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Showing results for tags 'Fatigue / exhaustion'.
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News ArticleA major London trust’s critical care staff have urged leaders to review elective work targets amid serious concerns over workload, safe staffing and burnout, HSJ has learned. In a letter to Guy’s and St Thomas’ Foundation Trust’s board, staff represented by trade union Unite said they had “repeatedly” raised concerns about the provider’s approach to elective work, as well as winter pressures and second wave planning, and the implications this has had for “the health, safety and wellbeing of both staff and patients”. The letter — which was also addressed to the trust’s health and safety committee and has been seen by HSJ — said: “Our primary concern is that the trust’s endeavours, and understandable need to square these circles, may be unrealistic given the current pressures on staffing and the high rates of sickness and burnout the trust is continuing to experience. “This is especially in critical care, where we are concerned this may compromise patient safety and is already damaging staff wellbeing and morale.” Read full story (paywalled) Source: HSJ, 18 December 2020
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News Article
‘We don't have enough nurses to keep all our patients safe,’ says RCN leader
Patient Safety Learning posted a news article in News
There are not enough nurses to safely care for patients in the UK, according to the body that represents the profession, and many of those who are working are suffering from anxiety and burnout after a gruelling nine months treating Covid patients. A year after the prime minister pledged during the 2019 election campaign to add 50,000 nurses to the NHS, the Royal College of Nursing has accused Boris Johnson of being “disingenuous” for claiming the government is meeting this 2025 target. Johnson claimed last week that the government had “14,800 of the 50,000 nurses already” during prime minister’s questions in the Commons. Yet the latest NHS figures show there were 36,655 vacancies for nursing staff in England in September, with the worst shortages affecting mental health care and acute hospitals. Staff in some intensive care units (ICUs) have quit since the pandemic, with those whom the Observer spoke to choosing to work instead in supermarkets or as dog-walkers. Dame Donna Kinnair, the RCN’s chief executive and general secretary, said: “The simple, inescapable truth is that we do not have enough nursing staff in the UK to safely care for patients in hospitals, clinics, their own homes or anywhere else.” She said that even before the pandemic, “heavy demand” was rising faster than the “modest increases” in staff numbers. Read full story Source: The Guardian, 12 December 2020 -
News Article
The battle for survival in Britain's intensive care units
Patient Safety Learning posted a news article in News
Across Britain, intensive care nurses and doctors are being pushed to their limits as they try to save lives from coronavirus. During 12-hour shifts in sweltering conditions, they are faced with technical and emotional challenges that many have never faced as they tackle a virus that has swept across the globe in a matter of days, threatening to kill tens of thousands in the UK. Britain has yet to even hit the peak of infections, but intensive care specialists are already asking how long they can keep working relentlessly. “We are trained for and used to dealing with difficult and emotional scenarios, but this is like a major incident that never ends,” says critical care nurse Karin Gerber. As an advanced nurse practitioner in critical care outreach, the 47-year-old sees patients in hospital who are getting sicker and may need to be admitted to intensive care. She says she has never seen anything “at this intensity”. The Royal London Hospital is at the forefront of the capital’s fight against the virus and has created more than 200 extra beds at its Whitechapel site in east London. They are filled with COVID-19 patients. Simon Richards, senior charge nurse at the Royal London’s critical care unit, tells The Independent: “In 20 years as a nurse this situation is by far the worst I have ever seen and totally unexpected, but the team spirit that people have shown has been amazing. “It’s extremely difficult, we are working so hard. The whole team is being pushed to their limit and you do wonder how long can this be sustained for? I wish we could see light at the end of the tunnel.” Read full story Source: The Independent, 24 November 2020 -
News Article"I still have nightmares most nights about being completely out of my depth." Gemma, a ward nurse in Northern Ireland, was redeployed to a critical care unit at the end of March when the first wave of coronavirus struck. "I had never looked after a critically ill intensive care patient in my life," she says. "I just thought, I'm coming in here and I'm going to die. I'm going to catch Covid and I'm going to be one of those patients in the beds." As the second wave of the pandemic takes deep root across parts of the UK, thousands of NHS workers are struggling to recover from what they have already been through. "We were all in PPE all the time," recalls Nathan, a senior intensive care nurse at a hospital in the Midlands. "All you can see is people's eyes, you can't see anything else." He describes trying to help junior members of staff survive long and difficult days. "And I'd see these eyes as big as saucers saying help me, do something. Make this right. Fix this." "The pressure was insane, and the anxiety just got me," he says. "I couldn't sleep, and I couldn't eat, I was sick before work, I was shaking before I got into my car in the morning." Nathan ended up having time off with severe anxiety, but he is now back at the hospital, waiting for the beds to fill up again. The BBC has spoken to a number of nurses and doctors across the UK who are deeply apprehensive about what lies ahead this winter. Read full story Source: BBC News, 24 October 2020
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News ArticleMany unpaid carers looking after vulnerable friends or relatives during the coronavirus crisis say they are worried about how they will cope this winter. Almost 6,000 unpaid carers completed a Carers UK online questionnaire. Eight in 10 said they had been doing more, with fewer breaks, since the pandemic began - and three-quarters said they were exhausted. The government said it recognised the "vital role" of unpaid carers. In the Carers UK survey, 58% of carers said they had seen their physical health affected by caring through the pandemic, while 64% said their mental health had worsened. People also said day centres and reductions in other services meant the help they once got had reduced or disappeared, leaving many feeling worn out and isolated. Carers UK wants such services up and running again as a matter of urgency. Helen Walker, chief executive of Carers UK, said: "The majority of carers have only known worry and exhaustion throughout this pandemic. "They continue to provide extraordinary hours of care, without the usual help from family and friends, and with limited or no support from local services." "It's no surprise that carers' physical and mental health is suffering, badly. I am deeply concerned that so many carers are on the brink and desperately worried about how they will manage during the next wave of the pandemic." Read full story Source: BBC News, 20 October 2020
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News ArticleDoctors and nurses in areas of northern England with some of the highest Covid infection rates have described being “physically and emotionally” exhausted, as the NHS braces itself for the second wave of the pandemic. Most of the north has been put into the tier 2 “high risk” category, with Merseyside in the highest – tier 3 – bracket. While politicians debate whether a nationwide circuit breaker would be a more effective instrument to curb spread of the virus, frontline staff – still scarred from the first wave – are under no illusions as to what lies in store. Carmel O’Boyle, a nurse in Liverpool, who is also chair of the Royal College of Nursing’s Greater Liverpool and Knowsley branch, said members of the public had used A&E and primary care sparingly during the first national lockdown but mixed messages and a lack of trust in the government had led to people throwing caution to the wind and attendances were rising accordingly. “The nurses across my branch are frightened and exhausted – physically and emotionally,” she said. “They’ve been dealing with this for months and now there are more people in hospitals than there were in March. Although we know a little bit more about how to treat people and the kind of path of the disease process, it’s still frightening. It’s just so demanding and so draining to be nursing people in this manner without any family involvement and with the complications that there are.” A consultant in Manchester, who did not want to be named, said her hospital coped with the first wave but “the difference this time is that we’re trying to continue all of the elective activity and that’s going to be challenging. “I do think that we will manage the Covid cases. I just now worry about whether we will be able to continue to keep the normal care for people who need their operations [and] need care for cancer." Read full story Source: The Guardian, 15 October 2020
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News ArticleGruelling 12-hour shifts, exhaustion and burnout are leading growing numbers of nurses to quit the NHS within three years of joining, new research reveals. Stress, lack of access to food and drink while at work, and the relentless demands of caring for patients are also key factors in the exodus, the King’s Fund thinktank found. The NHS must make it an urgent priority to tackle the worryingly poor working conditions nurses and midwives face in many hospitals or face worsening workforce shortages, it said. “Staff stress, absenteeism and turnover in the professions have reached alarmingly high levels,” the thinktank said after investigating the working conditions faced by NHS nurses and midwives. “This has been compounded by the Covid-19 pandemic, which has laid bare and exacerbated longer-term issues including chronic excessive workload, inadequate working conditions, staff burnout and inequalities, particularly among minority ethnic groups.” Read full story Source: 23 September 2020
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News Article
COVID-19: Doctors feel under pressure to work extra shifts unpaid, survey shows
Patient Safety Learning posted a news article in News
Thousands of doctors feel under pressure from their employers to work extra shifts, often unpaid, to help tackle the backlog of care caused by the covid pandemic, the BMA has warned. The warning came after results from the BMA’s latest tracker survey showed that more than half its respondents (58%, 2834 of 4876) had worked extra hours in the previous month as part of the response to the pandemic. Almost a third (29%, 1387) said they were not paid for the additional time they worked. More than two fifths (44%) of respondents (2086 of 4719) said they felt under pressure from their employer to do extra hours in the last month. And more than a third (36%, 1759) had either skipped taking full breaks altogether or taken them on rare occasions in the past fortnight. Nearly six in 10 doctors who responded (57%, 2889 of 5059) reported a higher than normal level of fatigue or exhaustion because of working or studying during the pandemic. Chaand Nagpaul, the BMA’s chair of council, said, “To learn that an already depleted and now exhausted workforce feels forced into doing more and more hours, with many reporting higher levels of fatigue than ever, is extremely worrying. It is putting them and their patients at risk. Working ‘flat out’ without a change to rest and recuperate is simply unsustainable and unsafe." Read full story Source: BMJ, 10 May 2021 -
News Article
GPs are at “breaking point” and in need of respite, leaders warn
Patient Safety Learning posted a news article in News
General practices are “reaching breaking point” because of the “intense” workload pressure facing doctors and staff, the country’s most senior GP leaders have warned. The warning came as new figures from NHS Digital showed that practices in England delivered almost five million more appointments in March 2021 than the month before and nearly three million more than in March 2019. Richard Vautrey, chair of the BMA General Practitioners Committee, said that the figures underlined the huge efforts practices were going to and the workload pressure on staff. He said, “GPs and their teams are consistently telling us they’re busier now than they have ever been, and this data—which does not include a large proportion of the vaccine programme undertaken by practices, nor a vast amount of other daily tasks—backs this up.” Last week the Ivy Grove Surgery in Derbyshire provided an example of the strain facing some practices in a 16 page open letter to its patients about the huge demand it was facing and the resulting risk of staff burnout. The surgery said it would be reducing its use of the video consultation tool eConsult, as it had seen a doubling of demand over recent months, with some patients submitting several requests a day. In a statement the practice told The BMJ, “We are aware of the stir our letter has caused but have also been overwhelmed by the kind feedback from our own patients, and the many encouraging messages of support we have received from GP surgeries all around the country. We therefore know that many of our GP colleagues are experiencing the same issues, but they may be fearful of articulating what is happening." “We feel that open and honest debate about demand and workload in general practice is vital. If this letter goes even a little way towards sparking some much needed discussion then it will have been a good thing.” Read full story Source: BMJ, 4 May 2021 -
News Article
We need to stop calling NHS staff heroes – for a very important reason
Patient Safety Learning posted a news article in News
When we put people on a pedestal, my experience is that they are less likely to be asked, ‘are you OK?’, writes Samantha Batt-Rawden, a senior registrar in intensive care medicine. Like many she has been touched by the groundswell of support from the public. But there’s a problem with this hero image, she says. "It’s not just that many NHS staff are feeling increasingly uncomfortable with being hailed as heroes for what they see as simply doing their jobs. Of course, we were going to step up to the plate when the COVID-19 pandemic hit. As doctors it was our duty. There was never any question. "But there’s something more than just feeling undeserving of the cape weighing heavily on our shoulders. The worst thing about being seen as a superhero? Very few think to ask if you’re OK. And herein lies the problem. Because healthcare workers are not heroes, we are human. Completely, painstakingly, fallibly human." Read full story Source: The Independent, 2 May 2021 -
News Article
NHS faces exodus of doctors after Covid pandemic, survey finds
Patient Safety Learning posted a news article in News
Thousands of UK doctors are planning to quit the NHS after the Covid pandemic because they are exhausted by their workloads and worried about their mental health, a survey has revealed. Almost one in three may retire early while a quarter are considering taking a career break and a fifth are weighing up quitting the health service to do something else. Long hours, high demand for care, the impact of the pandemic and unpleasant working environments are taking their toll on medics, the British Medical Association findings show. Dr Chaand Nagpaul, the leader of the BMA, said the high numbers of disillusioned doctors could worsen the NHS’s staffing problems and leave patients waiting longer for treatment. “It’s deeply worrying that more and more doctors are considering leaving the NHS because of the pressures of the pandemic – talented, experienced professionals who the NHS needs more than ever to pull this country out of a once-in-a-generation health crisis,” Nagpaul said. Read full story Source: The Guardian, 2 May 2021 -
News ArticleA quarter of NHS workers are more likely to quit their job than a year ago because they are unhappy about their pay, frustrated by understaffing and exhausted by COVID-19, a survey suggests. The findings have prompted warnings that the health service is facing a potential “deadly exodus” of key personnel just as it tries to restart normal care after the pandemic. A representative poll of 1,006 health professionals across the UK by YouGov for the IPPR thinktank found that the pandemic has left one in four more likely to leave than a year ago. That includes 29% of nurses and midwives, occupations in which the NHS has major shortages. Ministers must initiate a “new deal” for NHS staff that involves a decent pay rise, better benefits, more flexible working and fewer administrative tasks, the IPPR said. “The last 12 months have stretched an already very thin workforce to breaking point. Many are exhausted, frustrated and in need of better support. If the government does not do right by them now, more many leave their jobs,” said Dr Parth Patel, an NHS doctor and IPPR research fellow who co-wrote its new report on how the NHS can retain and recruit more staff. Read full story Source: The Guardian, 30 May 2021
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News Article
NHS poll shows rising toll of work stress on staff health
Patient Safety Learning posted a news article in News
The proportion of NHS staff in England who reported feeling unwell as a result of work-related stress increased by nearly 10% last year as the Covid pandemic took its toll, according to the health service’s 2020 survey. The survey found that 44% reported feeling unwell as a result of work-related stress in the previous 12 months, compared with 40.3% in 2019. The proportion has steadily increased since 2016 (36.8%). In a year like no other for the health service, the 2020 survey also found a slight reduction in respondents who said they often or always looked forward to going to work, and a bigger fall in those who said they were often or always enthusiastic about their job. Nevertheless, the survey – which was carried out before Boris Johnson announced plans to give NHS England healthcare workers a 1% pay rise next year, prompting widespread fury – found that the proportion of staff who were thinking of leaving the NHS fell from 19.6% to 18.2%. In a year in which ethnic minorities were heavily represented in the death toll of healthcare workers, and concerns were raised about being more likely to be pushed into frontline roles and about access to personal protective equipment, the responses relating to equality, diversity and inclusion were not so positive. The proportion of staff who said their employer provided equal opportunities fell compared with 2019, with a decrease among black and minority ethnic staff from 71.2% to 69.2%. Danny Mortimer, the chief executive of the NHS Confederation, said the overall picture was encouraging in the circumstances, adding: “There are, though, significant areas of concern, and the recent data on the continued poorer experience of ethnic minority staff starkly reminds NHS leaders that staff experience varies unacceptably in their organisations." Read full story Source: The Guardian, 11 March 2021 -
News Article
Healthcare staff must be given time to recuperate from pandemic, say leaders
Patient Safety Learning posted a news article in News
The NHS must have a realistic and steady approach to resuming services disrupted by the pandemic that explicitly recognises the need for staff to recover, NHS leaders have said. In a letter to the prime minister leaders from the NHS Confederation, which represents healthcare providers, warned, “The NHS cannot recover its services at the same rate of increase when staff are so exhausted.” The letter noted that there were over 5000 more patients with COVID-19 in UK hospitals right now that at the peak of the first wave and that this was taking its toll on staff. The leaders called for sustained local mental health support for the NHS workforce beyond the end of March and for a long term, fully funded plan to increase staffing numbers. The government must also set out clear expectations for the public on when routine procedures and other treatments would be fully back on line, they added. “With a workforce on its knees and many of the pre-pandemic challenges still very much at play they need your government both to acknowledge the consequences of the immense pressure their workers have been under so far, and to be realistic and honest with the public about what the NHS can safely deliver moving forward,” the letter said. Layla McCay, director of policy at the NHS Confederation, said that while health leaders would continue to prioritise urgent care and patients with the greatest clinical need, the prime minister must “be upfront with the public about what the NHS can safely deliver in this next phase.” Read full story Source: The BMJ, 11 February 2021 -
News ArticleMaternity staff are facing extreme burnout during the pandemic as staff shortages and longer, busier shift patterns lead to the workforce becoming increasingly overwhelmed, healthcare leaders warned. Senior figures working in pregnancy services told The Independent healthcare professionals are working longer hours, covering extra shifts around the clock, and spending more time on call to compensate for increasing numbers of employees taking time off work after getting coronavirus. Staff say stress-related absences have reached “worryingly” high levels, with junior doctors and midwives “thrown into the deep end” due to having to fill in for colleagues. Professionals argued the coronavirus crisis will lead to a rise in doctors, nurses and midwives suffering post-traumatic stress disorder (PTSD) and other mental health issues – raising concerns staff exhaustion could curb patient safety and standards of care. Read full story Source: The Independent, 31 January 2021
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News Article
COVID-19: 'Traumatised' hospital staff need time to recover
Patient Safety Learning posted a news article in News
"Traumatised" and "exhausted" medical staff need time to recover before tackling an NHS backlog, says the group representing hospitals in England. Many staff could resign if their wellbeing is not factored into plans to cut waiting lists, NHS Providers said. The number of people waiting more than a year for surgery rose 1,613 to 192,000 during the Covid pandemic. NHS Providers said demand for hospital beds is easing, but the pressure on intensive care units is still intense. NHS Providers estimates that it is going to be at least a month before the NHS gets back to normal winter pressures, and trusts are concerned about the transition into the next phase of the pandemic. Critical work that has been postponed, including a small number of urgent cancer cases, will be a priority, but there remains a need to tackle a wider backlog of routine operations alongside the vaccination programme. NHS Providers said trusts will work as fast as possible to tackle the backlog, but leaders cannot do so at the expense of staff burnout. Last month, a study suggested that many hospital staff treating the sickest patients during the first wave of the pandemic were left traumatised by the experience. Nearly half reported symptoms of severe anxiety, depression, post-traumatic stress disorder or problem drinking. One in seven had thoughts of self-harming or being "better off dead". Read full story Source: BBC News, 1 February 2021 -
News ArticleThe second wave of COVID-19 has put doctors under huge pressure, the Royal College of Physicians has warned, as two thirds of physicians report feeling tired or exhausted. A survey of 25 500 members of the college from across the UK, conducted on 2 November, received 1890 responses. It found that two thirds (64%, 931) felt tired or exhausted, 48% (687) felt worried, and just under a third (29%, 424) felt demoralised. Almost a fifth (19%, 280) said they have sought informal mental health support, such as speaking to colleagues or friends, during the pandemic. Just 10% (155) said they had sought formal mental health support from either their employer, GP, or external services. College president Andrew Goddard said he was concerned about the mental health of doctors, “There is no way to dress it up—it is pretty awful at the moment in the world of medicine. Hospital admissions are at the highest ever level, staff are exhausted, and although there is light at the end of the tunnel, it seems a long way away.” He said that before the pandemic, few physicians would have expected to need formal mental health support during their career. After the pandemic, staff will be in desperate need of a break, Goddard said, and will need specific time away if they’re to be at their best. “Doctors have demonstrated remarkable resilience throughout the pandemic, working under the most challenging conditions the NHS has ever faced, but they can’t continue working this way forever,” he said. Read full story Source: The BMJ, 21 January 2021
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News ArticleOne of the largest hospital trusts in England has been downgraded by the care watchdog amid safety fears and criticism that bosses did not act on staff concerns. The Care Quality Commission (CQC) said it found bedpans covered in faeces, urine and hair during 10 visits to wards at University Hospitals Birmingham Trust in June. Staff in A&E told inspectors they were put under pressure to nurse patients in corridors. At one stage 20 ambulances were queuing outside Heartlands Hospital with patients waiting outside. The CQC said staff felt “disconnected from leaders” who didn’t show an understanding of the pressures they were under. Consultants to the regulator staff were experiencing fatigue and they felt executives at the trust “were no longer interested in staff welfare”. In its inspection report, the CQC said staff did not always clean equipment and said labels for when items were last cleaned were being applied incorrectly. Read full story Source: The Independent, 8 October 2021
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News ArticleAlmost a fifth of nurses who left the profession cited a negative workplace culture as a reason for leaving along with almost a quarter saying they were under too much pressure. The nursing regulator, the Nursing and Midwifery Council (NMC) warned there could be an exodus of registered nurses after the coronavirus pandemic in its latest annual report. Despite a record number of nurses and midwives joining the profession across the UK, the NMC said pressure on frontline nurses could drive many away. In a survey of 5,639 nurses who left the register between July 2019 and June 2020, the NMC found that after retirement as the most common reason for leaving, almost a quarter of nurses (23%) said they left their jobs because of "too much pressure", leading to stress and poor mental health. A total of 18% blamed a negative workplace culture as the reason to leave. The NMC report warned: “These issues existed before the pandemic, and may well outlast it, further disrupting an already fatigued nursing and midwifery workforce. If not addressed, this could have a significant impact on the number of people we report leaving our register over the next year and beyond.” Read full story Source: The Independent, 20 May 2021
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EventThis Hospital at Night Summit focuses on out of hours care in hospitals delivering high quality safe care at night. Through national updates, networking opportunities and case studies this conference provides a practical guide to delivering a high quality hospital at night, and moving forward during and beyond the Covid-19 pandemic. The conference will also focus on improving staff well-being at night and reducing fatigue. Attending this conference will enable you to: Network with colleagues who are working to improve Hospital at Night Practice Learn from developments as a results of Covid-19 Improve your skills in the recognition management and escalation of deteriorating patients at night Understand and evaluate different models for Hospital at Night Examine the role of task management solutions for Hospital at Night, including handover and eObservations Ensuring effective and safe staffing at night, including adequate breaks Examine Hospital at Night team roles, competence and improve team working Improving safety through the reduction of falls at night Supporting staff and reducing fatigue at night Develop the role of Clinical Practitioner and Advanced Nursing Practice at night Identify key strategies to change practice and ways of working in Hospital at Night Understand how hospitals can improve conditions for night workers and support Junior Doctors Improve the management of pain at night Work across whole systems to improve support for patients out of hours Self assess and reflect on your own practice Gain CPD accreditation points contributing to professional development and revalidation Evidence Register There are a limited number of free places for hub members. Email: info@pslhuborg if interested. Follow on Twitter @HCUK_Clare #hospitalatnight
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EventThis Hospital at Night Summit focuses on out of hours care in hospitals delivering high quality safe care at night. Through national updates, networking opportunities and case studies this conference provides a practical guide to delivering a high quality hospital at night, and moving forward during and beyond the COVID-19 pandemic. The conference will also focus on improving staff well-being at night and reducing fatigue. For more information visit: https://www.healthcareconferencesuk.co.uk/virtual-online-courses/hospital-at-night-summit or email nicki@hc-uk.org.uk hub members receive a 20% discount. Please email info@pslhub.org for discount code Follow on Twitter @HCUK_Clare #hospitalatnight
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Event
'DO NO HARM' documentary screening
Patient Safety Learning posted an event in Community Calendar
untilA screening of 'DO NO HARM', a 60-minute documentary that discusses physician burnout and suicide followed by a 60-minute panel discussion. Doctors take an oath to save lives, yet they are taking their own at an alarming rate, trapped in a toxic healthcare system that puts their patients' lives at risk. This film and panel discussion bring awareness to the topic of this epidemic that's been covered up for decades until now. Register -
Content ArticleAfter 12 years of brutal service, Neil Barnard, an NHS emergency medicine consultant, is leaving his NHS post to work abroad. His decision to leave is driven by financial and personal reasons. More than anything, he says he's tired and has little more left to give to the NHS.
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Content ArticleIn this blog, nurse Carol Menashy describes her experience making an error in theatre fifteen years ago, and the personal blame she faced in the way the incident was dealt with at the time. She talks about how a SEIPS (Systems Engineering Initiative for Patient Safety) framework can transform how adverse incidents are dealt with, allowing healthcare teams to learn together and use incidents to help make positive changes towards patient safety. She describes the progress that has been made towards organisational accountability and systems thinking over the past fifteen years, and talks about the importance of staff support to allow for healing from adverse events.
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Content ArticleThis blog by doctors Clare Rayner and Amali Lokugamage argues that Long Covid rehabilitation needs a wider focus that goes beyond a purely biomedical paradigm to include complementary therapies and methods. The authors—who have both lived with Long Covid for more than two years—argue that although patients were the first to raise concerns about Long Covid, describe its symptoms and patterns and even research the condition, their narratives and voices are not being included in approaches to treatment. While the biomedical evidence surrounding Long Covid is currently limited, they highlight that there is much valuable lived-experience to be found in patient support and campaign groups, and that patients' knowledge should be drawn on to shape policy and guidance about the condition.
