Title: The determinants and effects of stress in junior doctors working in the National Health Service
Funder: Department of Health and Social Care

Abstract: Research questionWhat factors contribute to stress in junior doctors and how can this be evaluated in order to tailor interventions to improve wellbeing? Background Over 53,000 junior doctors provide 24-hour care in the United Kingdom (UK) and make up 35% of the UK medical profession. Moreover, the junior doctors' contract dispute has increased public awareness of their workplace pressures. Prolonged occupational stress can lead to burnout, which can affect job performance and patient care. However, the specific determinants of stress (the stressors) in UK junior doctors remain unclear without reliable and valid measurements. Studies examining stress in doctors have used generic instruments to measure the outcomes of stress such as Maslach Burnout inventory (MBI) but do not evaluate stressors. Literature searches did not identify comparable instruments measuring stressors that were specific to NHS junior doctors. Aims and objectives for the doctoral fellowship To develop an online instrument that evaluates the stressors identified in my previous research To assess face and content validity, as well as predictive validity of this instrument against burnout using the MBI. To understand how the study results can be applied to developing specific interventions and policies in the NHS by professional stakeholdersMethods and timeline for deliveryThe first part of the work has been completed and this involved identifying the stressors in junior doctors. A total of 44 junior doctors participated in 11 focus groups. Four main themes were identified: 1. Expectations and guilt, 2. Feeling undervalued, 3. Managing uncertainty and risk, 4. Work environment. These results will be used in developing the online instrument. The remaining 3 parts will take place within Health Education England (HEE) North-West, which is responsible for over 7000 trainees over 24 months. Part 2: Developing an instrument to measure and evaluate the stressors (10 months)Results from my completed work in part 1 will be used to develop a prototype instrument evaluating the stressors. A pilot will be undertaken to assess face validity. The Stakeholder Engagement group will be consulted to assess content validity. Part 3: Exploring the relationship between stressors and effects on junior doctors' wellbeing (10 months) This instrument will be randomly sent to 1000 North-West region trainees in the format of an anonymous online questionnaire. We will conduct a range of psychometric analyses to assess validity and reliability, including testing predictive validity against the MBI. Response biases will also be assessed using demographic data provided by HEE.Part 4: Understanding the applications of our results to intervention and policy development (4 months) We will convene two half-day conferences involving professional stakeholders who are involved in managing junior doctor wellbeing, policymakers and commissioners. Our study results will be presented, followed by small group discussions focused on how the evidence can support commissioning of services and policies to improve junior doctor wellbeing.Anticipated impact and disseminationBy developing a validated instrument that identifies stressors in junior doctors, we will be able to provide guidance on designing interventions and policies that address the psychosocial needs of junior doctors.

Lay abstract: Why are we doing this project? Junior doctors are qualified doctors who continue to learn whilst they are at work. They provide 24-hour medical care to patients in the National Health Service. News reports high levels of stress are present in junior doctors. Prolonged job stress can lead to a reaction called burnout where one experiences exhaustion, cynicism and feelings of lack of achievements. Burnout can threaten patient care and safety but we don't know much about what causes stress and burnout in junior doctors. We will design a tool to measure what causes stress and this will give us more information of how best to reduce stress to improve junior doctor wellbeing. How are we going to do this? The project is split into 4 parts and will take place in North-West England. This project started in October 2017 and the first part has now been completed. We invited junior doctors in the North-West to participate in focus groups where they talked about stress and what they thought were the biggest causes of stress. Forty-four junior doctors participated in 11 focus groups, with a range of different doctors taking part. Part 2: Designing the tool Now that we have information on what contributes to stress in junior doctors, we will move onto the second part, which will involve developing an online tool to measure these different contributors. We will ask junior doctors to test this tool out to make further improvements. Part 3: Making sure the tool works The online tool will be sent out to a group of randomly selected junior doctors in the North-West. As well as measuring the contributors of stress, it is important to know how this relates to the outcomes of stress. We will therefore include another tool, which measures burnout. Part 4: Understanding how our results can be used to design methods to improve junior doctor wellbeing After the results have been collected, we will share the results with professional stakeholders who are involved in junior doctor wellbeing. This can help us understand how our results could be applied to design interventions and policies to improve junior doctor wellbeing. How will patients and the public be involved? Patients and the public are involved so that we can understand a range of different views. The Primary Care Research in Manchester Engagement Resource (PRIMER) group consists of patients and the public who have a special interest in research. We will present our results to PRIMER on an annual basis so that members can guide our research. Also, we have organised a 6-monthly stakeholder advisory group, which includes members of the public who have an interest in junior doctors, to discuss project progress and areas of improvement. This group includes professional stakeholders, but patient and public views are particularly important because they can provide a different perspective on professional issues. Both groups can help with the tool design and development, as well as potential solutions to improve wellbeing. They can also advise on how to improve awareness of stress in junior doctors to the general public. All lay members will be supported by arranging opportunities to discuss the meeting agenda in advance and to assist with any training needs such as definitions and research methods. Feedback will also be sought from lay members after each meeting. How do we propose to share this information? Professional stakeholders involved in training junior doctors can increase awareness of the results to junior doctors. We plan to publish our work in journals so increase awareness in researchers. Lay members can share the results with other patients and the general public.

Research activity codes: 2.3 PSYCHOLOGICAL, SOCIAL AND ECONOMIC FACTORS;3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: MENTAL HEALTH