DEPRESSION

good evening, share your stories and support others you are not alone

RECENTLY RESONATED

STRESS

ANXIETY

ELATION

STORIES FROM OUR COMMUNIT Y T H E PAT I E N T I CANT FORGET

LONELINESS

TAKING IT HOME

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was. Very, very poorly education and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but she wouldn’t be stopped. And she

On one of the days when I was feeling the lowest, if anyo asked me a question I would go red and get really flustered I couldn’t get home without stopping on the way home and crying.

One of my F1 colleagues turn to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

SHARE YOUR STORY

it might be the key to helping someone else

Choose a theme of stories. All of the stories have been identified by fellow Junior Doctors as impacting their mental health and well-being

Users can swipe through different stories, until one resonates with them

Figure 20. Storyboard for ‘Share Your Story’. Figure 1 of 4 73 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

Share Your Story By sharing my story, I give you permission to share yours

Share Your Story

2/4

‘‘That story resonates with me.’ Share your story with a community of Junior Doctors who are unable to identify you and are not affiliated to your employer. By realising you are not alone, you learn and also support others

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

DEPRESSION

Inside it was so far from what I had been feeling. Maybe everyone had been feeling the same but no one was letting the cracks show.

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

Has this story resonated with you?

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Please consider sharing your own story with the community.

Your honesty might just be the key to helping someone else.

If there is a story a user likes, they can chose to dive deeper into the story

When the user has finished the story, they are prompted by the question, ‘Has this resonated with you?’

Figure 21. Storyboard for ‘Share Your Story’. Figure 2 of 4 74

Share Your Story By sharing my story, I give you permission to share yours

Share Your Story

3/4

‘That story resonates with me.’ Share your story with a community of Junior Doctors who are unable to identify you and are not affiliated to your employer. By realising you are not alone, you learn and also support others On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Inside it was so far from what I had been feeling. Maybe everyone had been feeling the same but no one was letting the cracks show.

Inside it was so far from what I had been feeling. Maybe everyone had been feeling the same but no one was letting the cracks show.

Has this story resonated with you?

Has this story resonated with you?

You are not alone

You are not alone

This story resonated with 32 others in the community

This story resonated with 32 others in the community

Your story might resonate with other members in the community Would you like to share it?

If the answer is yes, the app will tell you how many others in the community have also resonated

You have resonated with 5 other stories of experiencing anxiety and depression at work Have you considered discussing your feelings with someone at work?

Over the course of using the app, if a user continuously resonates with a certain theme, the app will prompt them

Figure 22. Storyboard for ‘Share Your Story’. Figure 3 of 4 75 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

Share Your Story By sharing my story, I give you permission to share yours On one of the days when I was feeling the lowest, if anyone asked

a question I would go red and get Share Your me Story

4/4

really flustered. I couldn’t get home

‘‘That story resonates with me.’ without stopping on the way Share home your story with a community ofOne Junior and crying. of my Doctors F1 colleagueswho are unable to identify and affiliated to turned toyou me and saidare ‘you not literally your employer.

Bylook realising you alone, always so happy, is thereare ever not a you learn and others dayalso wheresupport you aren’t happy?!’

Inside it was so far from what I had been feeling. Maybe everyone had been feeling the same but no one was letting the cracks show.

Has this story resonated with you?

DEPRESSION You are not alone This story resonated with 32 others in the community

You have resonated with 5 other stories of experiencing anxiety and depression at work

On one of the days when I was feeling the lowest, if anyone asked

“However hard it

me a question I would go red and is, always speak up.get

Have you considered discussing your feelings with someone at work?

really flustered.

I couldn’t get home Talk to everybody.

Ask them what without stopping on the way can homeyou can

do, soofthat a) colleagues you don’t feel and crying.

One my F1 scared and‘you b) literally you can sort turned to me and said the problems out.“

always look so happy, is there ever a day where you aren’t happy?!’

Senior O&G Consultant

Inside it was so far from what I had been feeling. Maybe everyone had

Not sure who to talk to in your Trust?

Can we direct you to someone?

(Don’t worry it’s confidential to access our directory)

been feeling the same but no one was letting the cracks show.

Have you thought about external support services?

The Practitioner Health Program?

Its confidential and they can offer immediate support May we share with you experiences of others in the community who have talked to someone?

Signposting to support services then appears.

The app acts as a directory to inform the user of support services available. This is confidential.

It does not share the fact that a user has accessed it with anyone

Supportive quotes from senior consultants are pushed at users throughout the experience. Junior Doctors valued words of encouragement and acceptance from senior colleagues, more than their peer group

Figure 23. Storyboard for ‘Share Your Story’. Figure 4 of 4 76

CONCEPT 03

The Work Emotion Diary “We are not allowed to reflect, as people were once able to reflect. So now I feel like people reflect in a very box ticky and inauthentic way. Just to get the required number of reflections up on their portfolios, so I don’t think that they are that honest.

And I think people are tired of doing it.”

Junior Doctor, 30

77

Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

The Work Emotion Diary Track your emotions and transform your work environment This app prompts you to answer the question, ‘How are you feeling Insight: 1, 3

Insight: 2,3,4,5,6

about going into work?’ every day, week or month, depending on Persona 1: Guy Psychiatry Trainee, 29

Persona 2: Jenny O&G Trainee, 31

how frequently you the user, open the app. This allows you to track Guy, a Junior Doctor whose

Jenny is a Junior Doctor from

to move to Basildon for a new

and bubbly, recently Jenny has

the prevalence rangeforced of your over a period of outgoing time. trainingand rotation himemotionsLondon.

Normally

This will provide youfar with a key metric which you can assess placement, removed from with become anxious and stressed

friends and family. When he due to back to back night shifts goes into work at this new the state of your mental health (Figure 24). and being involved in a patient hospital he doesn’t know incident at work anyone and feels isolated at Jenny is uneasy about speaking work and at home up to her colleagues as she The app will the data presented Guythen feelsaggregate lonely and and anonymize doesn’t want them to think she unsupported as he has no work can’t cope. She desperately

by Juniorfriends Doctors be really analysed towants develop to which confidecan in. He to bepotential reassured that wants to build a sense of team another Junior Doctor would with his new colleagues acted in provide the same way solutions spirit for the Trust to action.

Effectivelyhave the app will she did. She feels alone and Opportunity Area doesn’t know who to turn senior leaders with both the information and suggestions they needto

to

How might we create a working environment which improve Junior Doctor retention and fosters supportive relationships and camaraderie?

BenefitThe Virtual

Opportunity Area satisfaction.

How might we show them they are not alone in feeling this way and facilitate a private first step towards speaking up?

Doctors’ Mess Tracking the progression of mental health and well-being Share Your Story

Insight: 1,2,5,6

Persona 3: Melissa F1 placement in A&E, 25 Melissa is a Junior Doctor from Birmingham. Recently qualified and finding her job in a hospital can be overwhelming at times.

She feels her work negatively impacts her mental health but is unsure whether this is a normal feeling Melissa tries not to think about her mental well-being and to just push through. She does not want to be labelled as the only one that cannot cope Opportunity Area How might we encourage Junior Doctors to vocalise and track their well-being? And leverage the data set so it becomes a meaningful personal and transformative metric?

The Work Emotion Diary HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

to ascertain if you are in a pattern of behaviour

Motivation

DEPRESSION good evening,

RECENTLY RESONATED

Change your work environment and that of many others ANXIETY

ELATION

STORIES FROM OUR COMMUNIT Y

for the better

T H E PAT I E N T I CANT FORGET

dread

about going to work

share your stories and support others you are not alone

STRESS

Today I feel

LONELINESS

TAKING IT HOME

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

Today I feel

excited

about going to work

HOW YOU HAVE FELT ABOUT GOING TO WORK

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t On one of the days when I was happy?!’

Jan

Feb

Mar

feeling the lowest, if anyone asked

me a question I would go red and get really flustered. I couldn’t get home without stopping on the way home

Reward

and crying. One of my F1 colleagues SHARE YOUR STORY

it might be the key to helping someone else

turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

been feeling. Maybe everyone had

Inside it was so far from what I had been feeling. Maybe everyone had been feeling the same but no one was letting the cracks show.

effect change. Contribute to the transformation.

Has this story resonated with you?

Week

Month

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

Year 2020

been feeling the same but no one was letting the cracks show.

Has this story resonated with you?

Have your voice heard anonymously but used constructively to One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

HOW YOU HAVE FELT ABOUT GOING TO WORK

Inside it was so far from what I had

You are not alone

Jan

Feb

Mar

Today I feel

nervous

about going to work Apr

May

Jun

This story resonated with 32 others in the community

You have resonated with 5 other stories of experiencing anxiety and depression at work Have you considered discussing your feelings with someone at work?

You’ve been feeling less positive about going into work over the last few months

What could your employer do to improve your feelings about going to work? provide us with a doctors mess

Did anything change in April?

You are not alone This story resonated with 32 others in the community

Your story might resonate with other members in the community Would you like to share it?

Not sure who to talk to in your Trust?

Can we direct you to someone?

(Don’t worry it’s confidential to access our directory)

May we share this feedback anonymously with your employer?

If enough us speak up, together we can make a change.

Have you thought about external support services?

The Practitioner Health Program?

Its confidential and they can offer immediate support May we share with you experiences of others in the community who have talked to someone?

Figure 24. Melissa: Persona 3.

Concept Inspiration 78

The Work Emotion Diary Track your emotions and transform your work environment

The Work Emotion Diary

1/2

Record and confidentially tell your employer how they can help to improve your work experience.

Find ways to leverage the power of the data set generated by the Junior Doctor community to affect change

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

Today I feel Today I feel

dread

nervous

about going to work

about going to work

What could your employer do to improve your feelings about going to work? provide us with a doctors mess

May we share this feedback anonymously with your employer?

If enough us speak up, together we can make a change.

Users are asked about how they are feeling about going into work today. Negative, neutral and positive words act as a prompt in a drop down menu

If a user express a negative emotion about going into work, the app goes on to ask them how their employer could make their experience at work better

Figure 25. Storyboard for ‘The Work Emotion Diary’. Figure 1 of 2 79 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

The Work Emotion Diary Track your emotions and transform your work environment

The Work Emotion Diary

2/2

Record and confidentially tell your employer how they can help to improve your work experience.

Find ways to leverage the power of the data set generated by the Junior Doctor community to affect change

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

HOW YOU HAVE FELT ABOUT GOING TO WORK Week

Month

Year 2020

Today I feel

Jan

Feb

Mar

Apr

May

Jun

excited

about going to work

You’ve been feeling less positive about going into work over the last few months

HOW YOU HAVE FELT ABOUT GOING TO WORK

Jan

Feb

Did anything change in April?

Mar

Users feelings are recorded on their own private profile

An emotional diary is recorded and presented to the user. The data in the emotional diary is aggregated and given back to the user as a metric to understand how their feelings are evolving

Figure 26. Storyboard for ‘The Work Emotion Diary’. Figure 2 of 2 80

CHAPTER 6

User Testing & Feedback Analysis

Figure 5: Mapping the Research Process. Map of the Research Journey and Framework of Thesis 81 Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

82

User Testing The Aim To collect Quantitative and Qualitative data via Cultural Probes to gain insight on the validity of the concepts in reference to my research question.

Adjusting the Research Method: Covid–19 Simulating the User Journey – Storyboarding and Role Play To adjust to the remote research setting, I designed a test to simulate a face to face user test. I simulated the concepts and guided each participant through a role play exercise which put them in the position of the user. The three cultural probes used content and scenarios collected directly from Junior Doctors qualitative interviews, to further imbue a sense of reality into the probe and provoke meaningful feedback data. To prepare participants and get the most out of the user testing workshop, I sent them a PDF which simulated the three concepts and contextual research to prepare and set the agenda for the test workshop

Online testing mirrored the concepts more truthfully than face to face testing The online interactive provided a private space for Doctors to take part in the simulation with a lesser feeling of being observed by me the researcher. Doctors were more candid.

As I began the test by taking them through the storyboard of each concept, their screen filled up and they become immersed in the story telling of the concepts, without a sense of my physical presence. This degree of separation from my face and physical presence allowed them to suspend their disbelief and simulated the real life user experience of these interventions. Crucially, I think this made the test more robust as the value of these interventions is that they are a private and anonymous first step.

83

Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

Participant selection I included both senior and junior doctors as participants for user testing (Figure 27).

I wanted to include clinicians who were involved in managing and training Junior Doctors for their experience and perspective of the needs and attitudes of Junior Doctors.

Participant Level

Number that took part in User Testing Sessions

Junior Doctors (Foundation & Specialty Training)

5

Senior Doctors (Secondary & Primary Care Consultants)

2

Total

7

Figure 27. Table of User Testing Participants

84

Designing the Test Remote Participant Preparation & Test Criteria

85

Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

User Testing Pre-test Preparation for Participants I designed pre-test PDFs to set expectations and provide participants with the research context (Figure 28). This worked well to help guide participants and gain the most from the remote session. This formality, necessitated by a remote user test setting created a defined process, which ensured consistency across different user testing participants.

Evaluating the three concepts!

Testing Criteria After we have gone through each simulation I will ask you to rate each concept out of five in these criteria

Thank you for participating!!

This document is designed to let you know what to expect for our remote user testing session

Contents

What to expect on the call

1. Introduction & Background

Introductory Chat Remind you of the research question and scope of the research project

2. Testing Criteria 3. The Concepts

Begin the simulations I will guide you through each app.

User Feedback I will then ask you to rate each concept with the testing criteria provided Thank you!!

01

02

03

Concept Does the concept address a problem that Junior Doctors face?

Concept Does the concept address a problem that Junior Doctors face?

Concept Does the concept address a problem that Junior Doctors face?

Desirability Would you want to use this?

Desirability Would you want to use this?

Desirability Would you want to use this?

Viability Would this be a viable intervention for a Junior Doctor?

Viability Would this be a viable intervention for a Junior Doctor?

Viability Would this be a viable intervention for a Junior Doctor?

Impact Would this have an impact?

Impact Would this have an impact?

Impact Would this have an impact?

The Virtual Doctors’ Mess An online slack community to simulate a virtual Doctor’s Mess through a platform that is sensitive and responsive to your realities of working life as a Junior Doctor

The Virtual Doctors’ Mess

Background Research personas and hypothesis

Opportunity Area

Opportunity Area

Opportunity Area

How might we create a working environment which fosters supportive relationships and camaraderie?

How might we show them they are not alone in feeling this way and facilitate a private first step towards speaking up?

How might we encourage Junior Doctors to vocalise and track their well-being? And leverage the data set so that it becomes a meaningful personal and transformative metric?

Concept 02

Concept 02

Share Your Story

The Work Emotion Diary

‘That story resonates with me’. Share your stories with a community of Junior Doctors who are unable to identify you and are not affiliated to your employer. By realising you are not alone you learn and also support others

Record and confidentially tell your employer how to improve your work experience. Find ways to leverage the power of the data set generated by the Junior Doctor community to affect change

Concept 01 Insight: 1, 3

Persona 1: Guy

Insight: 2,3,4,5,6

Persona 2: Jenny

Insight: 1,2,5,6

The Virtual Doctors’ Mess

Persona 3: Melissa

An online Slack* community to simulate a virtual Doctor’s Mess through a platform that is sensitive and responsive to your realities of working life as a Junior Doctor

Psychiatry Trainee, 29

O&G Trainee, 31

F1 placement in A&E, 25

Guy, a Junior Doctor whose training rotation forced him to move to Basildon for a new placement, far removed from friends and family. When he goes into work at this new hospital he doesn’t know anyone and feels isolated at work and at home

Jenny, a Junior Doctor from London. Normally outgoing and bubbly, recently Jenny has become anxious and stressed due to back to back night shifts and being involved in a patient incident at work

Melissa, a Junior Doctor from Birmingham. Recently qualified and finding her job in a hospital can be overwhelming at times.

She feels her work negatively impacts her mental health but is unsure whether this is a normal feeling

Guy feels lonely and unsupported as he has no work friends to confide in. He really wants to build a sense of team spirit with his new colleagues

Hypothesis 01 Junior Doctors are increasingly isolated when they are forced to move job every six months.

Close relationships, support and rapport with seniors and peers are hard to cultivate This places them at a significant disadvantage for seeking help and advice

Jenny is uneasy about speaking up to her colleagues as she doesn’t want them to think she can’t cope. She desperately wants to be reassured that another Junior Doctor would have acted in the same way she did. She feels alone and doesn’t know who to turn to

Hypothesis 02 Junior Doctors often feel they are the only one not coping.

They are less likely to speak up, for fear of being labelled as weak or not resilient. Many do not know where to access help A private first step to vocalise their own feelings is crucial to building the confidence to start a conversation with someone else

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

DEPRESSION good evening, share your stories and support others you are not alone

Melissa tries not to think about her mental well-being and to just push through. She does not want to be labelled as the only one that cannot cope

Today I feel RECENTLY RESONATED

STRESS

ANXIETY

ELATION

STORIES FROM OUR COMMUNIT Y T H E PAT I E N T I CANT FORGET

LONELINESS

TAKING IT HOME

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

dread

about going to work

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Today I feel

excited

HOW YOU HAVE FELT ABOUT GOING TO WORK

without stopping on the way home

*Slack is an online messaging service. Its workspaces allow you to organize communications by channels for group discussions and allows for private messages to share information, files, and more all in one place

Hypothesis 03 Junior Doctors may have limited insight into their own mental health or well-being due to the fast paced, high stress environment they work in. Mental health and well-being ebbs and flows over time. It is hard to keep track of mental health over a period of time in this environment

Jan

and crying. One of my F1 colleagues SHARE YOUR STORY

it might be the key to helping someone else

turned to me and said ‘you literally

Feb

Mar

always look so happy, is there ever a day where you aren’t happy?!’

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Inside it was so far from what I had been feeling. Maybe everyone had been feeling the same but no one was letting the cracks show.

Has this story resonated with you?

Inside it was so far from what I had been feeling. Maybe everyone had

Your story might resonate with other members in the community Would you like to share it?

been feeling the same but no one was

Has this story resonated with you?

HOW YOU HAVE FELT ABOUT GOING TO WORK Week

Month

You have resonated with 5 other stories of experiencing anxiety and depression at work

Jan

Feb

Mar

Apr

May

Jun

Today I feel

nervous

about going to work

Have you considered discussing your feelings with someone at work?

You’ve been feeling less positive about going into work over the last few months Not sure who to talk to in your Trust?

Can we direct you to someone?

(Don’t worry it’s confidential to access our directory) Have you thought about external support services?

The Practitioner Health Program?

Its confidential and they can offer immediate support May we share with you experiences of others in the community who have talked to someone?

Share Your Story

Channels are chosen by the group of doctors to create a space which is meaningful and supportive to them

provide us with a doctors mess

May we share this feedback anonymously with your employer?

If enough us speak up, together we can make a change.

The Work Emotion Diary

1/4

2/2

Record and confidentially tell your employer how they can help to improve your work experience.

Find ways to leverage the power of the data set generated by the Junior Doctor community to affect change

The Work Emotion Diary

T H E PAT I E N T I C A N T FORGET

DEPRESSION

good evening, share your stories and support others you are not alone

Record and confidentially tell your employer how to improve your work experience. Leverage the power of the data set generated by the Junior Doctor community to affect change.

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

STRESS

ANXIETY

ELATION

STORIES FROM OUR COMMUNIT Y T H E PAT I E N T I CANT FORGET

LONELINESS

TAKING IT HOME

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was. Very, very poorly education and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but she wouldn’t be stopped. And she

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

03

Viability Would this be a viable intervention for a Junior Doctor?

SHARE YOUR STORY

it might be the key to helping someone else

Impact Would this have an impact?

Month

Year 2020

Jan

Feb

Mar

Apr

May

Jun

excited

about going to work

You’ve been feeling less positive about going into work over the last few months

Concept Does the concept address a problem that Junior Doctors face?

Desirability Would you want to use this?

HOW YOU HAVE FELT ABOUT GOING TO WORK Week

Today I feel

Desirability Would you want to use this?

Viability Would this be a viable intervention for a Junior Doctor?

Impact Would this have an impact?

What could your employer do to improve your feelings about going to work?

Did anything change

It is crucial to have an appreciation of when you are so down that you need to speak up

RECENTLY RESONATED

Concept Does the concept address a problem that Junior Doctors face?

Viability Would this be a viable intervention for a Junior Doctor?

in April?

Share Your Story

02

Desirability Would you want to use this?

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

Year 2020

You are not alone This story resonated with 32 others in the community

‘‘That story resonates with me.’ Share your story with a community of Junior Doctors who are unable to identify you and are not affiliated to your employer. By realising you are not alone, you learn and also support others

That story resonates with me. Share your story with a community of Junior Doctors.

Who are unable to identify you and are not affiliated to your employer. By realising you are not alone, you learn and also support others.

Concept Does the concept address a problem that Junior Doctors face?

letting the cracks show.

You are not alone This story resonated with 32 others in the community

01

about going to work

On one of the days when I was

feeling the lowest, if anyone asked

me a question I would go red and get really flustered. I couldn’t get home

This online slack community recreates the doctor’s mess. It provides a platform which is sensitive and responsive to the realities of a doctors working life

HOW YOU HAVE FELT ABOUT GOING TO WORK

Jan

Feb

Did anything change in April?

Mar

Impact Would this have an impact?

Choose a theme of stories. All of the stories have been identified by fellow Junior Doctors as impacting their mental health and well-being

Users can swipe through different stories, until one resonates with them

Figure 28. PDF given to Participants before the User Testing Session 86

Users feelings are recorded on their own private profile

An emotional diary is recorded and presented to the user. The data in the emotional diary is aggregated and given back to the user as a metric to understand how their feelings are evolving

User Testing The Test Collecting Quantitative and Qualitative Data Criteria I gave each participant the following criteria to judge each of the three concepts delivered through the cultural probe. The criteria were designed to provide a quantitative scale of effectiveness of each concept in relation to the research.

Each judging criteria was to be marked out of five, with five being excellent and one being poor.

1. Concept Does the concept address a problem that Junior Doctors face?

2. Desirability Would you want to use this?

3. Viability

5

4

3

2

Would this be a viable intervention for a Junior Doctor?

4. Impact Would this have an impact?

87

Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

1

User Feedback Analysis & Key Insights to take forward

88

User Feedback Analysis of Feedback I synthesised the feedback from my participants through the quantitative testing criteria and then aggregated the user testing data to come to a ‘User Testing Mark’ in Figure 29.

Each User Testing Criteria has been assigned a direct quote from a participant recorded during a test, to capture a prevalent participant feeling for a particular judging criteria.

Analysis Methodology I used a mixture of techniques to analyse my user feedback. First I adopted a technique often used in Grounded Theory to digest and absorb understandings; I listened to the user testing sessions multiple times. I then mapped the interactions of the main concepts that were raised, to visualise an appreciation of the understanding gained from the use of these cultural probes. The user testing criteria I designed, based on a Quantitative measurement scale of 1 to 5 measuring viability, desirability and impact of each concept is intended to temper the personal bias of the researcher in analysing the user feedback However, even with these quantitative pillars, the research synthesis could contain biases from the researcher.

Exploring Insight Interactions Interaction Analysis I have visualised the interaction insights gained through the testing of these concepts, social culturally and interpersonally (Grand, 2012). Figures 30, 31 & 32 employ the metaphor of an epicentre to map the central interactions. The outer rings represent interactions that threaten the emergence of the core aim of the concept.

This process was extremely useful in understanding the limitations and tensions within each of the concepts.

89

Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

The Virtual Doctors’ Mess

Share Your Story

The Work Emotion Diary HOW YOU HAVE FELT ABOUT GOING TO WORK Week

DEPRESSION

Month

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

Year 2020

good evening, share your stories and support others you are not alone

Jan

Feb

Mar

Apr

May

Jun

Today I feel

nervous

about going to work RECENTLY RESONATED

STRESS

ANXIETY

ELATION

STORIES FROM OUR COMMUNIT Y T H E PAT I E N T I CANT FORGET

LONELINESS

TAKING IT HOME

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

You’ve been feeling less positive about going into work over the last few months

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

What could your employer do to improve your feelings about going to work? provide us with a doctors mess

Did anything change in April?

May we share this feedback anonymously with your employer?

If enough us speak up, together we can make a change.

SHARE YOUR STORY

it might be the key to helping someone else

74% user testing mark ‘It would have a massive impact, even if it allowed one person to meet someone for a drink after work. So, even if that happened once it would have a huge impact and the whole of the team as well.’

Junior Doctor Concept ‘I don’t know if it is solving it.

But it is mitigating it. The solution is to not have them isolated.’

Senior Consultant Desirability

94% user testing mark

69% user testing mark

‘If you can guarantee anonymity then 5/5 for all of it. I think it’s a great idea. It just allows people to talk and get it off their chest.’

Junior Doctor

‘It does address a problem as Juniors say that people don’t understand what they are feeling.’’

Senior Consultant

Concept

Concept

‘I think it would be really useful.

When you are speaking to other Junior Doctors, if one person says ‘it’s shit’, you just feel so much better. Even though it’s not a direct solution, it makes you feel better. I think that bit is really good, letting people know.’

Junior Doctor

‘I think this will cause anxiety.

They will want to know how you are going to ensure confidentiality. I don’t think it is a solution really.’

Senior Consultant

Desirability

‘I think it would work for some and not for others if I am honest. I think it depends on your personality.’

Junior Doctor

‘I think it could help, but I wonder how different it is from WhatsApp? How much of a step up would it be?’

Junior Doctor

‘Seeing that 32 people have also liked it...it makes you feel a lot better.’

Junior Doctor

Viability

Viability

‘I expect they would like to use it, as they won’t want to be left out.

But there will be some that won’t bother, but most of them will.’

Senior Consultant

‘It is heavily reliant on people generating content, in a highly demanding environment. Some people might not think they are good writers... it could be podcasts or images and drawings.’

Junior Doctor

Impact ‘Slack also creates a gratification system, so are you really changing the WhatsApp concept? Both are on your phone and are messaging systems.’

Junior Doctor

Impact ‘What I think is really good for mental health, is being able to discuss a patient, or something that happened that was really difficult. Because, I’ve seen Junior Doctors desperate to tell those stories. And it’s completely eating them up inside.’

Junior Doctor

Figure 29. Overview of User Testing. Quotes and User Testing Marks 90

Desirability

Viability ‘I think it requires a lot from the person using it to come up with a reason, which they might not be able to.’

Junior Doctor Impact ‘If I was the person in charge of trying to get more Junior Doctors into post and I was facing this crisis, I would definitely support an online app and encourage everyone to make suggestions like a coffee bar to improve retention…I would do it.’

Senior Consultant

The Virtual Doctors’ Mess Generally participants liked this concept for its cheap and easy deployment. However doubts were cast over its potential impact, seeing it as an attempt to cover up an existing problem – isolation at work – rather than solve it (Figure 30). Further scepticism was expressed over the platforms suitability to replace WhatsApp. While many participants said the platform Slack, suited their workload more, many participants did not view Slack as a big enough step change to motivate a transition to this new platform. Out of all three concepts it was favoured the least, and though to have the less potential to be have a transformative affect on a Junior Doctor’s mental health and well-being. However, most of the participants reported it would have a positive impact at work, but not to a great extent when pertaining to the research question. (See Appendix A for full and extensive feedback).

The Virtual Doctors’ Mess

Share Your Story

The Work Emotion Diary HOW YOU HAVE FELT ABOUT GOING TO WORK Week

DEPRESSION

Month

M it i g a ti o n n o ts

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

Year 2020

good evening, share your stories and support others you are not alone

Jan

Feb

Mar

Apr

May

Jun

Today I feel

nervous

about going to work RECENTLY RESONATED

STRESS

ANXIETY

ELATION

STORIES FROM OUR COMMUNIT Y T H E PAT I E N T I CANT FORGET

LONELINESS

TAKING IT HOME

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

You’ve been feeling less positive about going into work over the last few months

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

What could your employer do to improve your feelings about going to work? provide us with a doctors mess

Did anything change in April?

May we share this feedback anonymously with your employer?

If enough us speak up, together we can make a change.

SHARE YOUR STORY

it might be the key to helping someone else

‘I think this will cause anxiety.

They will want to know how you are going to ensure confidentiality. I don’t think it is a solution really.’

Senior Consultant

Desirability

‘I think it would work for some and not for others if I am honest. I think it depends on your personality.’

Junior Doctor

‘I think it could help, but I wonder how different it is from WhatsApp? How much of a step up would it be?’

Junior Doctor

‘Seeing that 32 people have also liked it...it makes you feel a lot better.’

Junior Doctor

Viability

Viability

‘I expect they would like to use it, as they won’t want to be left out.

But there will be some that won’t bother, but most of them will.’

Senior Consultant

‘It is heavily reliant on people generating content, in a highly demanding environment. Some people might not think they are good writers... it could be podcasts or images and drawings.’

Junior Doctor

Impact ‘Slack also creates a gratification system, so are you really changing the WhatsApp concept? Both are on your phone and are messaging systems.’

Junior Doctor

Impact ‘What I think is really good for mental health, is being able to discuss a patient, or something that happened that was really difficult. Because, I’ve seen Junior Doctors desperate to tell those stories. And it’s completely eating them up inside.’

Junior Doctor

Desirability

tr

Creates community with minimal effort

rd

‘I think it would be really useful.

When you are speaking to other Junior Doctors, if one person says ‘it’s shit’, you just feel so much better. Even though it’s not a direct solution, it makes you feel better. I think that bit is really good, letting people know.’

Junior Doctor

S

wa

Concept

g gra d es

Desirability

Concept

t

he

‘I don’t know if it is solving it.

But it is mitigating it. The solution is to not have them isolated.’

Senior Consultant

c e rt ai n uits

on

nin

Concept

69% user testing mark ‘It does address a problem as Juniors say that people don’t understand what they are feeling.’’

Senior Consultant

ai

‘It would have a massive impact, even if it allowed one person to meet someone for a drink after work. So, even if that happened once it would have a huge impact and the whole of the team as well.’

Junior Doctor

94% user testing mark ‘If you can guarantee anonymity then 5/5 for all of it. I think it’s a great idea. It just allows people to talk and get it off their chest.’

Junior Doctor

tio

n

74% user testing mark

S t ill i s o l a t e d

olu

Viability ‘I think it requires a lot from the person using it to come up with a reason, which they might not be able to.’

Junior Doctor Impact ‘If I was the person in charge of trying to get more Junior Doctors into post and I was facing this crisis, I would definitely support an online app and encourage everyone to make suggestions like a coffee bar to improve retention…I would do it.’

Senior Consultant

Figure 30. Interaction Analysis: User Testing Feedback for ‘The Virtual Doctors’ Mess’ 91 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

The Work Emotion Diary Of the three culture probes under test, this concept exposed more diverse opinions across different generations of doctors and generated tensions amongst the Junior Doctor cohort.

These tensions were highlighted by using the probe and manifested in Junior Doctors expressing a lack of belonging to their NHS Trusts and expressing the culture in their workplaces of hostility or a fear of reprisals for speaking up. It revealed Juniors’ resentment for their senior leadership, as they felt that they did not care enough to ask or even listen concerns (Figure 31). Consequently, this concepts central aim, the leveraging of data generated by Junior Doctors, to improve their workplaces was seem as a great aim, but fundamentally pointless. Conversely the senior doctors participants favoured this concept, arguing if they had access to a data set, Junior Doctor concerns would not fall on deaf ears.

Furthermore, senior doctors interviewed expressed dismay that their Juniors accused them of not understanding, citing that they wanted to be told how they could practically help. (See Appendix A for full and extensive feedback).

Share Your Story

The Work Emotion Diary HOW YOU HAVE FELT ABOUT GOING TO WORK Week

DEPRESSION

Month

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

Year 2020

good evening, share your stories and support others you are not alone

Jan

Feb

Mar

Apr

May

Jun

Today I feel

nervous

about going to work RECENTLY RESONATED

STRESS

ANXIETY

ELATION

STORIES FROM OUR COMMUNIT Y T H E PAT I E N T I CANT FORGET

LONELINESS

TAKING IT HOME

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

You’ve been feeling less positive about going into work over the last few months

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

What could your employer do to improve your feelings about going to work?

U ser anonym

provide us with a doctors mess Did anything change in April?

May we share this feedback anonymously with your employer?

If enough us speak up, together we can make a change.

SHARE YOUR STORY

it might be the key to helping someone else

t is heavily reliant on people generating content, in a highly demanding environment. Some people might not think they are good writers... it could be podcasts or images and drawings.’ unior Doctor

mpact

What I think is really good for mental health, is being able to discuss a patient, or something hat happened that was really difficult. Because, I’ve seen unior Doctors desperate to tell hose stories. And it’s completely eating them up inside.’ unior Doctor

d

Viability

ntee

Seeing that 32 people have also liked it...it makes you feel a lot better.’ unior Doctor

Desirability

ara

‘I think it would work for some and not for others if I am honest. I think it depends on your personality.’

Junior Doctor

Actionable data for the trust to help retention rates

gu

Desirability

e

d ivisiv e nt -

‘I think this will cause anxiety.

They will want to know how you are going to ensure confidentiality. I don’t think it is a solution really.’

Senior Consultant

do

be

think it would be really useful.

When you are speaking to other unior Doctors, if one person says t’s shit’, you just feel so much better. Even though it’s not a direct solution, it makes you feel better. I think that bit is really good, letting people know.’ unior Doctor

Le

de

Concept

ep

t v alu e m e

Concept

a d e r s hi p

yd

st

en

‘It does address a problem as Juniors say that people don’t understand what they are feeling.’’

Senior Consultant

no

69% user testing mark

f you can guarantee anonymity hen 5/5 for all of it. I think it’s a great idea. It just allows people o talk and get it off their chest.’ unior Doctor

mu

s

94% user testing mark

P e r s o n a li t

it y

Viability ‘I think it requires a lot from the person using it to come up with a reason, which they might not be able to.’

Junior Doctor Impact ‘If I was the person in charge of trying to get more Junior Doctors into post and I was facing this crisis, I would definitely support an online app and encourage everyone to make suggestions like a coffee bar to improve retention…I would do it.’

Senior Consultant

Figure 31. Interaction Analysis: User Testing Feedback for ‘The Work Emotion Diary’ 92

Share Your Story The preferred concept By far this was the most preferred concept by participants. As a cultural probe it moved many participants and led them to share their own stories during the user testing sessions. All expressed a desire to use it personally and saw it as having a positive impact as it addressed the key missing interaction – to share their story – and normalise their feelings, which was cited as a major factor in improving mental health and well-being.

The main and often expressed concern was that it would need to guaranteed to be confidential (Figure 32). Junior and Senior doctors both emphasised this need to ensure content creation would take place, citing fear among Junior Doctors to speak up and reflect if their stories did not remain confidential. (See Appendix A for full and extensive feedback).

The Virtual Doctors’ Mess

Share Your Story

The Work Emotion Diary HOW YOU HAVE FELT ABOUT GOING TO WORK Week

DEPRESSION

Month

U ser anonym

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

Year 2020

good evening, share your stories and support others you are not alone

Jan

Feb

Mar

Apr

May

Jun

Today I feel

nervous

about going to work RECENTLY RESONATED

STRESS

ANXIETY

ELATION

STORIES FROM OUR COMMUNIT Y T H E PAT I E N T I CANT FORGET

LONELINESS

TAKING IT HOME

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

You’ve been feeling less positive about going into work over the last few months

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

What could your employer do to improve your feelings about going to work? provide us with a doctors mess

Did anything change

it y

in April?

re a t i o n

‘What I think is really good for mental health, is being able to discuss a patient, or something that happened that was really difficult. Because, I’ve seen Junior Doctors desperate to tell those stories. And it’s completely eating them up inside.’

Junior Doctor

tc

Impact

en

lack also creates a gratification ystem, so are you really hanging the WhatsApp oncept? Both are on your phone nd are messaging systems.’ unior Doctor

Impact

li re ily

‘If I was the person in charge of trying to get more Junior Doctors into post and I was facing this crisis, I would definitely support an online app and encourage everyone to make suggestions like a coffee bar to improve retention…I would do it.’

Senior Consultant

Figure 32. Interaction Analysis: User Testing Feedback for ‘Share Your Story’ 93 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

d

mpact

Viability ‘I think it requires a lot from the person using it to come up with a reason, which they might not be able to.’

Junior Doctor

ntee

‘It is heavily reliant on people generating content, in a highly demanding environment. Some people might not think they are good writers... it could be podcasts or images and drawings.’

Junior Doctor

ara

expect they would like to use it, s they won’t want to be left out. ut there will be some that won’t other, but most of them will.’ enior Consultant

gu

Viability

co

iability

s if y t y p e s of

‘I think it would work for some and not for others if I am honest. I think it depends on your personality.’

Junior Doctor

iv e r

Desirability ‘Seeing that 32 people have also liked it...it makes you feel a lot better.’

Junior Doctor

Desirability

Junior Doctors are desperate to tell these stories

ie s

‘I think this will cause anxiety.

They will want to know how you are going to ensure confidentiality. I don’t think it is a solution really.’

Senior Consultant

-d

think it could help, but I wonder how different it is from WhatsApp? How much of step up would it be?’ unior Doctor

‘I think it would be really useful.

When you are speaking to other Junior Doctors, if one person says ‘it’s shit’, you just feel so much better. Even though it’s not a direct solution, it makes you feel better. I think that bit is really good, letting people know.’

Junior Doctor

om ed

s to r

Desirability

Concept

ten

st

n

don’t know if it is solving it. ut it is mitigating it. The solution s to not have them isolated.’ enior Consultant

Concept

Ex

al

Concept

69% user testing mark ‘It does address a problem as Juniors say that people don’t understand what they are feeling.’’

Senior Consultant

c o n te nt g e n e n ra to tio n a dt ic

t would have a massive impact, ven if it allowed one person to meet someone for a drink after work. So, even if that happened nce it would have a huge impact nd the whole of the team as well.’ unior Doctor

94% user testing mark ‘If you can guarantee anonymity then 5/5 for all of it. I think it’s a great idea. It just allows people to talk and get it off their chest.’

Junior Doctor

mu

be

4% user testing mark

Heav

it might be the key to helping someone else

nt

May we share this feedback anonymously with your employer?

If enough us speak up, together we can make a change.

SHARE YOUR STORY

Key Insights from user testing Validations for ‘Share Your Story’ 1. Junior Doctors want to share their story.

Reading and sharing stories by their peer group was what one participant described as what her colleagues were ‘desperate’ to do’.

2. Social validation for feelings being ‘normal’ or ‘resonating’ with others was a powerful motivator to share more Throughout the testing, Junior Doctor participants were prompted to share their own stories after reading others on the simulated app.

Seeing how many others resonated with the story was described as helpful and cathartic

Key Insights to iterate ‘Share Your Story’ 1. Anonymity must be guaranteed How might we convey a sense of anonymity through the app user experience?

2. Sharing medical stories as well as mental health stories would address more aspects of mental health and well-being.

How might we include more diverse content for the user?

How mmight we include positive and sucess stories too?

3. Develop multiple ways to create content creation as writing might not suit everyone.

How might we include diverse content creation into the user experience?

4. Connecting to other Junior Doctors about shared stories of how their mental health is impacted at work was highly meaningfully How might we design in other community connections?

94

CHAPTER 7

Final Design: The Junior Doctor Circle

Figure 5: Mapping the Research Process. Map of the Research Journey and Framework of Thesis 95 Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

96

The Junior Doctor Circle The Why, The What & The How The Why Doctors have one of the highest suicide rates amongst professional groups. Paradoxically, they have some of the poorest access to mental health services. Many are left to suffer in silence (Figure 33). In 2018-2019 over 3,000,000 full time days were reported as lost to mental health related sick leave (Copeland, 2019). The real figure will be higher, yet stigma and shame conceal the true mental health toll. This costs the NHS millions and exacerbates pressures on the remaining workforce. Junior Doctors carry for the largest burden of mental heath issues (BMA, 2019; Gerada, 2018b) and suffer from high burnout rates and low retention rates. They make a significant contribution to the biggest crisis facing the NHS today – the mental well-being of its workforce.

“Medicine would be transformed if doctors were able to admit freely to vulnerabilities, fears and failings. Yet no one does, despite the terrible costs.

If even one of my peers had taken me aside and encouraged me to seek help, or even just let me know they were concerned and cared for me, I might have been able to halt the march of my depression before it became utterly devastating.�

Nancy, Junior Doctor “The final straw came when I worked 17 days in a row including five 25-hour shifts. [‌] Never had I experienced such darkness and hopelessness.

I found myself angry at the patients for being sick, and another night wishing that a sick patient would die so I could close my eyes for 10 minutes because I was so desperately tired. ‘I did not feel like myself on the inside anymore.�

Greta, Junior Doctor

Figure 33. The Junior Doctor Circle. The Why 97

Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

“Medicine would be transformed if doctors were able to admit freely to vulnerabilities, The How & The What fears and failings. Yet no one does, despite the terrible costs.

Harnessing the power of a digital community If even one of my peers had taken me aside and encouraged me to amongst seek help,the or even Junior Doctors are highly motivated and benevolent.

There is a desire just let me know they were concerned and cared for me, I might have these been existing able to halt cohort to help and support each other. This digital community harnesses the march of my depression before it became devastating.â€? forces by creating a platform that can connect utterly Junior Doctors in a meaningful way. SelfNancy, Junior Doctor generating content and peer to peer support ensures that The Junior Doctor Circle is “The final straw came when I worked 17 days unique amongst current mental health supportinservices for doctors. ensuring Junior a row including fiveBy 25-hour shifts. [‌] Never had I experienced such darkness and Doctors voices are the building blocks of the platform, the content and support it offers hopelessness.

I found myself angry at the patients for being is self- sustaining and can be simultaneously curated andanother tailorednight for and

by Junior sick, and wishing that a sick

patient would die so I could close my eyes for Doctors. By designing into the platform varying of user engagement, this platformtired.

10levels minutes because I was so desperately

‘I did not feel like myself on the inside anymore.� can be both a gateway to other support services or a haven to connect and begin much needed conversations (Figure 34).

Greta, Junior Doctor

 �

Â? Â? Â? Â?

Â?

DEPRESSION

by Clem, Junior Doctor, 29

The Specialty Today, this Traineehappened...

Circle

The Junior Doctor Circle

Stress

Has this story resonated with you?

a story of life on the wards

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

Depression

You are not alone

This story resonated with 32 others in the community

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Inspiration & Success

Why I love being a doctor

“Inside it was so far from what I had been feeling.�

May we show you coping strategies that others in the community are using who have resonnated with this story?

Anxiety

SUPPORT SERVICES EXTERNAL T H E PAT I E N T I C A N T FORGET

by Lesley, O&G Consultant, 63

Taking it home most Most resonated resonnated

T H E PAT I E N T I C A N T FORGET

T H E PAT I E N T I C A N T FORGET

by Lesley, O&G Consultant, 63

by Lesley, O&G Consultant, 63

“I can still see her face... and it’s thirty years ago.� a story of remembering and questioning

ou become an F1 and like shit hits the fan�

56

a story of feeling out of control

“Its been thirty years and I can still see her face� a story of remembering and questioning

ot he rs re sonnat e d

INTERNAL

T HE BR I T I S H M E DI CA L ASS OCIATION

WEB SITE LINK

The BMA wellbeing services are available to all doctors and their spouses and chilldren, 24/7 and free of charge P E E R S U P P O R T / CO U NS E L L I NG / P SYCHO T HE R AP Y / G M C I NVE ST I GAT I O N S U P P O R T /

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

“Actually no, this has gone a bit too far, I need to speak to someone about this.� a story of developing clinical ability to acknowledge my mental health

“I didn’t want to let my guard down.

I guess for anyone to know that I felt I wasn’t competent at my job.� a story of bottling it up

32

ot he rs re sonnat e d

28

ot he rs re sonnat e d

you go throughout your entire you know, from like secondary school, you’re the best in your class and you always get A’s in your GCSEs. You study, you get your A levels you study, get your A’s and get into university, you go through medical school, you pass every exam, you’ve done really well. You’re on sports teams, you’re just doing you know, you are acing life. You

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

A D VI C E F O R YO U R S L E F O R A CO L L EAGUE

T HE P R AC T I C I ON E R HE A LT H PROGRAMME

Practitioner Health is a free, confidential NHS service for doctors and dentists across England with mental illness and addiction problems, who are working or looking to return to clinical practice.

The service can help with issues relating to a mental health concern, including stress or depression or an addiction problem.

CO U NS E L L I NG / P SYC H O T H E R A P Y / AD D I CT I O N T R E AT ME NT/ CBT / I ND I VI DA U L I S E D C L I NI C I A N L E D CAS E MANAGE E NT / GR O UP S UP P O R T

“It’s incredibly distressing and when things go wrong you do take it very personally.� a story of remembering and questioning

ACA DE MY OF M E DI CA L R OYAL COLLEGES

19

ot he rs re sonnat e d

The Junior Doctor Circle is an app for Junior Doctors to share their stories with a community of other Junior Doctors. No one using the app can be identified and the app is not affiliated in any way to your employer By realising you are not alone you learn and support others

Figure 34. The Junior Doctor Circle. The How and The What 98

Positive & Inspirational Stories + Struggles with Mental Health The app will also include positive stories about the life of a Junior Doctor. It is important for doctors to share and resonate with stories that express the parts of their working lives that make them happy and proud to be doctors. At its heart, this is a fun and affirming space for doctors.

Language and Tone of Voice The tone of advice has been designed to allow users feel safe so they can express vulnerability without feeling judged. The language used has been taken from my research with Junior Doctors.

UX Co-design I organised a final UX co-design session with Victor Hwang, Lead Product Designer at Farewill (Figure 35). Victor’s design experience at Farewill has an interesting parallel with this research project and The Junior Doctor Circle app. Farewill is a company redesigning the death industry by bringing transparency and design into an intensely emotional and private industry. Our Co-design workshop focused on designing for sensitivity in arenas that are intensely personal.

To cater for this sensitivity we discussed the need for multiple levels of user engagement to reflect and cater to the specific needs of this subject area.

Figure 35. Co-design Workshop with Victor Hwang. Lead Product Designer at Farewill 99 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

The Junior Doctor Circle How it works: Features & User Walk Through

100

The Junior Doctor Circle How it works Designing in Levels of Engagement Designing for multiple user needs and levels of engagement is crucial to the concept of The Junior Doctor Circle. One of the ways this has been designed into the user experience is through having two viewing lenses to engage with the platform (Figure 36).

Deep Dive into User Features Figures 37–45 The next several pages take a closer look into the user features of The Junior Doctor Circle.

Depression

Today, this happened...

T H E PAT I E N T I C A N T FORGET

T H E PAT I E N T I C A N T FORGET

T H E PAT I E N T I C A N T FORGET

by Lesley, O&G Consultant, 63

by Lesley, O&G Consultant, 63

by Lesley, O&G Consultant, 63

ou become an F1 and like shit hits the fan” a story of feeling out of control

Why I love being a doctor

Stress

Inspiration & Success

Anxiety

you go throughout your entire you know, from like secondary school, you’re the best in your class and you always get A’s in your GCSEs. You study, you get your A levels you study, get your A’s and get into university, you go through medical school, you pass every exam, you’ve done really well. You’re on sports teams, you’re just doing you know, you are acing life. You

Today, this happened...

“Its been thirty years and I can still see her face” a story of remembering and questioning

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Depression

Stress Inspiration & Success

Why I love being a doctor

Anxiety

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

Taking it home most resonated Most resonnated “I can still see her face... and it’s thirty years ago.” a story of remembering and questioning

56

o the rs re so n n a te d

“Actually no, this has gone a bit too far, I need to speak to someone about this.” a story of developing clinical ability to acknowledge my mental health

“I didn’t want to let my guard down.

I guess for anyone to know that I felt I wasn’t competent at my job.” a story of bottling it up

“It’s incredibly distressing and when things go wrong you do take it very personally.” a story of remembering and questioning

32

o the rs re so n n a te d

28

o the rs re so n n a te d

19

o the rs re so n n a te d

User Lens 01 Individual Lens

User Lens 02 Popularity and Resonance Lens

Content is presented thematically on an equal hierarchy. Most suited for viewers who might want to browse stories by a particular theme

Content is presented thematically and organised by its popularity or ʻresonanceʼ in the community. This informational hierarchy expresses the wider communityʼs presence

Figure 36. The Junior Doctor Circle: Levels of user engagement: Two User ‘Lenses’ 101 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

The Junior Doctor Circle Deep Dive into User Features

The Junior Doctor Circle

1/9

The Junior Doctor Circle is an app for Junior Doctors to share their stories with a community of other Junior Doctors. No one using the app can be identified and the app is not affiliated in any way to your employer. By realising you are

not alone you learn and also support others

The Junior Doctor Circle

The Specialty Trainee Circle

Welcome to the Junior Doctor Circle a safe, confidential group to support you and your colleagues’ mental health and wellbeing.

Share your experiences and coping trategies, learn that you are not alone and be discreetly signposted to more support if you need it.

email

Join the circle

Once you graduate as a Junior Doctor you will be welcomed to join The Junior Doctor Circle.

A community of fellow Junior Doctors to share your stories with

Privacy and discretion are at the heart of The Junior Doctor Circle. To ensure our members can share, reect and support each other without fear of judgement or recrimination. As a new member is welcomed to the Circle this is explained to them

Figure 37. The Junior Doctor Circle: Storyboard of User Features, 1 of 9 102

The Junior Doctor Circle Deep Dive into User Features

The Junior Doctor Circle

2/9

User Lens 01.

Individual Lens

Depression

T H E PAT I E N T I C A N T FORGET

T H E PAT I E N T I C A N T FORGET

by Lesley, O&G Consultant, 63

by Lesley, O&G Consultant, 63

Today, this ou become an F1 and happened... like shit hits the fan” a story of feeling out of control

Why I love being a doctor

Stress

you go throughout your entire you know, from like secondary school, you’re the best in your Inspiration class and you always get A’s in & Success your GCSEs. You study, you get your A levels you study, get your A’s and get into university, you go through medical school, you pass every exam, you’ve done really well. You’re on sports teams, you’re just doing you know, you are acing life. You Anxiety

“Its been thirty years and I can still see her face” a story of remembering and questioning

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

Browse and read stories from others in the community through themes devised by Junior Doctors Success and positive stories about the life of a Junior Doctor are also key. Doctors can resonate with why they fell in love with their job

Figure 38. The Junior Doctor Circle: Storyboard of User Features, 2 of 9 103 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

The Junior Doctor Circle Deep Dive into User Features

The Junior Doctor Circle

3/9

User Lens 02 Popularity and Resonance Lens

T H E PAT I E N T I C A N T FORGET

Taking it home most Most resonated resonnated

by Lesley, O&G Consultant, 63

Today, this happened...

Depression

Why I love being a doctor

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

Stress She really was.

Inspiration Very, very poorly educated and & Success extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

Anxiety

“I can still see her face... and it’s thirty years ago.” a story of remembering and questioning

“Actually no, this has gone a bit too far, I need to speak to someone about this.” a story of developing clinical ability to acknowledge my mental health

“I didn’t want to let my guard down.

I guess for anyone to know that I felt I wasn’t competent at my job.” a story of bottling it up

“It’s incredibly distressing and when things go wrong you do take it very personally.” a story of remembering and questioning

In User Lens 2 browse and read stories from others in the community through themes devised by Junior Doctors by popularity and resonance

56

o t he rs re s o n n a t e d

32

o t he rs re s o n n a t e d

28

o t he rs re s o n n a t e d

19

o t he rs re s o n n a t e d

See stories sorted by popularity and resonance in the community

Figure 39. The Junior Doctor Circle: Storyboard of User Features, 3 of 9 104

The Junior Doctor Circle Deep Dive into User Features

The Junior Doctor Circle

DEPRESSION

by Clem, Junior Doctor, 29

4/9

T H E PAT I E N T I C A N T FORGET

by Lesley, O&G Consultant, 63

“Inside it was so far from what I had been feeling.”

“I can still see her face... and it’s thirty years ago.”

a story of life on the wards

a story of remembering and questioning

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

Read real front line stories by other Junior Doctors and resonate with them

Figure 40. The Junior Doctor Circle: Storyboard of User Features, 4 of 9 105 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

The Junior Doctor Circle Deep Dive into User Features

The Junior Doctor Circle

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Has this story resonated with you?

You are not alone

This story resonated with 32 others in the community

May we show you coping strategies that others in the community are using who have resonnated with this story?

The app tracks if you are resonating with multiple stories from the same theme and gently nudges the user

Figure 41. The Junior Doctor Circle: Storyboard of User Features, 5 of 9 106

5/9

The Junior Doctor Circle Deep Dive into User Features

The Junior Doctor Circle

The story I resonated with “Inside it was so far from what I had been feeling.� a story of feeling depressed on the wards

6/9

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“I felt like, ‘oh god, how have I got myself into this situation.

I don’t know enough to do this job at all.� a story of feeling overwhlemed

“I think I probably did underplay it a little bit.

I don’t want to make it seem like I am complaining.

I don’t want to seem like I am not coping.�

sarahj21

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View and suggest coping strategies to others in the community

Figure 42. The Junior Doctor Circle: Storyboard of User Features, 6 of 9 107 Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

Your honesty might just be the key to helping someone else

The Junior Doctor Circle Deep Dive into User Features

The Junior Doctor Circle

7/9

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LISTEN TO THIS...

“However hard it is, always speak up.

Talk to everybody.

Ask them what you can do, so that a) you don’t feel scared and b) you can sort the problems out.“ Senior O&G Consultant

You are not alone

You have resonated with 5 other stories of experiencing anxiety and depression at work over the last 3 months

Have you considered discussing your feelings with someone at work?

“Come and see us.

We can help you to get out of the mess that you think you are in. Because there is nothing worse than feeling that you are alone."

Clare Gerada, GP & Head of The Practicioner Health Programme

MAY WE...

Discreetly Signpost you to Support Services Show you some coping strategies the community have developed No, thank you. I’ll keep reading

Gentle nudges and words of encouragement from senior clinicians are designed to prompt the user to access support if they continuously resonate with a theme

Figure 43. The Junior Doctor Circle: Storyboard of User Features, 7 of 9 108

The Junior Doctor Circle Deep Dive into User Features

The Junior Doctor Circle

8/9

SUPPORT SERVICES EXTERNAL

INTERNAL

THE BRI TI S H M E D ICA L ASS O CIAT IO N

WE BS IT E L I N K

The BMA wellbeing services are available to all doctors and their spouses and chilldren, 24/7 and free of charge PEER S UPPORT / COU N SE LLI N G / P SYC H OTH E R A P Y / G MC INVESTI GATI ON SU P P OR T /

Brief description of the service as many Junior Doctors do not know what services are on offer

A DVICE FOR YOU R SLE F OR A COLLE AGU E

THE PRACTICIO N E R HE ALT H P R O G R A M M E

Practitioner Health is a free, confidential NHS service for doctors and dentists across England with mental illness and addiction problems, who are working or looking to return to clinical practice.

The service can help with issues relating to a mental health concern, including stress or depression or an addiction problem.

Breakdown support by different service offers

Quick links to engaging with the service to encourage user conversion rate

COUNS ELLING / P SYC H OTH E R A P Y / A D D I C TI ON TR E ATM E N T/ CBT / INDIVIDA ULIS E D C LI N I C I A N LE D CASE M A N AGE E N T / GR OU P SU P P O RT

ACAD EMY OF M E D ICA L R OYAL CO L L E G E S

Get signposted to support services and gain access to a comprehensive list of all support services available to Doctors

Figure 44. The Junior Doctor Circle: Storyboard of User Features, 8 of 9 109 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

The Junior Doctor Circle Deep Dive into User Features

The Junior Doctor Circle

9/9

good evening jenny, share your stories and support others YOU ARE NOT ALONE

SHARE YOUR STORY Please consider sharing your own story with the community

STORIES YOU ARE RESONATING WITH

Your honesty might just be the key to helping someone else

2020

WRITE YOUR STORY

JAN

FEB

MAR

APR

M AY

SPEAK YOUR STORY MARCH

Taking it home

Depression

Stress

In the Users Private area, Track the stories you are resonating with over time and identify patterns

DRAW YOUR STORY

Share your stories in different ways. Multiple content generation methods to cater for all users

Figure 45. The Junior Doctor Circle: Storyboard of User Features, 9 of 9 110

The Junior Doctor Circle Three User Journeys

Insight: 1, 3

Persona 1: Guy

Psychiatry Trainee,

Guy, a Junior Docto training rotation for to move to Basildon placement, far remo friends and family. W goes into work at th hospital he doesn’t anyone and feels iso work and at home

Guy feels lonely and unsupported as he friends to confide in wants to build a sen spirit with his new c

Hypothesis 01

Junior Doctors are in isolated when they a to move job every six Close relationships, and rapport with sen peers are hard to cult

This places them at a disadvantage for seek and advice

Insight: 1, 3

Insight: 2,3,4,5,6

Persona 1: Guy

Persona 2: Jenn

Guy, a Junior Doctor whose training rotation forced him to move to Basildon for a new placement, far removed from friends and family. When he goes into work at this new hospital he doesn’t know anyone and feels isolated at work and at home

Jenny, a Junior Doct London. Normally ou and bubbly, recently become anxious and due to back to back and being involved in incident at work

Psychiatry Trainee, 29

Guy feels lonely and unsupported as he has no work friends to confide in. He really wants to build a sense of team spirit with his new colleagues

Hypothesis 01 Junior Doctors are increasingly isolated when they are forced to move job every six months.

Close relationships, support and rapport with seniors and peers are hard to cultivate This places them at a significant disadvantage for seeking help and advice

111 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

O&G Trainee, 31

Jenny is uneasy abou up to her colleagues doesn’t want them to can’t cope. She desp wants to be reassure another Junior Docto have acted in the sam she did. She feels alo doesn’t know who to

Hypothesis 02

Junior Doctors often fe are the only one not c They are less likely to s for fear of being labe weak or not resilient. M not know where to acc

A private first step to v their own feelings is cr building the confidenc conversation with som

The Junior Doctor Circle Overview of Multiple User Journeys Designing for three personas Using the original three Junior Doctor personas I created out of the my user research, I have designed three distinct user journeys through the Junior Doctor.

Figure 46 shows an overview of all the user Journeys before we delve more deeply into each journey.

1.

Guy’s User Journey 2 Level of User Engagement Browse & Read Stories Track Mental Well-being Reference Support Database Contribute a story

Insight: 1, 3

Insight: 2,3,4,5,6

Insight: 1,2,5,6

Persona 1: Guy

Persona 2: Jenny

Persona 3: Melissa

Guy, a Junior Doctor whose training rotation forced him to move to Basildon for a new placement, far removed from friends and family. When he goes into work at this new hospital he doesn’t know anyone and feels isolated at work and at home

Jenny, a Junior Doctor Junior Doctor Circle from London. Normally outgoing and bubbly, recently Jenny has become anxious and stressed due to backdocguy@gmail.com to back night shifts email and being involved in a patient incident at work

Psychiatry Trainee, 29

O&G Trainee, 31

Guy feels lonely and unsupported as he has no work friends to confide in. He really wants to build a sense of team spirit with his new colleagues

Hypothesis 01 Junior Doctors are increasingly isolated when they are forced to move job every six months.

Close relationships, support and rapport with seniors and peers are hard to cultivate This places them at a significant disadvantage for seeking help and advice

a safe, confidential group to support you and your colleagues’ mental health and wellbeing.

Share your experiences and coping trategies, learn that you are not alone and be discreetly signposted to more support if you need it.

Join the circle

Jenny is uneasy about speaking up to her colleagues as she doesn’t want them to think she can’t cope. She desperately wants to be reassured that another Junior Doctor would have acted in the same way she did. She feels alone and doesn’t know who to turn to

Hypothesis 02

2.

Junior Doctors often feel they are the only one not coping.

They are less likely to speak up, for fear of being labelled as weak or not resilient. Many do not know where to access help

Persona 2: Jenny

Persona 3: Melissa

or whose rced him n for a new oved from When he his new know olated at

Jenny, a Junior Doctor from London. Normally outgoing and bubbly, recently Jenny has become anxious and stressed due to back to back night shifts and being involved in a patient incident at work

Melissa, a Junior Doctor from Birmingham.

Recently qualified Welcome to the Junior Doctor Circle and finding her job in a hospital can be overwhelming at times.

She feels her work negatively impacts her mental health jenben@gmail.com email whether this is a but is unsure normal feeling

a significant king help

O&G Trainee, 31

Jenny is uneasy about speaking up to her colleagues as she doesn’t want them to think she can’t cope. She desperately wants to be reassured that another Junior Doctor would have acted in the same way she did. She feels alone and doesn’t know who to turn to

Hypothesis 02 Junior Doctors often feel they are the only one not coping.

They are less likely to speak up, for fear of being labelled as weak or not resilient. Many do not know where to access help A private first step to vocalise their own feelings is crucial to building the confidence to start a conversation with someone else

INTERNAL

WEBSITE L INK

The BMA wellbeing services are available to all doctors and their spouses and chilldren, 24/7 and free of charge

2020

a story of remembering and questioning

56

othe rs re sonnate d

P E E R S U P P ORT / COU NS E LLING / P SYC H OT H E RA P Y / GM C INVE ST IGAT ION S U P P ORT /

“Actually no, this has gone a bit too far, I need to speak to someone about this.� a story of developing clinical ability to acknowledge my mental health

“I didn’t want to let my guard down.

I guess for anyone to know that I felt I wasn’t competent at my job.� a story of bottling it up

32

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

28

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

othe rs re sonnate d

othe rs re sonnate d

WRITE YOUR STORY

THE P R AC TIC IONER HEALTH P R OG R AMME

JAN

a story of remembering and questioning

FEB

MAR

APR

M AY

Practitioner Health is a free, confidential NHS service for doctors and dentists across England with mental illness and addiction problems, who are working or looking to return to clinical practice.

The service can help with issues relating to a mental health concern, including stress or depression or an addiction problem.

SPEAK YOUR STORY MARCH

DRAW YOUR STORY “It’s incredibly distressing and when things go wrong you do take it very personally.�

A DVIC E F OR YOU RS LE F OR A COLLE AGU E

Taking it home

Depression

Stress

COU NS E LLING / P SYC H OT H E RA P Y / A DDIC T ION T RE AT M E NT/ C BT / INDIVIDA U LIS E D C LINIC IA N LE D CAS E M A NAGE E NT / GROU P S U P P ORT

ACADEMY OF MEDICAL R OYAL COL L EG ES

19

othe rs re sonnate d

Hypothesis 03 Junior Doctors may have limited insight into their own mental health or well-being due to the fast paced, high stress environment they work in. Mental health and well-being ebbs and flows over time. It is hard to keep track of mental health over a period of time in this environment

3 It is crucial to have an appreciation of when you are so down that you need to speak up

F1 placement in A&E, 25 DEPRESSION

by Clem, Junior Doctor, 29

Today, this happened...

a safe, confidential group to support you and your colleagues’ mental health and wellbeing.

Share your experiences and coping trategies, learn that you are not alone and be discreetly signposted to more support if you need it.

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a story of life on the wards

Has this story resonated with you?

Has this story resonated with you?

Has this story resonated with you?

SUPPORT SERVICES EXTERNAL

The story I resonated with

INTERNAL

“Inside it was so far from what I had been feeling.�

THE BR ITISH MEDICAL ASSOC IATION

WEBSITE L INK

a story of feeling depressed on the wards

The BMA wellbeing services are available to all doctors and their spouses and chilldren, 24/7 and free of charge P E E R S U P P ORT / COU NS E LLING / P SYC H OT H E RA P Y / GM C INVE ST IGAT ION S U P P ORT /

Stress

You are not alone

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Inspiration & Success

Why I love being a doctor

A DVIC E F OR YOU RS LE F OR A COLLE AGU E

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

Depression

Join the circle

Melissa tries not to think about her mental well-being and to just push through. She does not want to be labelled as the only one that cannot cope

Anxiety

You are not alone

This story resonated with 32 others in the community

This story resonated with 32 others in the community

May we show you coping strategies that others in the community are using who have resonnated with this story?

May we show you coping strategies that others in the community are using who have resonnated with this story?

You are not alone

THE P R AC TIC IONER HEALTH P R OG R AMME

Have you considered discussing your feelings with someone at work?

Practitioner Health is a free, confidential NHS service for doctors and dentists across England with mental illness and addiction problems, who are working or looking to return to clinical practice.

The service can help with issues relating to a mental health concern, including stress or depression or an addiction problem.

a story of feeling overwhlemed

INDIVIDA U LIS E D C LINIC IA N LE D CAS E M A NAGE E NT / GROU P S U P P ORT

“I think I probably did underplay it a little bit.

I don’t want to make it seem like I am complaining.

I don’t want to seem like I am not coping.� a story of feeling overwhlemed

Hypothesis 03 Junior Doctors may have limited insight into their own mental health or well-being due to the fast paced, high stress environment they work in. Mental health and well-being ebbs and flows over time. It is hard to keep track of mental health over a period of time in this environment

3.

Melissa’s User Journey

It is crucial to have an appreciation of when you are so down that you need to speak up

Melissa tries not to think about her mental well-being and to just push through. She does not want to be labelled as the only one that cannot cope

LISTEN TO THIS...

Welcome to the Junior Doctor Circle

Depression

a safe, confidential group to support you and your colleagues’ mental health and wellbeing.

Share your experiences and coping trategies, learn that you are not alone and be discreetly signposted to more support if you need it.

melissahm@gmail.com email

Today, this happened...

T H E PAT I E N T I C A N T FORGET

T H E PAT I E N T I C A N T FORGET

by Lesley, O&G Consultant, 63

by Lesley, O&G Consultant, 63

ou become an F1 and like shit hits the fan� a story of feeling out of control

Why I love being a doctor

Inspiration & Success

Join the circle Stress

Anxiety

you go throughout your entire you know, from like secondary school, you’re the best in your class and you always get A’s in your GCSEs. You study, you get your A levels you study, get your A’s and get into university, you go through medical school, you pass every exam, you’ve done really well. You’re on sports teams, you’re just doing you know, you are acing life. You

“Its been thirty years and I can still see her face� a story of remembering and questioning

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

good evening jenny,

“However hard it is, always speak up.

Talk to everybody.

Ask them what you can do, so that a) you don’t feel scared and b) you can sort the problems out.“ Senior O&G Consultant

“Come and see us.

We can help you to get out of the mess that you think you are in. Because there is nothing worse than feeling that you are alone."

share your stories and support others YOU ARE NOT ALONE STORIES YOU ARE RESONATING WITH

2020

Clare Gerada, GP & Head of The Practicioner Health Programme JAN

FEB

MAR

APR

M AY

MARCH MAY WE...

Discreetly Signpost you to Support Services Show you some coping strategies the community have developed

Taking it home

Depression

Stress

No, thank you. I’ll keep reading

Hypothesis 03 Junior Doctors may have limited insight into their own mental health or well-being due to the fast paced, high stress environment they work in. Mental health and well-being ebbs and flows over time. It is hard to keep track of mental health over a period of time in this environment

Figure 46. The Junior Doctor Circle: Overview of Three User Journeys, derived from Personas 112

It is crucial to have an appreciation of when you are so down that you need to speak up

The story I resonated with

Coping Strategies from the community

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“I felt like, ‘oh god, how have I got myself into this situation.

I don’t know enough to do this job at all.�

Insight: 1,2,5,6

Melissa, a Junior Doctor from Birmingham. Recently qualified and finding her job in a hospital can be overwhelming at times.

She feels her work negatively impacts her mental health but is unsure whether this is a normal feeling

clarebear

Other community members coping strategies

sarahj21

mike121

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COU NS E LLING / P SYC H OT H E RA P Y / A DDIC T ION T RE AT M E NT/ C BT /

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F1 placement in A&E, 25

Coping Strategies from the community

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You have resonated with 5 other stories of experiencing anxiety and depression at work over the last 3 months

Browse & Read Stories Track Mental Well-being

Persona 3: Melissa

vocalise rucial to ce to start a meone else

a story of remembering and questioning

THE BR ITISH MEDICAL ASSOC IATION

STORIES YOU ARE RESONATING WITH

Your honesty might just be the key to helping someone else

1

tor from utgoing y Jenny has d stressed night shifts n a patient

eel they coping. speak up, elled as Many do cess help

Anxiety about to think her mental well-being and to just push through. She does not want to be labelled as the only one that cannot cope

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Level of User Engagement

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ut speaking s as she o think she perately ed that or would me way one and o turn to

stop her coming because I knew I was leaving for London, but

EXTERNAL

good evening jenny, SHARE YOUR STORY

by Lesley, O&G Consultant, 63

“I can still see her face... and it’s thirty years ago.�

Browse & Read Stories Track Mental Well-being Reference Support Database Contribute Stories Contribute Coping Strategies Self Refer to Support Services via app

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creasingly are forced x months. support niors and tivate

Inspiration & Success

Why I love being a Melissa tries doctornot

T H E PAT I E N T I C A N T FORGET

Taking it home most Most resonated resonnated

Level of User Engagement

Insight: 1,2,5,6

d has no work n. He really nse of team colleagues

T H E PAT I E N T I C A N T FORGET

Melissa, a Junior Doctor from Today,qualifi this ed Birmingham. Recently and finding herhappened... job in a hospital I had these two patients can be overwhelming at times. who had followed me from Depression Cambridge, where I had been a She feels her work negatively senior registrar and one was a trapeze artist and she was the impacts her mental health most extraordinary character.

Stress She really was. but is unsure whether this is a Very, very poorly educated and extremely bright. She came to normal feeling me in Cambridge and I tried to

Jenny’s User Journey

A private first step to vocalise their own feelings is crucial to building the confidence to start a conversation with someone else

Insight: 2,3,4,5,6

, 29

SUPPORT SERVICES

F1 placement in A&E, 25

by Lesley, O&G Consultant, 63

Welcome to the

Please consider sharing your own story with the community

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Your honesty might just be the key to helping someone else

The Junior Doctor Circle Melissa’s User Journeys Melissa - Level 1 user engagement Melissa (Figure 47) represents a user who engages with a couple of the platform’s features. Melissa predominantly uses the platform to track her own mental health and well-being at work. Viewing content through the ‘individual’ lens to build a picture of how she is coping at work. Melissa might not yet feel comfortable sharing her own story with the community, but she likes to browse and read stories and words of encouragement from senior clinicians. Melissa is building up her vocabulary to talk about her mental health and well-being. The platform for Melissa allows her to take a moment and privately reflect on her feelings towards work.

1 Level of User Engagement Browse & Read Stories Track Mental Well-being

5,6

Insight: 1,2,5,6

Jenny

Persona 3: Melissa

31

F1 placement in A&E, 25

Doctor from ally outgoing ently Jenny has s and stressed back night shifts ved in a patient k

about speaking gues as she em to think she desperately ssured that Doctor would he same way els alone and ho to turn to

02

ften feel they e not coping. ly to speak up, labelled as ient. Many do o access help

p to vocalise s is crucial to fidence to start a h someone else

Melissa, a Junior Doctor from Birmingham. Recently qualified and finding her job in a hospital can be overwhelming at times.

She feels her work negatively impacts her mental health but is unsure whether this is a normal feeling

Welcome to the Junior Doctor Circle

Today, this happened...

Depression

a safe, confidential group to support you and your colleagues’ mental health and wellbeing.

Share your experiences and coping trategies, learn that you are not alone and be discreetly signposted to more support if you need it.

T H E PAT I E N T I C A N T FORGET

T H E PAT I E N T I C A N T FORGET

by Lesley, O&G Consultant, 63

by Lesley, O&G Consultant, 63

ou become an F1 and like shit hits the fan” a story of feeling out of control

melissahm@gmail.com email

Why I love being a doctor

Inspiration & Success

Stress

Anxiety

Join the circle

you go throughout your entire you know, from like secondary school, you’re the best in your class and you always get A’s in your GCSEs. You study, you get your A levels you study, get your A’s and get into university, you go through medical school, you pass every exam, you’ve done really well. You’re on sports teams, you’re just doing you know, you are acing life. You

Melissa tries not to think about her mental well-being and to just push through. She does not want to be labelled as the only one that cannot cope LISTEN TO THIS...

Hypothesis 03 Junior Doctors may have limited insight into their own mental health or well-being due to the fast paced, high stress environment they work in. Mental health and well-being ebbs and flows over time. It is hard to keep track of mental health over a period of time in this environment

good evening jenny,

“However hard it is, always speak up.

Talk to everybody.

Ask them what you can do, so that a) you don’t feel scared and b) you can sort the problems out.“ Senior O&G Consultant

“Come and see us.

We can help you to get out of the mess that you think you are in. Because there is nothing worse than feeling that you are alone."

share your stories and support others YOU ARE NOT ALONE STORIES YOU ARE RESONATING WITH

2020

Clare Gerada, GP & Head of The Practicioner Health Programme JAN

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Discreetly Signpost you to Support Services Show you some coping strategies the community have developed

Taking it home

Depression

Stress

No, thank you. I’ll keep reading

It is crucial to have an appreciation of when you are so down that you need to speak up

Figure 47. The Junior Doctor Circle: Melissa’s User Journey 113 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

“Its been thirty years and I can still see her face” a story of remembering and questioning

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

The Junior Doctor Circle Guy’s User Journeys Guy - Level 2 user engagement Guy (Figure 48) represents a user who engages with many of the platform’s features.

Guy predominantly uses the platform to feel connected to other Juniors, browsing and viewing content through the ‘resonance’ lens to build a virtual support network. Guy has a very good relationship with his clinical supervisor and feels his mental well-being is positively supported at work. Consequently he likes to use the platform to track his wellbeing and connect with other Junior Doctors. By sharing and reading stories about his own and other specialities he realises he is not alone.

2 Level of User Engagement Browse & Read Stories Track Mental Well-being Reference Support Database Contribute a story

Insight: 1, 3

Insight: 2,3,4,5,6

Insight: 1,2,5,6

Persona 1: Guy

Welcome to the PersonaJunior 2: Jenny Doctor Circle

Persona 3: Melissa

Psychiatry Trainee, 29 Guy, a Junior Doctor whose training rotation forced him to move to Basildon for a new placement, far removed from friends and family. When he goes into work at this new hospital he doesn’t know anyone and feels isolated at work and at home Guy feels lonely and unsupported as he has no work friends to confide in. He really wants to build a sense of team spirit with his new colleagues

O&G Trainee, 31

a safe, confidential group to support you and your colleagues’ mental health and wellbeing.

Share your experiences and coping trategies, learn that you are not alone and be discreetly signposted to more support if you need it.

Jenny, a Junior Doctor from email London. Normally outgoing and bubbly, recently Jenny has Join the circle become anxious and stressed due to back to back night shifts and being involved in a patient incident at work docguy@gmail.com

Jenny is uneasy about speaking up to her colleagues as she doesn’t want them to think she can’t cope. She desperately wants to be reassured that another Junior Doctor would have acted in the same way she did. She feels alone and doesn’t know who to turn to SHARE YOUR STORY

Please consider sharing your own story with the community

Hypothesis 01

Your honesty might just be the key to helping someone else

This places them at a significant disadvantage for seeking help and advice

by Lesley, O&G Consultant, 63

Today, this F1 placement in A&E, 25 happened...

Hypothesis 02

SPEAK YOUR STORY

DRAW YOUR STORY

A private first step to vocalise their own feelings is crucial to building the confidence to start a conversation with someone else

a story of developing clinical ability to acknowledge my mental health

a story of bottling it up

32

28

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

o t he rs re s o n n a t e d

“It’s incredibly distressing and when things go wrong you do take it very personally.”

19

a story of remembering and questioning

o t he rs re s o n n a t e d

SUPPORT SERVICES EXTERNAL

Hypothesis 03

a story of remembering and questioning

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

o t he rs re s o n n a t e d

“I didn’t want to let my guard down.

I guess for anyone to know that I felt I wasn’t competent at my job.”

Melissa tries not to think about her mental well-being and to just push through. She does not want to be labelled as the only one that cannot cope

INTERNAL

T H E B R I T I S H M E D I CAL ASS O C I AT I O N

W E B S I T E LI NK

STORIES YOU ARE RESONATING WITH

Junior Doctors may have limited insight into their own mental health or well-being due to the fast paced, high stress environment they work in. Mental health and well-being ebbs and flows over time. It is hard to keep track of mental health over a period of time in this environment JAN

Junior Doctors often feel they are the only one not coping.

They are less likely to speak up, for fear of being labelled as weak or not resilient. Many do not know where to access help

“Actually no, this has gone a bit too far, I need to speak to someone about this.”

Anxiety

share your stories and support others YOU ARE NOT ALONE

56

o t he rs re s o n n a t e d

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

good evening jenny,

“I can still see her face... and it’s thirty years ago.”

a story of remembering and questioning

Melissa, a Junior Doctor from Depression Birmingham. Recently qualified and finding her job in a hospital can be overwhelming at times.

Why I love She feels being a her work negatively doctor her mental health impacts but is unsure whether this is a normal feeling Inspiration & Success

by Lesley, O&G Consultant, 63

“I can still see her face... and it’s thirty years ago.”

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Stress

T H E PAT I E N T I C A N T FORGET

Taking it home

most resonated Most resonnated

2020

WRITE YOUR STORY

Junior Doctors are increasingly isolated when they are forced to move job every six months.

Close relationships, support and rapport with seniors and peers are hard to cultivate

T H E PAT I E N T I C A N T FORGET

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Depression

P E E R SU P P ORT / COU N SE LLI N G / P SYC HOTHE RAP Y / GMC I N VE STI GATI ON SU P P ORT / ADVI C E FOR YOU RSLE F OR A COLLE AGU E

T H E PR AC T I C I O NE R H E ALT H PR O GR AM M E

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Taking it home

The BMA wellbeing services are available to all doctors and their spouses and chilldren, 24/7 and free of charge

Stress

Practitioner Health is a free, confidential NHS service for doctors and dentists across England with mental illness and addiction problems, who are working or looking to return to clinical practice.

The service can help with issues relating to a mental health concern, including stress or depression or an addiction problem.

COU N SE LLI N G / P SYC HOTHE RAP Y / ADDI C TI ON TRE ATME N T/ C BT / I N DI VI DAU LI SE D C LI N I C I AN LE D CASE MAN AGE E N T / GROU P SU P P ORT

ACAD E MY OF M E D I CAL R OYAL CO LLE GE S

It is crucial to have an appreciation of when you are so down that you need to speak up

Figure 48. The Junior Doctor Circle: Guy’s User Journey 114

The Junior Doctor Circle Jenny’s User Journeys Jenny - Level 3 of user engagement Jenny (Figure 49) represents a user who wants to engage with all of the platforms features. Jenny feels she is the only one not coping and does not have a support network at work. She feels she does not yet have the vocabulary to voice her feelings about her mental health, but when she resonates with a story, she enjoys seeing that many others have resonated with the same story.

She builds her confidence and engages with the coping strategies forum to see how others have tried to manage. Jenny did not know of mental health support services on offer for doctors nationally or within her trust, so she references the support services. Jenny continues to read stories in the community and reflect on her own mental well-being by tracking stories she resonates with. After some time Jenny realises that her mental health has not been good for a while and she reads some words of encouragement from senior clinicians on the app urging her to speak up. Jenny decides to consult the support services directory and then takes the brave step to self refer to an appropriate service.

115 Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

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3 Level of User Engagement Browse & Read Stories Track Mental Well-being Reference Support Database Contribute Stories Contribute Coping Strategies Self Refer to Support Services via app

Insight: 2,3,4,5,6

Insight: 1,2,5,6

Persona 2: Jenny

Persona 3: Melissa

Jenny, a Junior Doctor from London. Normally outgoing and bubbly, recently Jenny has become anxious and stressed due to back to back night shifts and being involved in a patient incident at work

Melissa, a Junior Welcome to theDoctor from Junior Doctor Circle Birmingham. Recently qualified and finding her job in a hospital can be overwhelming at times.

She feels her email work negatively impacts her mental health but is unsure whether this is a Join the circle normal feeling

O&G Trainee, 31

F1 placement in A&E, 25 DEPRESSION

by Clem, Junior Doctor, 29

Jenny is uneasy about speaking up to her colleagues as she doesn’t want them to think she can’t cope. She desperately wants to be reassured that another Junior Doctor would have acted in the same way she did. She feels alone and doesn’t know who to turn to

Hypothesis 02 Junior Doctors often feel they are the only one not coping.

They are less likely to speak up, for fear of being labelled as weak or not resilient. Many do not know where to access help A private first step to vocalise their own feelings is crucial to building the confidence to start a conversation with someone else

Today, this happened...

a safe, confidential group to support you and your colleagues’ mental health and wellbeing.

Share your experiences and coping trategies, learn that you are not alone and be discreetly signposted to more support if you need it.

jenben@gmail.com

Melissa tries not to think about her mental well-being and to just push through. She does not want to be labelled as the only one that cannot cope

“Inside it was so far from what I had been feeling.� a story of life on the wards

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

Depression

Stress

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Inspiration & Success

Why I love being a doctor

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Hypothesis 03 Junior Doctors may have limited insight into their own mental health or well-being due to the fast paced, high stress environment they work in. Mental health and well-being ebbs and flows over time. It is hard to keep track of mental health over a period of time in this environment Has this story resonated with you?

It is crucial to have an appreciation of when you are so down that you need to speak up

SUPPORT SERVICES EXTERNAL

Has this story resonated with you?

You are not alone

WEBSITE LINK

a story of feeling depressed on the wards

The BMA wellbeing services are available to all doctors and their spouses and chilldren, 24/7 and free of charge PEER SUPPORT / COUNSELLI NG / PSYCHOTHERAPY / GMC I NVESTI GATI ON SUPPORT / ADVI CE FOR YOURSLEF OR A COLLEAGUE

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THE PRAC TIC IONER HEALTH PROGRAMME

Practitioner Health is a free, confidential NHS service for doctors and dentists across England with mental illness and addiction problems, who are working or looking to return to clinical practice.

The service can help with issues relating to a mental health concern, including stress or depression or an addiction problem.

Have you considered discussing your feelings with someone at work?

May we show you coping strategies that others in the community are using who have resonnated with this story?

“Inside it was so far from what I had been feeling.�

THE BRITISH MEDICAL ASSOC IATION

You are not alone

You have resonated with 5 other stories of experiencing anxiety and depression at work over the last 3 months

This story resonated with 32 others in the community

The story I resonated with

INTERNAL

Has this story resonated with you?

Other community members coping strategies

May we show you some other community strategies?

“I felt like, ‘oh god, how have I got myself into this situation.

I don’t know enough to do this job at all.� a story of feeling overwhlemed

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ACADEMY OF MEDICAL ROYAL COLLEGES

“I think I probably did underplay it a little bit.

I don’t want to make it seem like I am complaining.

I don’t want to seem like I am not coping.� a story of feeling overwhlemed

Figure 49. The Junior Doctor Circle: Jenny’s User Journey

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Please consider sharing your own story with the community

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Your honesty might just be the key to helping someone else

Adverts for Junior Doctors

The Junior Doctor Circle Building the Circle: Advertising & The Business Model

Figure 50. The Junior Doctor Circle: Adverts for Junior Doctors (Left) and NHS Hospital Trusts (Right)

117 Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

The Junior Doctor Circle How to build the Circle Advertising Strategy - Users and Customers To build the Circle we need Junior Doctors and NHS Hospital Trusts to join the Circle.

Both have distinct needs and benefits, two advertising strategies reflect this (Figure 50).

Junior Doctors will be recruited online via social media. NHS Trusts will be recruited by prioritising buy in from senior doctors in the Royal Medical Colleges and NHS Hospital

Adverts for NHS Hospital Trusts

Trusts.

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The Junior Doctor Circle Building the Circle - A Visual Culture Using the visual language of the Circle (Figure 51) to create a celebratory visual culture.

Junior Doctors should be proud to be a member of the Circle. The visual dissemination of the brand is key to activating Junior Doctors as change-makers for removing the stigma surrounding mental health and well-being. Wearing ‘a badge’ that denotes you as a member of the Circle, Junior Doctors can create a culture and widen discussion for others in the NHS, such as Nurses and Midwives.

thejuniordoctorcircle Imperial College

220 likes thejuniordoctorcircle Join the Circle.

The Junior Doctor Circle is available on the App and Google Store. You are not alone...more

Figure 51. The Junior Doctor Circle: Examples of Branding around a Hospital

Users and Customers The Junior Doctor Circle has two audiences – the customer and the user. Both have distinct needs and benefits. The customer is the NHS Hospital Trust who would procure a licence for their Junior Doctors to access the service and the users are the Junior Doctors.

119 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

The Business Model Figure 52 outlines the potential revenue stream for The Junior Doctor Circle.

The pitch to an NHS Trust would be that The Junior Doctor Circle is part of the Hospital Trust’s mental health support package for Junior Doctors. In 2017 to 2018 The NHS spent £5.5 billion on temporary staff (The Health Foundation, 2018).The Junior Doctor Circle would ask for a small percentage of the savings the NHS Trust gained through using the platform, to pay for the licence fee. (Please refer to Appendix B for further details).

Benefits & Success Metrics

NHS Hospital Trusts (Customer)

Junior Doctors (Users)

Decrease Junior Doctor Burnout Increase Retention Rates

Learn and access support services available to you

Decrease days lost to sick leave

Increase Job Satisfaction

Get actionable and anonymous data about the satisfaction rate of your Junior Doctors

Meaningfully connect with other Junior Doctors

Empower and equip Junior Doctors

Reduce social isolation and realise you are not alone

Save £££ millions on locum doctor and agency fees

Gain insight by tracking your mental health and well-being over time Build confidence and a vocabulary to begin a conversation

Revenue Stream

Licence Fee

FREE

Percentage of savings incurred by the Trust (subject to a cost benefit analysis)

Part of their mental health and well-being package offered by their NHS Hospital Trust

Figure 52. The Junior Doctor Circle: User and Customer Benefits & Revenue Stream

Pilot Scheme and Cost Benefit Analysis To begin with an initial pilot scheme would be launched with one NHS Hospital Trust with a BETA version or soft launch of the app. After six months, a cost benefit analysis report would be commissioned alongside user feedback to gain actionable and persuadable 120

data about the validity of The Junior Doctor Circle in improving the lives of Junior Doctors and saving the NHS Trust money in retaining and reducing burnout.

121 Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

The Junior Doctor Circle Future Circles: Other User Segments & the Gifting Community

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The Junior Doctor Circle Future Circles Complementary Circles Life-course Holistic Approach The intention would be to roll out The Junior Doctor Circle to Medical students and Speciality Trainees after Junior Doctors (Figure 53). This would ensure that support for their .mental health and well-being would continue throughout their early clinical career. The NHS has set out its intention to become a disease prevention service, rather than a disease intervention service (NHS, 2017). Mental health support for Doctors must mirror this. We must provide them with continuous support in order to prevent them developing poor mental health. The more experience you get the more likely you are to have developed individual coping strategies or fallen through the cracks. Providing Medical students at the start of their clinical training with the tools and platform to develop coping strategies, learn and share is crucial to empowering them.

The Medic Circle

The Junior Doctor Circle

The Specialty The Specialty Trainee CircleTrainee Circle

Figure 53. Future Circles: Future Applications for Medical Students and Specialty Trainees 123 Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

Graduate to your next Circle As you progress to a new stage in your clinical training you would be invited to join the next ‘Circle’ (Figure 54). The platform can adjust to offer support that is tailored to your new role and training stage. As you enter your new Circle you can feel pride and a sense of community as your virtual community progresses with you.

Cross-generational Gifting and Sharing Crucially you have gifted your stories and experiences for the next generation of the Circle to benefit from. Those who come after you can gain from your experiences and you can gain in your new Circle from the clinicians that have come before you. This cross generational dissemination of stories allows for a meaningful knowledge exchange and might open up dialogues between different clinical generations, building understanding and support horizontally and vertically across clinicians. Extending the reach of an intervention has been highlighted throughout this research process as one of the most meaningful factors to support mental health and well being at work.

The Junior Doctor Circle

The Specialty Trainee Circle

Congratulations Jenny !

Figure 54. Graduating to the next Circle 124

The Specialty Trainee Circle

Welcome to the Circle Jenny

CHAPTER 8

Conclusion & Reflections

Figure 5: Mapping the Research Process. Map of the Research Journey and Framework of Thesis 125 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

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The Research Aim The aim of this research has been to design a tool for Junior Doctors to track and identify patterns in their mental health and be signposted to support services.

By creating a digital community Junior Doctors can share their story with others, to authentically reflect, learn they are not alone and support others. The Junior Doctor Circle addresses issues my research identified such as social isolation at work, a lack of knowledge of the support available to you and a perceived stigma of being the first to speak up were key triggers and I set out to design methods of mitigating them through leveraging the power of a peer to peer community.

Key Insights from the Research 1. Disclosing privately and safely with professional peers motivated Junior Doctors to seek support more than talking to friends and family. Resonating with people who ‘really understood’ or ‘had been there’ facilitated opening up as it was less burdensome to the recipient. The knowledge that another member of the community could relate to the same e disclosure provided these doctors with an emotionally safe space in which to be vulnerable.

2. A private, online platform gave Juniors the space to take a first step to track and understand their mental health and well-being without fear of judgement.

3. Junior Doctors described not having the words to express their feelings to peers, supervisors or family and friends. The Junior Doctor Circle potentially provides them with the safe space and vocabulary that are needed to develop the confidence to star a real time conversation about their concerns.

127 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

Junior Doctors want to share their story and described doing so as having a directly positive affect on their mental health Asking for, or acknowledging you need help can be the hardest words for a Junior Doctor. Up to now the call to ‘just be more resilient’ has hindered Juniors from seeking help as they felt unworthy of it, they ‘should just be better’.

Seeing how many others had identified with a story on The Junior Doctor Circle encouraged and empowered the Juniors I tested the hypothesis with. The social validation specifically from their professional peer group made them feel seen and created a temporary safe space to acknowledge and explore their mental health at work.

A peer to peer community is essential for support and the nature of the Junior Doctor profession can ensure it flourish Clemmie, a Junior Doctor who I have had the fortune to work with throughout this research process exemplifies this insight. Clemmie’s story inspired The Junior Doctor Circle and has formed much of the content that has populated the app. A few years ago Clemmie reached a breaking point and accessed help.

Clemmie has now become an advocate in her hospital for speaking up about mental health. She writes letters to colleagues if she is worried about them, she shares her experience openly and begins conversations. In all she does, she communicates that mental health issues are nothing to be ashamed of and that others have been there too. It takes a professional peer group, which you respect to motivate and quieten fears. Not all Junior Doctors will have the luck of having a colleague like Clemmie, but we can leverage technology to build a community of Junior Doctors to ensure that the power of what Clemmie does can be accessed by many.

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Designing in Compassion for Themselves and Others ‘If someone came to me, I would say, ‘I completely understand, it is really hard, you should not feel bad about this,’ I would never think that they are a failure, that they have let anybody down. But for me, that is different. It wouldn’t be the same for me.’

Junior Doctor, 28

Throughout this research I have been struck by the benevolence and motivation of Junior Doctors. They have shared their stories to help others and in turn have been helped. Many times in interviews they said they would always want to help a colleague and never judge them but that they judged themselves for needing help.

The power of a Junior Doctor community lets doctors extend their compassion through storytelling to other juniors in the circle and potentially while reflect back on to the, when they realise that they are not alone in feeling that way.

Junior are Scared to have these Conversations – They Fear they will be Blamed We need to create a space to facilitate them This research revealed a startling culture of fear. Fear to reflect honestly, in professionally mandated reflections was often reported, in case they inadvertently admitted something they might be blamed for. Many cited the Bawa Garba case as the lightening rod of this culture. Dr Bawa Garba, a Junior Doctor, was wrongly convicted of gross negligence manslaughter in 2015. This case lives on in the minds of Junior Doctors today as in court the prosecution used Garba’s private reflective notes to convict her of manslaughter. Her conviction was later overturned and her reflective notes ruled inadmissible in court, yet many feel that Garba was scapegoated rather than attribute the tragedy to the systemic failings of the health system. This case has resulted in a fear of authentic reflections which has huge implications for Junior Doctors training, learning and attitudes towards their own mental health and well-being. To change this culture we need to create a space for doctors

129 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

to be able to reflect without fear of blame. Many Juniors reported a lack of physical spaces to have these conversations at work. Anecdotes of having to disclose to a sensitive issue clinical supervisor in a busy hospital corridor in between clinics was not uncommon.

Senior Doctors - We Need You! Medicine is a hierarchical game - for good reason. Chains of command are crucial in managing acute situations. WHO Safety check-lists borrow the aviation industry’s codified hierarchy structures to ensure patient safety. Hierarchy is embedded into the workforce and the work flow of a hospital. The nature of training embeds this respect and deference for senior colleagues. Many Juniors described feeling dismissed as “moaning millennials” by their senior colleagues, who were convinced that their own, older generation “had it harder”. Senior doctors can play a vital role in supporting their Juniors simply by speaking up about the importance of mental health. A senior colleague sharing their experience was cited many times as a key indicator for seeking and addressing the need for help.

Furthermore, Senior Doctors I spoke to, reported sharing their experience as being one of the most rewarding and tangibly successful in helping colleagues who were struggling.

Medicine is taught by transferring knowledge and facilitating experiences. Just as senior doctors teach and transfer their knowledge their knowledge of physical illnesses, they also need to ensure that they disseminate their personal experiences of mental health.

An Urgent Call for Change We must ensure Junior Doctors are able to continue working, but without causing further detriment to their own health. This is especially pertinent when we look at the changing demographic of the profession. Currently, there are more women trainees than men and the data demonstrate that female doctors are at four times greater risk of suicide compared to men Tackling this issue is crucial to the future of the NHS. Covid-19 has inadvertently highlighted the need for more support for doctors, further research will be crucial to understanding the impact on the profession.

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Recommendations for Change 1. Abolish Resilience Training and Remove the Culture of Blame Resilience training cannot and should not be the answer to the NHS’s mental health crisis as it directly perpetuates the cycle of blame, shame and secrecy surrounding a doctors mental health. It is an avoidance strategy not a coping strategy. It shifts the blame on to the shoulders of the Junior Doctor and so it becomes another burden for them. It is hard work being a Junior Doctor. Many factors weave together to create the highs and lows of their working lives. Underplaying the fact that sometimes the strain can be too much and they feel unable to cope, leading many Junior Doctors to feel unworthy. This in turn leads to further mental distress and in some cases tragedy, when one of them falls through the net or slips through the cracks in a system that is not actively supporting them

2. Focus on Prevention and Monitoring – Not Intervention Junior Doctors need to be able to access continuous support tools during their training.

These should include ongoing mental health support, to acknowledge, track and signpost Junior Doctors to support services before they present with serious mental health issues.

We need to offer pre-emptive support to doctors before they develop burnout or are forced to take sick leave. Tools such as The Junior Doctor Circle can help by intervening before it is too late. Such tools provide a vocabulary for Junior Doctors to begin difficult conversations and encourages them to disclose b before they race breaking point. More must be done to educated doctors on what services are available. The Junior Doctors in this research, who had sought support had been forced to go on lonely, lengthy journeys to try and discover where to access help. One doctor said she has never been told about the mental health and well-being services at her Trust, but had received instructions about the hospitals fire code on five separate occasions.

131 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

3. Prepare Doctors at Medical School A must have in Future Curricula Many Junior doctors described arriving at their first post and feeling overwhelmed and unprepared. They expressed the wish that their curriculum should include teaching about the messy realities’ of being a doctor and the importance of a clinicians mental health.

Recent graduates coming back to medical schools and sharing genuine reflections about their first experiences working as a Junior Doctor could greatly help newly qualified Juniors cope with the nature and place their experiences in a manageable perspective.

4. More Research for Holistic and Embedded Support The current data is alarming and not nuanced enough Invaluable research has been done by The Practitioner Health Programme into the determinants of mental ill health amongst doctors. However, little research exists into how best to support doctors before they present with serious pathology. Only recently studies are being conducted to look at why doctors are leaving or even recording how many are. Crucial research conducted by the British Medical Association specifically address Junior Doctors and mental health (BMA, 2019). However, if 80% of all doctors are at risk of burnout, this casts doubt over the very survival of the NHS. Much of the current research into mental health are surveys gathering anecdotal insights into how Junior Doctors are feeling or how many self report to have bad mental health. We need more substantial research into why and how many Junior Doctors present with mental health issues. Why are so many leaving the profession and how can they be supported before they present with serious mental health issues? The last NHS Five Year Forward Plan sets out high quality mental health care for all as its goal, but barely acknowledges its own staff’s mental health and well-being of its own staff. The NHS is the biggest employer in Europe, we cannot afford to get this wrong and ignore the high attrition rates of Junior Doctors, we must demand national research and embed its findings into goals of our National Health Service.

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Reflections Process & Future Research

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“Medicine is best practiced rather like looking at a moving picture. And we don’t do that.

We now look at a series of stills.

We have now got a whole generation of doctors delivering treatment without ever having seen the whole thing through.

They only time they see the consequences of their decisions are when they have gone very wrong.”

Medical Litigation Lawyer

Figure 55. Practicing Medicine as a Series of Still Images: The Training Model as described by a Medical Lawyer

Future Research The Impact of the Junior Doctor Training Model The above insight (Figure 55) was contributed by a medical lawyer, who represents doctors in litigation claims. I wish to investigate the affect of the new training model on Junior Doctors further, as it could not be addressed adequately within this thesis’ scope.

The metaphor of moving stills is particularly pertinent when we think about the mental health of Junior Doctors. They need to understand the healthcare story from beginning to end to place in perspective their work, by only seeing the negative consequences of an intervention, this adds to the blame culture discussed earlier and skews their learning by disrupting clinical confidence.

134 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

The rest of the NHS workforce Junior Doctors are only a small percentage of the wider NHS workforce. More research is urgently needed to support other healthcare professionals in clinical roles. The scope of this research could not include other clinicians, such as nurses and midwives who need and deserve more research into supporting their mental health and well-being.

They are undertaking jobs with unique challenges and emotional burdens.

More research needed after Covid -19 New research questions to arise This research is especially pertinent at a time when the NHS workforce is being placed under immense strain during the Covid-19 pandemic. The extra pressure on the health service will mean that all risk factors that lead to negative mental health and well-being will be more prevalent now than before. The impact on the workforce could be the beginning of a step change in how the medical profession acknowledges, tracks and deals with mental health among its employees. More research is essential to track the progression of mental health and well-being among Junior Doctors and all NHS staff after the full impact of Covid-19 has been realised.

135 Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

Future Research Questions Culture • How might we address Junior Doctor fears?

Medical Education • How can we meaningfully prepare Medical Students for their first Junior Doctor position?

• How might we introduce a consistent and national mental health and well-being medical school curriculum?

Clinical Training • How might we ensure that all Junior Doctors receive the same mental health and wellbeing support across the UK?

• How might we account for differences in medical specialty when designing mental health support for Junior Doctors?

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List of Figures Figure 1: Executive Summary

Figure 2: Table of Useful Terminology

Figure 3: Definition of a Junior Doctor. Source:‘Journey through medical training’, (BDI Resourcing, 2016) Figure 4: Overview of my Research Process. The Research Journey is Mapped in Four Stages – Highlighting Key Methods, Themes & Insights which led to the Design Solution Figure 5: Mapping the Research Process. Map of the Research Journey and Framework of Thesis Figure 6: My Reflective Research Journal

Figure 7: Table of Qualitative Interview Participants

Figure 8: My Reflective Research Journal. Interview Analysis Figure 9: Interview Analysis on Miro – A Virtual Whiteboard

Figure 10: Insight Themes from Semi-Structured Interviews Figure 11. Key Insights from Semi-Structured Interviews Figure 12. Three Junior Doctor Personas Figure 13. Three Hypotheses

Figure 14. Three Opportunity Areas. Three Design Briefs Figure 15. Three Concepts. The Three Cultural Probes

Figure 16. Three Co-design Workshops. Documentation Through Drawing.

Figure 17. Guy: Persona 1. Concept Inspiration

Figure 18. Storyboard of ‘The Virtual Doctors’ Mess’ Figure 19. Jenny: Persona 2. Concept Inspiration

Figure 20. Storyboard for ‘Share Your Story’. Figure 1 of 4 Figure 21. Storyboard for ‘Share Your Story’. Figure 2 of 4 Figure 22. Storyboard for ‘Share Your Story’. Figure 3 of 4 Figure 23. Storyboard for ‘Share Your Story’. Figure 4 of 4 Figure 24. Melissa: Persona 3. Concept Inspiration

Figure 25. Storyboard for ‘The Work Emotion Diary’. Figure 1 of 2 Figure 26. Storyboard for ‘The Work Emotion Diary’. Figure 2 of 2 Figure 27. Table of User Testing Participants

Figure 28. PDF given to Participants before the User Testing Session Figure 29. Overview of User Testing. Quotes and User Testing Marks

Figure 30. Interaction Analysis: User Testing Feedback for ‘The Virtual Doctors’ Mess’ Figure 31. Interaction Analysis: User Testing Feedback for ‘The Work Emotion Diary’ Figure 32. Interaction Analysis: User Testing Feedback for ‘Share Your Story’ Figure 33. The Junior Doctor Circle. The Why

Figure 34. The Junior Doctor Circle. The How and The What

Figure 35. Co-design Workshop with Victor Hwang. Lead Product Designer at Farewill Figure 36. The Junior Doctor Circle: Levels of user engagement: Two User ‘Lenses’ Figure 37. The Junior Doctor Circle: Storyboard of User Features, 1 of 9 Figure 38. The Junior Doctor Circle: Storyboard of User Features, 2 of 9 Figure 39. The Junior Doctor Circle: Storyboard of User Features, 3 of 9 Figure 40. The Junior Doctor Circle: Storyboard of User Features, 4 of 9 Figure 41. The Junior Doctor Circle: Storyboard of User Features, 5 of 9 137 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

Figure 42. The Junior Doctor Circle: Storyboard of User Features, 6 of 9 Figure 43. The Junior Doctor Circle: Storyboard of User Features, 7 of 9 Figure 44. The Junior Doctor Circle: Storyboard of User Features, 8 of 9 Figure 45. The Junior Doctor Circle: Storyboard of User Features, 9 of 9

Figure 46. The Junior Doctor Circle: Overview of Three User Journeys, derived from Personas Figure 47. The Junior Doctor Circle: Melissa’s User Journey Figure 48. The Junior Doctor Circle: Guy’s User Journey

Figure 49. The Junior Doctor Circle: Jenny’s User Journey

Figure 50. The Junior Doctor Circle: Adverts for Junior Doctors (Left) and NHS Hospital Trusts (Right) Figure 51. The Junior Doctor Circle: Examples of Branding around a Hospital

Figure 52. The Junior Doctor Circle: User and Customer Benefits & Revenue Stream

Figure 53. Future Circles: Future Applications for Medical Students and Specialty Trainees Figure 54. Graduating to the next Circle

Figure 55. Practicing Medicine as a Series of Still Images: The Training Model as described by a Medical Lawyer

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References Aldiabat, K, M., Le Navenec, C. (2011) Philosophical Roots of Classical Grounded Theory: Its Foundations in Symbolic Interactionism. The Qualitative Report. 16 (4), 1063-1080. Available from: https://nsuworks.nova.edu/tqr/vol16/iss4/9 [Accessed Jan 2020] BDI Resourcing. (2016) Career Progression and Training Grades for Doctors. Available from: https:// bdiresourcing.com/news/career-progression-and-grades-for-uk-doctors/202 [Accessed Mar 2020].

BMA. (2019) Caring for the Mental Health of the Medical Workforce. The British Medical Association.

BMA. (2020) COVID-19: your wellbeing. Available from: https://www.bma.org.uk/advice-and-support/ covid-19/your-health/covid-19-your-wellbeing [Accessed May 23, 2020].

Boorman, S. (2009) NHS Health and Well-being Final Report. The Department of Health.

Boyd, C. O. (1989) CHENITZ, W.C., AND SWANSON, J. M. (1986). From Practice to Grounded Theory: Qualitative Research in Nursing Menlo Park, CA: Addison-Wesley. Nursing Science Quarterly. 2 (1).

Available from: doi: 10.1177/089431848900200113.

Brooks, S., Chalder, T., Gerada, C. (2011) Doctors Vulnerable to Psychological Distress and Addictions: Treatment from the Practitioner Health Program. Journal of Mental Health. 20 (2), 157-164. Available from: doi: 10.3109/09638237.2011.556168.

Cantopher, T. (2012) Depressive Illness: The Curse Of The Strong. Third edition. London, Sheldon Press.

Collins, A. (2019) Managers most likely to say mental ill-health caused sick leave. Available from: https:// www.hsj.co.uk/workforce/managers-most-likely-to-say-mental-ill-health-caused-sick-leave/7025831.article [Accessed Feb 21, 2020].

Copeland, A. (2019) NHS sickness absence: let’s talk about mental health. Available from: https://www. kingsfund.org.uk/blog/2019/10/nhs-sickness-absence [Accessed May 20, 2020].

Dawson, J. (2014) STAFF EXPERIENCE AND PATIENT OUTCOMES: WHAT DO WE KNOW? NHS Employers.

Dawson, J. (2018) Links between NHS staff experience and patient satisfaction: Analysis of surveys from 2014 and 2015. NHS England.

139 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

Gaver, W., Boucher, A., Pennington, S. & Walker, B. (2004) Cultural Probes and the Value of Uncertainty.

Interactions. 11, 53-56. Available from: doi: 10.1145/1015530.1015555.

Gerada, C. (2018a) Doctors and Suicide. British Journal of General Practice. 68 (669), 168-169. Available from: doi: 10.3399/bjgp18X695345.

Gerada, C. (2018b) The Wounded Healer: Report on the First 10 years of Practioner Health Service. The Practicioner Health Service.

GMC. (2019) Caring for doctors, Caring for patients. The General Medical Council.

Grand, S. (2012) Mapping Design Research. Basel, Switzerland, Birkhauser.

Health Education England. (2019) NHS Staff and Learners’ Mental Wellbeing Commission. NHS. Hemmings, C. (2018) Doctors’ mental health at tipping point . Available from: https://www.bbc.co.uk/ news/health-45356349 [Accessed Feb, 2020].

Henderson, M., Brooks, S. K., del Busso, L., Chalder, T., Harvey, S. B., Hotopf, M., Madan, I. & Hatch, S. (2012) Shame! Self-stigmatisation as an obstacle to sick doctors returning to work: a qualitative study.

BMJ Open. 2 (5). Available from: doi: 10.1136/bmjopen-2012-001776.

Horsfal, S. (2014) Doctors who commit suicide while under GMC fitness to practise investigation. The General Medical Council.

Lambert, T. W., Smith, F. & Goldacre, M. J. (2018) Why doctors consider leaving UK medicine: qualitative analysis of comments from questionnaire surveys three years after graduation. Journal of the Royal Society of Medicine. 111 (1), 18-30. Available from: doi: 10.1177/0141076817738502. [Accessed Mar 6, 2020].

Maben, J., Taylor, C., Dawson, J., Leamy, M., McCarthy, I., Reynolds, E., Ross, S., Shuldham, C., Bennett, L. & Foot, C. (2018) A Realist Informed Mixed-Methods Evaluation of Schwartz Center Rounds ® in England. Health Services and Delivery Research. 6 (37). Available from: doi: 10.3310/hsdr06370.

McCrone, P., Dhanasiri, S., Patel, A., Knapp, M. & Lawton-Smith, S. (2008) Paying The Price: The cost of mental health care in England to 2026. The King’s Fund.

140 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

NHS. (2017) Next Steps on the NHS Five Year Forward View. NHS. NHS. (2019) NHS Mental Health Implementation Plan 2019/20 – 2023/2. NHS.Available from: https://www. longtermplan.nhs.uk/publication/nhs-mental-health-implementation-plan-2019-20-2023-24 [Accessed Jan 21, 2020] NHS Staff Survey. (2018) NHS Staff Survey 2018. NHS. Available from: https://www.nhsstaffsurveys.com/ Page/1021/Past-Results/Historical-Staff-Survey-Results [Accessed May 19, 2020] NHS Employers. (2019) Workforce Health and Wellbeing Framework. London, NHS Employers.

Orr, C. (2020) ‘COVID-19 kills in many ways’: The suicide crisis facing health-care workers. Available from: https://www.nationalobserver.com/2020/04/29/analysis/covid-19-kills-many-ways-suicide-crisis-facinghealth-care-workers [Accessed May 19, 2020].

Pfeifer, R. & Bongard, J. (2006) How the Body Shapes the Way We Think: a New View of Intelligence. MIT Press.

Phillips, J. (2019) The grief over my daughter’s suicide never ends, but I can help other junior doctors. The Guardian. Available from: https://www.theguardian.com/society/2019/oct/10/grief-daughters-suicide-neverends-help-junior-doctors [Accessed May 20, 2020].

Raw, J. (2003) The doctors’ mess: the unsung resource . BMJ. 327 (7416), 689. Available from: https://www. ncbi.nlm.nih.gov/pmc/articles/PMC196412 [Accessed May 20, 2020].

RCOG. (2019) The O&G Workforce Infographics. Available from: https://www.rcog.org.uk/en/careerstraining/workplace-workforce-issues/status-report-2018/og-workforce/ [Accessed May 23, 2020].

Rimmer, A. (2019) Doctors still see own mental health problems as sign of weakness, research finds. BMJ. 365 (1861). Available from: doi: 10.1136/bmj.l1861.

Royal College of Physicians. (2016) Being a junior doctor. Experiences from the front line of the NHS. Royal College of Physicians.

Roycroft, M. (2020) The mental health of junior doctors. Available from: https://www.rcplondon.ac.uk/news/ mental-health-junior-doctors [Accessed Feb, 2020].

Schon, D. (1983) The Reflective Practitioner. San Francisco, Basic Books: Harper Collins.

Simmons, A. (2006) The Story Factor: Inspiration, Influence, and Persuasion Through the Art of Storytelling.

Second edition. UK, Basic Books.

141 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

Stor, W. (2019) The Science of Storytelling. UK, William Collins.

Sykes, C., Borthwick, C. & Baker, E. (2019) Mental Health & wellbeing in the Medical Profession. The British Medical Association.

The Health Foundation. (2018) The Healthcare Workforce in England. Make or Break? The King’s Fund.

The Point of Care Foundation. (2018) Our impact: The Schwartz Rounds Programme. The Point of Care Foundation.

West, C. P., Tan, A. D., Habermann, T. M., Sloan, J. A. & Shanafelt, T. D. (2009) Association of Resident Fatigue and Distress With Perceived Medical Errors. JAMA. 302 (12), 1294-1300. Available from: doi: 10.1001/jama.2009.1389 West, M. (2019) The NHS crisis of caring for staff: what do we need to do? Available from: https://www. kingsfund.org.uk/blog/2019/03/nhs-crisis-caring [Accessed Feb, 2020].

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Appendices Appendix A – User Testing Scores Appendix B – Investor Facing Website Appendix C – Royal College of Art 2020 Work in Progress Show

The data collected during User Testing is extensive.

I have included the additional information in Appendix A in case any reader would like to have more detail.

Building on the Business Model for The Junior Doctor Circle mentioned in Chapter 6, I have included an Investor Facing Website in Appendix B. I designed an interactive installation at the Royal College of Art’s 2020 Work in Progress Show to interrogate my original hypothesis that sharing stories might be an effective tool for clinicians to discuss their mental health. I created two typologies of stories as a stimulus and then invited people to share a story that changed their world. Details of the exhibition are in Appendix C I have transcribed all of the material in the recorded interviews I undertook. Due to their length and the personal content and reflections that my interviewees shared with me, I have taken the decision not to publish them within this thesis.

If any reader would like more details regarding these interviews please contact me at clare.summerfield@network.rca.ac.uk

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Appendix A User Testing Scores – Quantitative Data Quantitative data collected for each concept during User Testing.

The Virtual Doctors’ Mess

SCORE

Concept

Desirability

Viability

Impact

01

13

2

4

2

5

02

17

4

5

4

4

03

13

3

4

3

3

04

14

2

4

4

5

05

17

4

4

5

4

06

7

1

1

3

2

07

8

2

1

3

2

SCORE

Concept

Desirability

Viability

Impact

01

20

5

5

5

5

02

19

5

5

4

5

03

18

4

5

4

5

04

17

4

5

5

3

05

20

5

5

5

5

06

15

5

4

2

4

07

20

5

5

5

5

PARTICIPANT

Share Your Story PARTICIPANT

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User Testing Scores Quantitative Data The Work Emotion Diary

SCORE

Concept

Desirability

Viability

Impact

01

17

3

4

5

5

02

17

5

5

3

4

03

14

3

4

3

4

04

13

3

2

4

4

05

8

2

2

2

2

06

16

4

5

2

5

07

11

3

2

2

4

PARTICIPANT

145 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

User Testing Scores Qualitative Data The Virtual Doctors’ Mess

PARTICIPANT

01 Junior Doctor

SCORE

Share Your Story

The Work Emotion Diary

13

20

17

‘Most jobs I’ve been on I’ve been on the opposite side of the hospital from the mess. So by the time it takes me to get there and make a cup tea and sit down it just isn’t worth it, so you end up not going.’

‘Especially because its anonymous as well, seeing that 32 people have also liked it makes you feel a lot better.’

‘I think it would be useful to say, ‘do you know why?/ As if it’s that you are on call, they could see that you are feeling anxious because it’s about an on call. What is it about the on call’.

‘Most of the time the mess is just too far, I’m tired. If you go all the way there, I’ll just get bleeped to come back.’

‘I’d give all of those a five, I think it would be really useful actually. Especially because its anonymous as well. If you are not the person that want to admit to someone else, especially at the start, in F1 you never want to be the first one to say it.’

My solution would be to hire more people, and that Is never going to happen.’

‘Its so rare that you have another F2 on the job, I might know a lot of other people in the year and I could message, but in my actually 9-5 job I was completely alone and that was the problem.’

‘I think it would be really useful, it’s like when you are speaking to other Junior Doctors, if one person says it’s shit and you just feel so much better. Even though it’s not a direct solution it makes you feel better. I think that bit is really good, letting people know.’

‘It’s a really good idea for speaking to junior doctors, but for being on the ward I don’t know if it addresses the right problem. As yeah you are going to be chummy with your other juniors.

But like with your frauds on your phone, I can message them all day but doesn’t mean that wen I look up from my phone I am still isolated on the ward.’

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User Testing Scores Qualitative Data The Virtual Doctors’ Mess Share Your Story

PARTICIPANT

02 Junior Doctor

SCORE

SCORE

03 Junior Doctor

The Work Emotion Diary

17

19

17

‘Oh wow yeah the channels, that’s such a good idea, as that would make it so much better than WhatsApp.’

‘I think the main things are sharing stories, maybe there also could be sharing stories of more medical stories.

So its definitely really good to talk about mental health.

But what I think is really good for mental health, is being able to discuss a patient, or something that happened that was really difficult. Because, I’ve seen Junior Doctors desperate to tell those stories. And it’s completely eating them up inside.’

’That’s really good as the tracking, as also taking the time put to say how do I fell would massively impact mental health as people don’t do that.’

‘Yeah I think that’s a great idea, in terms of bringing people together and in terms of meeting people this would be a good solution.’

‘That’s really cool. I really like that. Definitely addresses the right problem.’

‘I think it would work for some and not for others if I am honest. I think it depends on your personality.’

13

18

‘People are so terrified of commenting on WhatsApp groups aren’t they. They don’t want to comment on a night shift if someone is asleep.’

‘Obviously there are mistakes made as a Junior Doctor, which you don’t realise, and knowing that another Junior Doctor would have managed it in the same way is really important.’

‘People are already doing this on WhatsApp even with all its limitations, so with the channels, I think it would work so much better for a Junior Doctor’

‘We do a lot of reflections but reflections are very personal. But if you could have public reflections that would be good as well.’

Some members of the team, because they are so precious with their time and they want to leave so quickly, there is quite a lot of strain on the team.

Where if there was an easier way of meeting after work, that definitely would change things.’

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14

The Virtual Doctors’ Mess Share Your Story

PARTICIPANT

04 Junior Doctor

SCORE

14

‘You can’t share patients sensitive information on WhatsApp.’

17

‘I think the hardest part would be to start, like with all things, is to get people to contribute, but then it would be really good.’

‘I think it could help, I wonder how different it is from WhatsApp, how much of a step up it would be.’

The Work Emotion Diary

13

‘Some things might not have a clear reason, like not having anywhere to have lunch with your colleagues.

Somethings might not fit in a box. I think it would be ok, to leave an explanation’ ‘I think it requires a lot from the person using it to come up with a reason, which they might not be able to’.

‘Some people might not know why they are feeling anxious or nervy.’

SCORE

14

20

‘I don’t know if it is solving it. But it is mitigating it. The solution is to not have them isolated.’

05 Senior Doctor

8 ‘I think this will cause anxiety. They will want to know how you are going to ensure confidentiality. I don’t think it’s a solution really.’

‘I think people are too nervous about things like this.’

SCORE

06 Senior Doctor

7

15

16

‘I expect they would like to use it, as they won’t want to be left out. But there will be some that won’t bother but most of them will.’

‘I am not sure about the impact, because I just don’t know until I saw it.’

‘On the other hand, if I was the person in charge of trying to get more Junior Doctors in, and I am facing this crisis. I suppose I would say…if I could support online apps and get suggestions like a coffee bar to improve retention…they I would do it.’

‘It does address a problem as they say that people don’t understand what they are feeling.’

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User Testing Scores Qualitative Data The Virtual Doctors’ Mess Share Your Story

PARTICIPANT

07 Junior Doctor

SCORE

8

20

The Work Emotion Diary

11

‘Slack also creates a gratification system, so are you really changing the WhatsApp concept, both are on your phone and are messaging systems.’

‘Make sure the content is diverse, as not everyone is the same.’

’That’s really good as the tracking, as also taking the time put to say how do I fell would massively impact mental health as people don’t do that.’

‘If you were able to get enough psychological insights into what doctors were experiencing in their night shifts, maybe you could create a slack bot that is smart enough to provide caring things, generate links to apps like calm.’

‘It is heavily reliant on people generating content, in an already highly demanding, pressured environment.

Also some people might not think they aren’t good writers, could be podcasts, where you modify the voice, images, drawings.’

‘Selecting your keywords through psychological data would be an ungodly amount of time and money.’

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Appendix B The Investor Facing Website

The Junior Doctor Circle

Doctors have one of the highest suicide rates amongst professional groups; and yet have some of the poorest access to mental health services. Many doctors are left to suffer in silence and do not speak up, with work absences due mental health making up almost a quarter of all sick leave within the NHS at a cost of ÂŁ250,000,000 a year.

 �

Â? Â? Â? Â?

Â?

DEPRESSION

by Clem, Junior Doctor, 29

The Specialty Today, this Traineehappened...

Circle

The Junior Doctor Circle

Stress

Has this story resonated with you?

a story of life on the wards

You are not alone

This story resonated with 32 others in the community

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Inspiration & Success

Why I love being a doctor

“Inside it was so far from what I had been feeling.�

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

Depression

May we show you coping strategies that others in the community are using who have resonnated with this story?

Anxiety

SUPPORT SERVICES EXTERNAL T H E PAT I E N T I C A N T FORGET

by Lesley, O&G Consultant, 63

Taking it home most resonated Most resonnated

T H E PAT I E N T I C A N T FORGET

T H E PAT I E N T I C A N T FORGET

by Lesley, O&G Consultant, 63

by Lesley, O&G Consultant, 63

“I can still see her face... and it’s thirty years ago.� a story of remembering and questioning

ou become an F1 and like shit hits the fan�

56

a story of feeling out of control

“Its been thirty years and I can still see her face� a story of remembering and questioning

o t he rs re s o n n a t e d

INTERNAL

T H E BRI T I S H M E DI CA L ASS O CI AT I O N

W E BS I T E L I N K

The BMA wellbeing services are available to all doctors and their spouses and chilldren, 24/7 and free of charge PE E R S UPPOR T / COUN S E LLI N G / PSYCH OTH E R A PY / G MC I N VE STI GATI ON S UPPOR T /

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

“Actually no, this has gone a bit too far, I need to speak to someone about this.� a story of developing clinical ability to acknowledge my mental health

“I didn’t want to let my guard down.

I guess for anyone to know that I felt I wasn’t competent at my job.� a story of bottling it up

32

o t he rs re s o n n a t e d

28

o t he rs re s o n n a t e d

you go throughout your entire you know, from like secondary school, you’re the best in your class and you always get A’s in your GCSEs. You study, you get your A levels you study, get your A’s and get into university, you go through medical school, you pass every exam, you’ve done really well. You’re on sports teams, you’re just doing you know, you are acing life. You

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Very, very poorly educated and extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

A D VI CE F OR YOUR S LE F OR A COLLE AG UE

T H E PRACT I CI O N E R H E A LT H PRO GRA M M E

Practitioner Health is a free, confidential NHS service for doctors and dentists across England with mental illness and addiction problems, who are working or looking to return to clinical practice.

The service can help with issues relating to a mental health concern, including stress or depression or an addiction problem.

COUN S E LLI N G / PSYCH OTH E R A PY / A D D I CTI ON TR E ATME N T/ CB T / I N D I VI DA ULI S E D CLI N I CI A N LE D CAS E MA N AG E E N T / G R OUP S UPPOR T

“It’s incredibly distressing and when things go wrong you do take it very personally.� a story of remembering and questioning

ACA DE MY OF M E DI CA L ROYA L CO L L E GE S

19

o t he rs re s o n n a t e d

Junior Doctors are uniquely disadvantaged in accessing mental health services, with systemic and endemic actors exacerbating the prevalence of negative mental health and well-being within this cohort. High burnout and low retention rates of Junior Doctors form the biggest crisis the NHS is facing today.

The Junior Doctor Circle is an app for Junior Doctors to share their stories with a community of other Junior Doctors. Who are unable to identify you and are not afďŹ liated to your employer. By realising you are not alone you learn and also support others.

Join the circle

In the UK the total cost to employers of mental health problems among their staff is estimated at nearly £26 billion each year • £8.4 billion

from sickness absences

• £15.1 billion

from reduced productivity at work

The NHS is the largest employer in the UK Employing over a million people

The British Medical Association has declared a Mentmal Health Crisis in the NHS Workforce

80% of doctors are at risk of burnout Over $200 Billion spent on mental health management in the US alone

85%

of doctors have experienced a mental health problem

250,000 full time work

days lost as sick leave due to mental ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com 150 Clare Summerfield 1/10 pounds spent by the health issues in April 2019 alone

Department of Health and Social Care was on mental health in 2018/19

employer in the UK

Employing over a million people The British Medical Association

Appendix Bhas declared a Mentmal Health Crisis in the NHS Workforce User Testing Scores – Investor Facing Website

80% of doctors are at risk of burnout Over $200 Billion spent on mental health management in the US alone

1/10 pounds spent by the

Department of Health and Social Care was on mental health in 2018/19

85%

of doctors have experienced a mental health problem

250,000

full time work days lost as sick leave due to mental health issues in April 2019 alone

Costing the NHS ÂŁ250,000,000 ever year

The last NHS FIVE YEAR FORWARD VIEW sets mental health as the main NHS goal for the next 5 years COVID-19 has set a new landscape for doctors mental health, highlighting it as one the most urgent issues facing our NHS

JUNIOR DOCTORS ARE A UNIQUELY DISADVANTAGED GROUP They are 2 x more likely to suffer from negative mental health and well-being Junior Doctors are unaware of existing support services Stigma surround mental health amongst doctors means that many more will be in need of help but have not yet self disclosed JUNIOR DOCTORS ARE THE CHANGE MAKERS - Politically active and vocal and mental health and well-being - Represent the biggest proportion of doctors - Can advocate change and change culture

The Junior Doctor Circle Features

T H E PAT I E N T I C A N T FORGET

by Lesley, O&G Consultant, 63

Today, this happened...

Depression

Stress

Why I love being a doctor

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Inspiration Very, very poorly educated and & Success extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

Anxiety

Junior Doctor User Testing Feedback

Taking it home most Most resonated resonnated “I can still see her face... and it’s thirty years ago.� a story of remembering and questioning

56

others reson n ated

“Actually no, this has gone a bit too far, I need to speak to someone about this.� a story of developing clinical ability to acknowledge my mental health

“I didn’t want to let my guard down.

I guess for anyone to know that I felt I wasn’t competent at my job.� a story of bottling it up

“It’s incredibly distressing and when things go wrong you do take it very personally.� a story of remembering and questioning

 �

32

others reson n ated

28

others reson n ated

19

others reson n ated

The Virtual That story resonates with me. Share your story with a Doctors’ Mess community of Junior Doctors.

Who are unable to identify you and are not afďŹ liated to your employer. By realising you are not alone you learn and also support others.

Browse and read stories 74% user testing mark from others in the community ‘It would through themes devised by have a massive impact, even if it allowed one person to Junior Doctors by popularity meet someone for a drink after and resonance work. So, even if that happened once it would have a huge impact and the whole of the team as well.’ Junior Doctor Concept

Share Your Story

DEPRESSION

by Clem, Junior Doctor, 29

“Inside it was so far from what I had been feeling.� a story of life on the wards

Has this story

Read real front line stories ‘I don’t know if it is solving it. by other Junior DoctorsBut and it is mitigating it. The solution resonate with them.

Week

Month

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

Year 2020

good evening, share your stories and support others you are not alone

Jan

Feb

Mar

Apr

May

Jun

Today I feel

nervous

about going to work RECENTLY RESONATED

STRESS

ANXIETY

ELATION

STORIES FROM OUR COMMUNIT Y T H E PAT I E N T I CANT FORGET

LONELINESS

TAKING IT HOME

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really ustered.

I couldn’t get home without stopping on the way home and crying.

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

You’ve been feeling less positive about going into work over the last few months

What could your employer do to improve your feelings about going to work? provide us with a doctors mess

Did anything change in April?

May we share this feedback anonymously with your employer?

If enough us speak up, together we can make a change.

SHARE YOUR STORY

it might be the key to helping someone else

94% user testing mark

69% user testing mark

‘If you can guarantee anonymity then 5/5 for all of it. I think it’s a great idea. It just allows people to talk and get it off their chest.’ Junior Doctor

‘It does address a problem as Juniors say that people don’t understand what they are feeling.’’ Senior Consultant

Concept

Concept

‘I think it would be really useful.

When you are speaking to other Junior Doctors, if one person says ‘it’s shit’, you just feel so much better. Even though it’s not a direct solution, it makes you feel better. I think that bit is really

‘I think this will cause anxiety.

They will want to know how you are going to ensure confidentiality. I don’t think it is a solution really.’ Senior Consultant

151 Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

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The Work Emotion Diary HOW YOU HAVE FELT ABOUT GOING TO WORK

DEPRESSION

T H E PAT I E N T I C A N T FORGET

Taking it home most Most resonated resonnated

by Lesley, O&G Consultant, 63

Today, this happened...

“I can still see her face... and it’s thirty years ago.� a story of remembering and questioning

Stress

“Actually no, this has gone a bit too far, I need to speak to someone about this.� a story of developing clinical ability to acknowledge my mental health

a story of bottling it up

Anxiety

32

others reson n ated

“I didn’t want to let my guard down.

I guess for anyone to know that I felt I wasn’t competent at my job.�

Inspiration Very, very poorly educated and & Success extremely bright. She came to me in Cambridge and I tried to stop her coming because I knew I was leaving for London, but

Why I love being a doctor

56

others reson n ated

I had these two patients who had followed me from Cambridge, where I had been a senior registrar and one was a trapeze artist and she was the most extraordinary character.

She really was.

Depression

The Virtual That story resonates with me. Share your story with a Doctors’ Mess community of Junior Doctors.

Who are unable to identify you and are not afďŹ liated to your employer. By realising you are not alone you learn and also support others.

a story of remembering and questioning

19

others reson n ated

 �

DEPRESSION

“Inside it was so far from what I had been feeling.�

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really flustered.

I couldn’t get home without stopping on the way home and crying.

You are not alone

This story resonated with 32 others in the community

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

May we show you coping strategies that others in the community are using who have resonnated with this story?

Coping Strategies from the community

a story of feeling depressed on the wards

EXTERNAL

INTERNAL

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Other community members coping strategies

THE BRITISH MEDICAL ASSOCIATION

WEBSITE LINK

share your stories and support others YOU ARE NOT ALONE STORIES YOU ARE RESONATING WITH

The BMA wellbeing services are available to all doctors and their spouses and chilldren, 24/7 and free of charge

2020

PEER SUPPORT / COUNSELLING / PSYCHOTHERAPY / GMC INVESTIGATION SUPPORT / ADVICE FOR YOURSLEF OR A COLLEAGUE

THE P RACTICIONER HEALTH P ROGRAMME

JAN

FEB

MAR

APR

M AY

sarahj21

fairydoc

Practitioner Health is a free, confidential NHS service for doctors and dentists across England with mental illness and addiction problems, who are working or looking to return to clinical practice.

The service can help with issues relating to a mental health concern, including stress or depression or an addiction problem.

COUNSELLING / PSYCHOTHERAPY / ADDICTION TREATMENT/ CBT /

Write

Speak

Draw

Please consider sharing your own story with the community

INDIVIDAULISED CLINICIAN LED CASE MANAGEENT / GROUP SUPPORT

Your honesty might just be the key to helping someone else

ACADEMY OF MEDICAL ROYAL COLLEGES

Taking it home

Depression

Stress

Junior Doctors voices at the heart of The Junior Doctor Circle Unique to current support services - self generated content

- facilitating meaningful connections between Junior Doctors

- signposting to mental health services

- empowering Junior Doctors to express their

feels and take the first anonymous step to seek help without fear or judgement

You’ve been feeling less positive about going into work over the last few months

One of my F1 colleagues turned to me and said ‘you literally always look so happy, is there ever a day where you aren’t happy?!’

Today I feel

nervous

What could your employer do to improve your feelings about going to work? provide us with a doctors mess

Did anything change in April?

May we share this feedback anonymously with your employer?

If enough us speak up, together we can make a change.

94% user testing mark

69% user testing mark

‘If you can guarantee anonymity then 5/5 for all of it. I think it’s a great idea. It just allows people to talk and get it off their chest.’ Junior Doctor

‘It does address a problem as Juniors say that people don’t understand what they are feeling.’’ Senior Consultant

Concept

Concept

‘I think it would be really useful.

When you are speaking to other Junior Doctors, if one person says ‘it’s shit’, you just feel so much better. Even though it’s not a direct solution, it makes you feel better. I think that bit is really good, letting people know.’ Junior Doctor

‘I think this will cause anxiety.

They will want to know how you are going to ensure confidentiality. I don’t think it is a solution really.’ Senior Consultant

Desirability

‘I think it would work for some and not for others if I am honest. I think it depends on your personality.’ Junior Doctor

Viability

Track the stories you are resonating with over time and identify patterns

Mar

Jun

it might be the key to helping someone else

Get signposted to support services and ‘Slack also creates a gratification access to a comprehensive so are you really list ofsystem, all support services changing the WhatsApp available concept? Both are on your phone to Doctors and are messaging systems.’

The Junior Doctor Circle can help reduce the need for locums by 50% by keeping doctors in work and save the Trust money by reducing attrition rates

TAKING IT HOME

Viability

Receive encouragement and success stories from others who have taken the step

HOW ARE YOU FEELING ABOUT GOING TO WORK TODAY?

Year

Feb

May

SHARE YOUR STORY

community

In 2010 the NHS spent almost ÂŁ800 million pounds on filling vacant posts with Locum Doctors

ELATION

LONELINESS

‘Seeing that 32 people have also liked it...it makes you feel a lot better.’ Junior Doctor

Impact

Month

2020

On one of the days when I was feeling the lowest, if anyone asked me a question I would go red and get really ustered.

I couldn’t get home without stopping on the way home and crying.

‘I think it could help, but I wonder how different it is from WhatsApp? How much of a step up would it be?’ Junior Doctor

Junior Doctor

MARCH

ANXIETY

T H E PAT I E N T I CANT FORGET

‘I expect they would like to use it, as they won’t want to be left out.

But there will be some that won’t but mostcoping of them will.’ Viewbother, and suggest Senior strategiesConsultant to others in the

SUPPORT SERVICES

The story I resonated with “Inside it was so far from what I had been feeling.�

STRESS

STORIES FROM OUR COMMUNIT Y

Read real front line stories ‘I don’t know if it is solving it. by other Junior DoctorsBut and it is mitigating it. The solution resonate with them. is to not have them isolated.’ The app tracks if you are Senior Consultant resonating with multiple stories Desirability form the same theme and gently nudges the user.

Has this story resonated with you?

a story of life on the wards

Week

Jan

Apr

about going to work RECENTLY RESONATED

Concept

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by Clem, Junior Doctor, 29

HOW YOU HAVE FELT ABOUT GOING TO WORK

good evening, share your stories and support others you are not alone

once it would have a huge impact and the whole of the team as well.’ Junior Doctor

The Work Emotion Diary

DEPRESSION

Browse and read stories 74% user testing mark from others in the community ‘It would through themes devised by have a massive impact, even if it allowed one person to Junior Doctors by popularity meet someone for a drink after and resonance work. So, even if that happened

28

others reson n ated

“It’s incredibly distressing and when things go wrong you do take it very personally.�

Share Your Story

‘It is heavily reliant on people generating content, in a highly demanding environment. Some people might not think they are good writers... it could be podcasts or images and drawings.’ Junior Doctor Impact ‘What I think is really good for mental health, is being able to discuss a patient, or something that happened that was really difficult. Because, I’ve seen Junior Doctors desperate to tell those stories. And it’s completely eating them up inside.’ Junior Doctor

ÂŁÂŁÂŁ Save millions of pounds on Locum & agency fees

How does The Junior Doctor Circle positively impact an NHS Trust?

Decrease Junior Doctor Burnout Increase retention rates Decrease days lost to sick leave Get actionable and annonymised data about the satisfaction rate of your Junior Doctors

Empower and equip 152 Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

Junior Doctors to do their job

Desirability

Viability ‘I think it requires a lot from the person using it to come up with a reason, which they might not be able to.’ Junior Doctor Impact ‘If I was the person in charge of trying to get more Junior Doctors into post and I was facing this crisis, I would definitely support an online app and encourage everyone to make suggestions like a coffee bar to improve retention‌I would do it.’ Senior Consultant

rate of your Junior Doctors Empower and equip Junior Doctors to do their job

Appendix B User Testing Scores – Investor Facing Website

A holisitc, meaningful, life course approach to Junior Doctor mental health A communication platform that evolves with and is sensitive to the unique needs of Junior Doctors

The Junior Doctor Circle

The Specialty Trainee Circle

Doctors have one of the highest suicide rates amongst professional groups; and yet have some of the poorest access to mental health services. Many doctors are left to suffer in silence and do not speak up, with work absences due mental health making up almost a quarter of all sick leave within the NHS at a cost of £250,000,000 a year.

Junior Doctors are uniquely disadvantaged in accessing mental health services, with systemic and endemic factors exacerbating the prevalence of negative mental health and well-being within this cohort. High burnout and low retention rates of Junior Doctors form the biggest crisis the NHS is facing today.

The Junior Doctor Circle is an app for Junior Doctors to share their stories with a community of other Junior Doctors. Who are unable to identify you and are not affiliated to your employer. By realising you are not alone you learn and also support others

The Medic Circle For Medical Students Engage them in the platform as they train so they grow and continue to use the platform througout their career The Specialty Trainnee Circle For Senior Junior Doctors Once Juniors complete their F2 jobs they graduate to the Speciality Trainnee Circle, the STC.

J u nio r Doc to r s a nd m e d ic a l Stu d e n t s have th e hig h e s t b u rd e n of m e n ta l h ea l th is su e s a mo ng d oc to r s. T h ey n e e d a nd d e s e r ve su p p o r t

We are asking for an initial £50,000 First six months...

Fundraising Built the Core Team Proof of Concept Key Partners Extensive market and Junior Doctor User Research

Develop Beta app

Gain persuasive data

User Research

Launch powerful Social Media and awareness campaign

Soft launch with Imperial College Trust Focus on content creation

Develop product for UK NHS Trust wide roll out

The following six months...

The Revenue Streams 1. Licence fees from the NHS Trust Fundraise for the next £30,000

Roll out to other UK Trusts

Continue UK expansion with results from the pilot study

Gain foothold in the market

2. Percentage of the savings gained by the NHS Trusts through using The Junior Doctor Circle

Build key nationwide partnerships

THE TEAM 153 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

154 Clare Summerfield ¡ Royal College of Art 2020 ¡ hello@thejuniordoctorcircle.com

STOR I ES

Appendix C – Royal College of Art 2020 Work in Progress Show

to see with another person’s eyes.’

Oliver Sacks

T H AT

Title of your story

C H A NGED

The First Insight Doctors are the only profession who receive medical treatment from their colleagues

How it changed your world

T H E W EST ER N

Medicine is the front-line of taboo as it facilitates people making choices that are identity affirming. Taboo’s are created. Over time they ebb and they

The Odyssey

by Homer, 8th century The journey of Odysseus defined a streak of individualism particular to Western culture that has led to much change in the world – good and bad.’

Bethanne Patrick

WOR LD,

flow. When we think of medical taboos, we might first think of abortion or euthanasia. However, I would argue that those are simply contexts which

Frankenstein

by Mary Shelley, 1818

The Vindicati the Rights of W

by Mary Wolls

A lens through which to read our world.

Frankenstein is not only the first creation story to use scientific experimentation as its method, but it also presents a framework for narratively examining the morality and ethics of the experiment and experimenter.

Audrey Shafer

Wollstonecraft that inequality i morally and eth but is also econ socially irrespon

Ring of Gyges

by Plato, 380BC

Relativity: The and General T

by Albert Einst

taboo lies in. The consistent taboo is that doctors are the only profession to SC I ENC E

be treated by their medical colleagues.

we cannot find a way of telling our story, our story tells us— am these stories, we develop symptoms, find ourselves acting in ways we don’t understand.’

n Grosz

‘Language, that most human invention, can enable what, in principle, should not be possible.

It can allow all of us, even the congenitally blind,

Initial Problem Statement Doctors have one of the highest suicide rates amongst professional groups; and yet have some of the poorest access to mental health services

The Selfish Gene

by Richard Hawkins, 1976

As long as we study life, it will be read...If Attenborough was the gateway drug to a love of evolution, Dawkins made me an addict Adam Rutherford

The grounding story for the necessity of scientific integrity and reproducibility as a key priciple in the validity of scientific prrof to temper human deciet in the search of glory.

Transformed ou living in the cos most beautiful history of scien Gwen Ifill

Title of your story &

How it changed your world

M EDIC I N E

Fear that their ‘taboo’ health issues, such as addiction or mental health might put into question their ability to practice, means many that many doctors are left to suffer in silence and do not seek

The Man Who Mistook His Wife for a Hat

by Oliver Sacks, 1985 Patient and physician were co-equals . . . learning from and helping the other . . . between them arriving at new insights and treatment.

It shows that normal and abnormal are not mutually exclusive categories but arbitrary points on a continuum, influenced by their context.

David Warriner

When Breath Becomes Air

by Paul Kalanithi, 2016

Do No Harm

by Henry Mars

The real question we face, Kalanithi writes, is not how long, but rather how, we will live – and the answer does not appear in any medical textbook.

Alice O’Keeffe

Every surgeon himself a small where from tim goes to pray – terness and reg must look for a for his failures.

René Leriche, La philosophie d 1951

professional help. Who heals the healer?

e Health Gap Professor Sir Michael ormot, 2015

Wisteria

by Carol P. Herbert, 2013

Typologies of stories that changed the world

Breaking and Mending

by Joanna Cannon, 2019

Initial Hypothesis Words are never, ever, From ‘Wisteria’ we learn of By telling your story you give someone just words. a garden of memory, where each plant is a reminder of a person known, patient theirs and act upon it permission to atell remembered, where ugliness

journey of ysseus defined a streak ndividualism particular to stern culture that has led much change in the rld – good and bad.’ hanne Patrick

Title of your story

Title youryourstory How of it changed world

is transformed into beauty. I will never look at wisteria in my garden without thinking of this story.

How it changed your world

Title of your story

An invitation to share a How it changed world story thatyourchanged your world

e Selfish Gene Richard Hawkins, 1976

long as we study life, it will read...If Attenborough was gateway drug to a love of olution, Dawkins made me addict

Ring of Gyges

by Plato, 380BC

Relativity: The Special and General Theory

by Albert Einstein 1916

The grounding story for

Transformed our way of

as a key priciple in the validity of scientific prrof to temper

history of science.

Gwen Ifill

Figure A: The Royal College of Art, Wo

necessity of scientific living in the cosmos, with the Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com 155 Clarethe integrity and reproducibility most beautiful theory in the Title of your story

Title of your story

Draw an image that

Draw an image that makes you think of your story

How it changed your world

Everyone has a story that changed the way they have looked at something. Can we use this to disrupt the fear and concealment around self disclosure of mental ill health or taboo?

A C LI N IC I A NS

Testing the Hypothesis The Health Gap

by Professor Sir Michael Mormot, 2015

The journey of Odysseus defined a streak of individualism particular to Western culture that has led to much change in the world – good and bad.’

Bethanne Patrick

Wisteria

by Carol P. Herbert, 2013

Breaking and Mending

by Joanna Cannon, 2019

From ‘Wisteria’ we learn of a garden of memory, where each plant is a reminder of a person known, a patient remembered, where ugliness is transformed into beauty. I will never look at wisteria in my garden without thinking of this story.

Words are never, ever, just words.

I designed an interactive installation at the Royal College of Art’s 2020 Work in Progress Show WOR LD

ur way of smos, with the theory in the nce.

Stephen Grosz

C H A NGED

e Special Theory tein 1916

‘When we cannot find a way of telling our story, our story tells us— we dream these stories, we develop symptoms, or we find ourselves acting in ways we don’t understand.’

T H AT

demonstrated is not only hically wrong, nomically and nsible.

STOR I ES

ion of Women stonecraft, 1792

Initial Research Question How might we create space for doctors to share their stories about their mental health?

Title of your story

Draw an image that

How it changed your world

(Figure A), to interrogate my original hypothesis that sharing stories might be an effective tool for clinicians to discuss their mental health. I created two typologies (Figure B p.157) of stories as the stimulus and then invited people to share a story that changed their world and add it to the The Selfish Gene

by Richard Hawkins, 1976

Ring of Gyges

by Plato, 380BC

Relativity: The Special and General Theory

by Albert Einstein 1916

shelf. I gathered a library of stories that have changed people’s worlds.

As long as we study life, it will be read...If Attenborough was the gateway drug to a love of evolution, Dawkins made me an addict Adam Rutherford

The grounding story for the necessity of scientific integrity and reproducibility as a key priciple in the validity of scientific prrof to temper human deciet in the search of glory.

Transformed our way of living in the cosmos, with the most beautiful theory in the history of science.

Gwen Ifill

Title of your story

Draw an image that

How it changed your world

Draw an image that makes you think of your story

The Man Who Mistook His Wife for a Hat

by Oliver Sacks, 1985

sh, 2014

carries within cemetery, me to time he a place of bitgret, where he an explanation

Patient and physician were co-equals . . . learning from and helping the other . . . between them arriving at new insights and treatment.

It shows that normal and abnormal are not mutually exclusive categories but arbitrary points on a continuum, influenced by their context.

David Warriner

de la chirurgie,

When Breath Becomes Air

by Paul Kalanithi, 2016

Do No Harm

by Henry Marsh, 2014

The real question we face, Kalanithi writes, is not how long, but rather how, we will live – and the answer does not appear in any medical textbook.

Alice O’Keeffe

Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures.

René Leriche, La philosophie de la chirurgie, 1951

Title of your story

Draw an image that

How it changed your world

All sorrows can be borne if you put them into a story or tell a story about them.

Karen Blixen

Draw an image that makes you think of your story

Title of your story

Draw an image that

Draw an image that makes you think of your story How it changed your world

Draw an image that makes you think of your story

Title of your story

How it changed your world

ork in Progress Show 2020

156 Draw an image that makes you think of your story

Draw an image that

T H AT

T H AT

C H A NGED

C H A NGED

A

A

C LI N IC I A NS

C LI N IC I A NS

It can allow allStephen of us, Grosz even the congenitally blind,

to see with another person’s eyes.’

Oliver Sacks

Breaking and Mending Frankenstein Wisteria The Vindication of The Odyssey The Health Gap by 1818 Carol P. Herbert, the 2013Rights of Women

by Joanna Cannon, 2019

by Professor Sir Michael

by Mary Shelley,

by Homer, 8th century Mormot, 2015

by Mary Wollstonecraft, 1792

‘When we cannot way of find telling our story, our story tells us— ‘Whenfind we acannot a way of telling our story, our story tells us— we dream stories, we develop symptoms, we dream these stories,these we develop symptoms, or we find ourselves in ways we don’t understand.’ or we find ourselves acting in waysacting we don’t understand.’

Stephen Grosz Stephen Grosz

Breaking and Mending Health Gap Wisteria Wisteria Breaking and Mending The HealthThe Gap Carol P. Herbert, 2013by Joanna Cannon,

by Joanna2019 Cannon, 2019 Professor Herbert, 2013

by ProfessorbySir MichaelSir Michael by Carol P. by Mormot, 2015 Mormot, 2015

realised women weren’tFrom dy- ‘Wisteria’ are never, ever, Fromwe ‘Wisteria’ of are Words never, ever, The journeyI of learn ofwe learnWords ing because we could notasave garden ofwhere memory, where Odysseus defined a streak just words. just words. garden ofamemory, theirparticular lives, but because society plant is aofreminder of of individualism to each plant iseach a reminder did not value a person known, a patient Western culture that has their led lives. a person known, a patient Professor remembered, where ugliness to much change in theDame Lesley Regan remembered, where ugliness is transformed world – good and bad.’ is transformed into beauty.into I beauty. I will never look in at wisteria in Bethanne Patrick will never look at wisteria my garden without thinking my garden without thinking of this story.of this story.

WOR LD

of the experiment and experimenter.

Audrey Shafer

WOR LD

WOR LD

WOR LD,

dy-through From Words are never, ever, of The journey of I realised women weren’t Wollstonecraft demonstrated A lens which‘Wisteria’ we learn ing abecause notread saveour world. a garden of memory, that where Odysseus defined streak we couldto inequality isjust notwords. only lives, but society plantthe is a reminder of and ethically wrong, of individualismtheir particular to because morally Frankenstein is each not only nothas value a person Western culturedid that led their lives. but is also economically and first creation story to useknown, a patient Regan experimentation remembered, where socially uglinessirresponsible. to much changeProfessor in the Dame Lesley scientific is transformed into beauty. I world – good and bad.’ as its method, but it also will never look at wisteria in Bethanne Patrick presents a framework my garden without thinking for narratively examining of ethics this story. the morality and

STOR I ES

STOR I ES

C LI N IC I A NS

W EST ER N

A

T H E

C H A NGED

C H A NGED

T H AT

T H AT

STOR I ES

STOR I ES

Title of your story

How it changed your world

‘When cannot find a way of telling our story, our story tells us— ‘Language, that mostwe human invention, we dream these stories, we develop symptoms, can enable what, in principle, we find ourselves acting in ways we don’t understand.’ should not be or possible.

SC I ENC E

Draw an image that makes you think of your story

Being Mortal Vera Drake Dr Daksha Emson’s story Atul Gawande, 2014

by Mike Leigh, 2004 Ring of Gyges Relativity: ThebySpecial The Selfish Gene and General Theory

by Richard Hawkins, 1976

by Plato, 380BC

by Albert Einstein 1916 A talented young psychiatrist What we need in medical In 1967 the Abortion Act was with afor history of bipolar affective our schools passed, abortionThe wasgrounding no Transformed way ofis not to teach story As long as we study life,and it will empathy, much as to longer illegal. wasnecessity a living in the cosmos, withasthe ofdisorder, scientifickilled herself and be read...If Attenborough wasWhen Ithe her three-month-old baby in preserve gynaecology ward sister at the most beautiful theory in it...The the process of integrity and reproducibility the gateway drug to a love of 2000. Dakshahistory was of science. learning huge volumes of Elizabeth Anderson as a key pricipleOctober in the validity evolution, Dawkins madeGarrett me terrified that if her mental information about disease, hospital in London, I of wasscientific prrof Gwen Ifill to temper an addict more widely known of learning a specialised sometimes asked whether humanordeciet inillnesswas the search Adam Rutherford she would lose her job. What language, can ironically make not I approved of it. My reply of glory. treatment she had was secretive one lose sight of the patient was that I did not regard it as and hurried in hospital corridors. one came to serve; empathy a moral issue, but as a medical Her story highlighted the urgent can be replaced by cynicism. issue. A minority of women need for doctors to have access Abraham Verghese will always want an abortion. to mental health services. And Therefore, it must be done led to the foundation of The properly.

Practicioner Health Program the Jennifer Worth first GP service for doctors.

A talented young psychiatrist What we need in medical In 1967 the Abortion Act was withstory a history is not Transformedschools our way of to teach for of bipolar affective passed, wasThe no grounding As long as we study and life, itabortion will disorder, killed herself and living in theempathy, as much cosmos, with the as to of scientific longer illegal. When a necessity be read...If Attenborough was I wasthe three-month-old baby most in preserve beautiful theoryit...The in theprocess of integrity reproducibility ward the andher the gatewaygynaecology drug to a love of sister at October 2000.

Daksha washistory of science. learning huge volumes of as a key priciple in the validity Elizabethmade Garrett evolution, Dawkins me Anderson if her mental Gwen Ifill information about disease, prrof tothat temper an addict hospital in London, I wasof scientific terrified illnesswas more widely known of learning a specialised human in the search sometimes asked whether or deciet Adam Rutherford language, can ironically make of glory. she would lose her job. What not I approved of it. My reply treatment she had was secretive one lose sight of the patient was that I did not regard it as and hurried in hospital corridors. one came to serve; empathy a moral issue, but as a medical Her story highlighted the urgent can be replaced by cynicism. issue. A minority of women need for doctors to have access Abraham Verghese will always want an abortion. to mental health services. And Therefore, it must be done led to the foundation of The properly.

Practicioner Health Program the Jennifer Worth first GP service for doctors.

The Man Who Mistook When Breath Becomes Air Do No Harm Do2014 No Harm Far 2016 from the Tree:byParents,

by Paul Kalanithi, Henry Marsh, His Wife for aThe HatEmperor of All Maladies Children and the Search for by Dr. Danielle Ofri, 2020 Siddhartha Mukherjee, 2010

by Oliver Sacks,by1985 Identity by Andrew Solomon, 2012 Every surgeon carries within The real question we face, Patient and physician were himself a small cemetery, Kalanithi writes, is not how ‘Parenting is no sport for I found myself in this book co-equals . . . learning from The underlying structurallong, but rather how, we will where from time to time he perfectionists’ By militating when everyday I practice and helping the other . . . dynamic of his book turnslive out– and the answer does goes to pray – a place of bitagainst perfectionism, he only defensive medicine, ordering between them arriving at to be the riddle of progress terness and regret, where he not appear in any medical leaves the reader in greater more tests than neccessary new insights anditself, treatment. the application of reason must look for an textbook. awe of the art of the justexplanation in case I miss something.

It shows that normal and to chaos and and science Alice O’Keeffe for his failures. achievable.

O&G Junior Doctor abnormal are not mutually disease – the uber-project René Leriche, Emma Brockes exclusive categories but of modernity that, even if it La philosophie de la chirurgie, arbitrary pointshas on achieved a too much to 1951 continuum, influenced bya failure, can never be called their context. finally succeed.

David WarrinerAlexander Linklater

The Man Who Mistook When Breath Becomes Air Do No Harm The Emperor of All Maladies Do No2014 Harm Far from the Tree: Parents,

by Paul Kalanithi, 2016

by Henry Marsh, His Wife for a Hat Children and the Search for by Dr. Danielle Ofri, 2020

by Siddhartha Mukherjee, 2010

by Oliver Sacks, 1985 Identity by Andrew Solomon, 2012 The real question we face, Every surgeon carries within Patient and physician were Kalanithi writes, is not how himself a small cemetery, ‘Parenting is no sport for I found myself in this book co-equals . . . learning from long, but rather how, we will where from time to time he The underlying structural perfectionists’ By militating when everyday I practice and helping the other . . . live – and the answer does goes to pray – a place of bitdynamic of his book turns out against perfectionism, he only defensive medicine, ordering between them arriving at not appear in any medical terness and regret, where he to be the riddle of progress leaves the reader in greater more tests than neccessary new insights and treatment. textbook. must look for an explanation itself, the application of reason awe of the art of the just in case I miss something.

It shows that normal and for his failures. and science to chaos and Alice O’Keeffe achievable.

O&G Junior Doctor abnormal are not mutually René Leriche, disease – the uber-project Emma Brockes exclusive categories but La philosophie de la chirurgie, of modernity that, even if it arbitrary points on a 1951 has achieved too much to continuum, influenced by be called a failure, can never their context. finally succeed.

David Warriner Alexander Linklater

Vera Drake Mike Leigh, 2004 The SelfishbyGene

by Richard Hawkins, 1976

Being Mortal Dr Daksha Emson’s story Atul Gawande, 2014 Ring of Gyges Relativity: by The Special

by Plato, 380BC and General Theory

by Albert Einstein 1916

& Karen Blixen

Title of your story

All sorrows canifbe borne you into put them a story or tell a story about them.

All sorrows can be borne you put if them a storyinto or tell a story about them.

Karen Blixen Karen Blixen

Draw an image that makes you think of your story

akes you think of your story

How it changed your world

akes you think of your story

Figure B: Two Typologies, ‘Stories That Changed The World’ 157 Clare Summerfield · Royal College of Art 2020 · hello@thejuniordoctorcircle.com

akes you think of your story

M EDIC I N E

Title of your story

All sorrows can be borne if you put them into a story or tell a story about them.

Typologies of stories that changed the world I collected stories that: Changed the Western World, Changed the Scientific World, Changed the Medical World and Changed a Clinician’s World (Figure B). I collected 24 story responses. All were deeply poignant and personal. They demonstrated the power of storytelling to encourage people to open up and reveal their story.

The themes from these 24 responses can be classified as ‘taboo’, ranging from psychotic episodes, racism, to the acceptance of profound disability. These complex and previously untold stories illustrate the power of storytelling to convey complex meaning and be a conduit to placing yourself in some one else’s shoes (Simmons, 2006).

The power of storytelling for doctors Will Stor states that the ‘consolation of story is truth’. Stories allow us to not feel alone as we can view someone else’s mind and be consoled that we are not alone. It isn’t only us (Stor, 2019). Narrative medicine is used in clinical training to encourage doctors to empathise with their patients by using story to simulate clinical scenarios.

This teaches doctors to empathise with their patients but what about themselves?

Stories are how humans convey complex bits of information. Storytelling can address the philosophical, social and professional complexities of the space between illness and health.

‘Story is like mental software that you supply so your listener can run it again later using new input specific to the situation.’

(Simmons, 2006. p.41)

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