1. ‘Looking after You’ Wellbeing Workshop

2. Learning objectives:
Understand the significance of stress and mental health disorder in the National Health Service.
Identify the stressors which may occur during a career in medicine and how to manage this.
Know about the difference resources available for help and psychological support available to junior doctors
Understand the importance of maintaining wellbeing and what you can do to improve this

3. Ice Breaker
Anti Anxiety Facial Yoga This is purely an ice breaker but the exercises may be used to help with relaxation. face-yoga-poses

4. Impact of Stress on the NHS
Accounts for over 30 per cent of sickness absence in the NHS,
£ million per year cost to the NHS.
Affects up to 38% of NHS Staff
Stress can happen in different ways in different NHS organisations
NHS Staff have to deal with traumatic and harrowing circumstances
‘Health and Wellbeing Framework’
Standards that NHS organisations need to maintain in order to support staff in feeling well and being healthy and happy at work. 
experience/health-and-wellbeing

5. Stress Situations or events that put pressure on us
A reaction to being under pressure
It can be just a normal response and part of life
Stress can be become overwhelming and start to cause problems.
Can lead to mental health problems, or make existing problems worse.

6. Symptoms of Stress Physical Symptoms Headaches Muscle tension or pain
Emotional Symptoms
Overwhelmed 
Irritable  
Fearful 
lacking in self-esteem
Racing thoughts 
Constant worrying 
Difficulty concentrating  
Difficulty making decisions 
Physical Symptoms
Headaches
Muscle tension or pain 
Dizziness
Sleep Problems
feeling tired all the time
eating too much or too little 
Behaviours
Drinking alcohol
Smoking  
Being short tempered 
Avoidance

7. Causes of Stress Being under pressure Having to deal with change
Lack of control
Overwhelming responsibilities
Life events
Personal
Friends/family
Employment/Study
Long term health problems
Housing
Money
Can be dependent on a perception of a situation and our emotional resilience to stressful situations

8. Maintaining wellbeing and emotional resilience
Identify stressful triggers
Time management
Avoid unreasonable and unrealistic demands
Relaxation
Interests and hobbies
Exercise
Find time for friends
Eat well
Reward yourself for achievement
Acknowledge your support network
Take a break
Holiday
Get a change of scenery

9. Good Sleep Hygiene Regular bedtime routine Sleep at regular times
Between 6-9 hours needed
Wind down (e.g warm bath)
Organise your thoughts before going to bed (e.g.write a list.) 
Relaxation exercises
Relaxation Music
Make your bedroom sleep-friendly and relaxing
Avoid TVs and other electronic gadgets, light, noise, and a bad mattress or bed. 
Bedroom should be dark, quiet, tidy and an acceptable temperature
Thick curtains
Avoid caffeine in the evening
Earplugs and eye mask especially during the day when on nights

10. Cases and Coping Strategies

11. Case 1
You are a second year GP specialist trainee currently working on a cardiology rotation. You are enjoying the job and your peers have already provided you with positive feedback regarding your performance. You do a regular general cardiac clinic on a Tuesday afternoon. This week there is no cardiology consultant present but you are being supported by the Cardiology specialist registrar. There was meant to be a Cardiology Consultant present but they have unfortunately had to take the day of sick. There are four new patients on the clinic list and the SPR has asked you to start with the first new patient. You are happy to do so and have already seen three new patients before under the consultant supervision in the past. You read the referral letter from the GP which tells you that Mr Garmin is an 82- year-old man, with a history of osteoarthritis and gout. He has experienced two episodes of syncope which he has recovered fully from. The GP carried out a 12 lead ECG which showed tri-vesicular block and a cardiology referral was recommenced. Mr Garmin has waited 6 weeks for this appointment and attended with his wife and two daughters. You invite the patient and the family members into your clinic room. You introduce yourself politely and ask Mr Garmin to confirm his details. One of his daughters, gets red in the face and tells you that they have arrived today expecting to see a consultant. They have waited six stressful weeks for this appointment and feel they won’t be moving forward whatsoever by seeing yourself today. After taking time to listen to the daughter’s concerns, you apologise and explain that it is not always possible to see the consultant. You explain that you will be carrying out a thorough assessment and will involve the registrar if there are any questions which can’t be answered. The daughter tells you that it is absolutely unacceptable that they are not seeing a consultant and just want to get the consultation over and done with. You do offer the patient and family the opportunity to see the SPR but they all decline. The patient is very silent through the whole of this discussion. You see no alternative but to proceed with the consultation but feel extremely uncomfortable throughout.

12. Case 2
You are a foundation year 1 (F1) doctor, working on the vascular ward as part of your surgical rotation. On Monday, you did an evening oncall from 17:00 to 21:00. You attended handed over and received four jobs from your F1 colleagues which included assessing two patients, reviewing bloods and confirming chest drain placement on chest xray. The surgical registrar contacted you 40 minutes after handover, whilst you were in the middle of reviewing a post op patient who was presenting with cough, shortness of breath and pyrexia. You interrupted the review to answer the bleep. The surgical SPR was quite pleasant and said that he would hopefully be up on the ward later to ensure you were ok. He did however ask if you could book a CT chest, abdomen and pelvis for a patient called Ryan Hardaker who was post op emergency laparotomy for obstruction secondary to bowel cancer. The reason for the investigation was for completion of staging. Later on that evening, you needed to get to the 21:00 handover. Just before attending this you remembered last minute that you needed to book the scan and so planned to do this quickly before you attended handover. Unfortunately, three hours had passed since taking the instruction from the SPR and you only vaguely remember the name of the patient as you didn’t write it down. You had already made three calls through the evening to the SPR so didn’t want to call again. You proceeded on booking the scan but incorrectly requested it for Robert Hardman who was also on the ward. This patient also had a diagnosis of cancer but this was rectal cancer. He had already had completed his staging investigations and his surgery was elective. The incorrect patient received the scan. Two days later, you had just finished the ward round with the consultant. A consultant who was head of the surgical directorate came onto the ward and asked to speak to you. You were told of your mistake, the scan had also shown possible liver metastasis which the patient didn’t know about. Although the consultant displayed a supportive manor, he was clearly disappointed and asked for you to complete an incident form. He advised that the surgical SPR had already spoken to the patient and explained the situation but thought you should consider also speaking the patient in patient. The patient accepted that this was a mistake and did not want to take any further action.

13. Case 3
You are a foundation year 1 doctor and on your third week of your second medical rotation which is on the endocrine and general medicine ward. You had enjoyed your first medical job and although it was busy, you were well supported by the senior members of the team. You have noted that there is a significantly busy turnover on this ward. There are two endocrine consultants who each do two ward rounds per week of their own patients. In addition to this there are often at least five outliers on the ward which these consultants will not see. There are meant to be two F1’s covering the ward but the one assigned has gone off on long term sick and has not been replaced. There is also an endocrine SPR who you are able to contact but they visit rather infrequently. It is down to you, to see most of the patients each day, do the jobs and deal with anyone who is particularly sick. Over the last three weeks, you have called the MET team three times. You have not left before seven every night and feel extremely unsupported. When you do make it home, you are exhausted but still thinking about the patients and whether you have missed anything. You have met with your educational supervisor who has escalated this. Arrangements are being made to move a foundation year 2 doctor onto the ward but you are still having to deal with the currently.

14. Case 4
Your mum and dad live together, about two hours away from where you live and you try and go back to visit them every few months. Your last visit home was during the Christmas period. Your mum mentioned that she was slightly worried about your dad as he seemed to be telling her the same stories over and over again. You dad has always been a quiet man but you get on very well and you hold him in very high regard. He previously worked a Vet and owned his own practise. He is now aged 62 and decided to retire last year so he could concentrate on his love of golf. Christmas was a very busy time and you didn’t get much chance to chat alone with your dad. Two months following this, you had a call from your mum. She informed you that she was getting increasingly concerned about your dad. He was struggling to remember things short term. This was causing an increasing number of arguments and he was also declining to seek any help. The night before, however, your mum woke up to a knocking on the door in the middle of the night. It was the next door neighbour standing alongside your dad. They had found him trying to get into their garage. You decided to return home during your annual leave and speak to your dad. He decided to attend the GP and was referred to memory clinic as a result. Over the next three weeks, work were very supportive and let you attend these appointments with your dad. Following thorough investigation, your dad was diagnosed with early onset Alzheimer’s disease. You initially took a day off work but decided to return to take your mind off things. Your dad is currently living with you mum who is managing to support him. You would ultimately like to move closer to home but have only completed four months of your foundation year 2. You are now starting your second rotation on the gerontology ward. You are working with a good team and the workload is manageable. You are however noting that your mood is becoming increasingly low. You are struggling to be around those suffering with dementia and find that you dad is on your mind constantly.

15. Coping Strategies
Take time to debrief with colleagues i.e. go for a coffee
Arrange a meeting with you supervisor to talk things through and develop a plan to move forward.
Start a Balint Group
Small discussion group of health care professionals (8-12 participants)
Meet monthly (or regularly)
Aims to explore patient and clinician relationship
Supportive environment and helps to prevent ‘burnout’
Attend a Swartz Rounds
Forum for hospital staff to come together and talk about emotional and social challenges they come across in caring for patients.
Reflection
Deep Breathing exercises
If time then here is a short video to practise some deep breathing exercises which can help with relaxation.
Practise a Breathing Exercise.

16. Reflection

17. What
So What
Now What
Important not to get stuck on the first two stages
This can happen through conversations with supervisors
Over a cup of coffee
Time thinking away from the situation
Further reading
Attending a course

19. Services and Resources
General Practitioner (your own)
Lead Employer-
             Self-Referral
             Psychological Support/Counselling
GP Health Service
The NHS GP Health Service is a free and confidential service for GPs and GP trainees    working or looking to return to clinical practice in England who are suffering with a mental health concern, including stress or depression, or an addiction issue.  
GP First5
Aims to support GPs in the first five years post MRCGP through to revalidation
BMA Doctor Support Service
Doctors who face GMC investigations or license withdrawal have access to a confidential support service from the BMA
BMA wellbeing support services
Confidential, 24/7 telephone counselling and peer support. Free of charge to all doctors and medical students.

20. Wellbeing Charades Please split into two groups.
Over a timed 2 minute period, one nominated student from the each group will take it in turn to come forward to act out the wellbeing activity.
The team that guesses the most correct wellbeing activities in two minutes, are the winners. Please keep a scorecard.
Player Rules
Take the set of charade cards
Act out the activity in silence.
Hold up fingers to indicate number of syllabus in the answer.
The member on your team, shout out the activity until it is correct, then move onto the next card.

21. Mindfulness Easy to rush through life
This activity aims are to make you more aware of the present moment.
Improving your mental wellbeing
Becoming more aware of the present moment, helps us understand ourselves better and enjoy life
Recommended by NICE as a way to prevent depression
Other mindfulness practices include Yoga and tai-chi
To end, play these two videos to take part in a short mindfulness activity

22. Questions and summary

23. References
NHS Employers. Health and Wellbeing. workforce/retain-and-improve/staff-experience/health-and-wellbeing (accessed 19th March 2019)
Mind. How to manage stress. manage-stress_2015.pdf (accessed 19th March 2019)
NHS. How to deal with stress. depression/understanding-stress/ (accessed 19th March 2019)
NHS. Sleep and Tiredness: How to get sleep. tiredness/how-to-get-to-sleep/ (accessed 19th March 2019)