Introduction: Newly qualified doctors are frequently first to the scene in managing acutely unwell in-patients. Failures in clinical assessment, basic management and early escalation of care lead to avoidable patient morbidity and mortality. Analyses of adverse events have highlighted the importance of non-technical skills training to improve patient safety. These are a combination of cognitive (such as decision making) and social skills (such as team working), which complement knowledge and technical ability, and contribute to safe and effective care. In order to train and assess junior doctors in these skills, we must first have an accurate understanding of what they involve. This research project was designed to identify the critical non-technical skills required by junior doctors to manage acutely unwell patients safely and effectively. It aimed to develop a tool to observe these skills that could be used in training, assessment and research. Method: A literature review was used to develop an initial framework to categorise the non-technical skills required in this domain. Twenty-nine in depth semi-structured interviews were then completed with junior doctors. A critical incident technique was utilised: Junior doctors were asked to recall a challenging case in which they managed an acute medical emergency. Interviews were transcribed and coded using template analysis. A panel of subject matter experts were then consulted in order to refine this framework and develop an assessment tool for observing these skills. This involved two focus groups and an iterative process, returning to the original data to verify any changes. Results: Four categories of critical non-technical skills were identified: Situation awareness, decision-making, task management and teamwork. Each of these had between three and four sub-categories. Descriptors, exemplar behaviours and an assessment scale were developed to allow these non-technical skills to be observed and rated using a behavioural marker system. During the development of this tool, exploration of the data revealed the influence of factors such as hierarchy and culture on the behaviour of junior doctors. Conclusions: The performance of newly qualified doctors in acute care is influenced by the complex clinical environments in which they work. This can have profound implications for patient outcomes. The framework developed by this research allows us to be explicit about the types of behaviours that are required to keep patients safe. If this tool can be integrated into clinical training, then it could be used by clinicians to support the development of safe and effective skills and reduce the current level of avoidable patient harm.

While there is extensive research on medical doctors and their mental health, little is known about the specific barriers which prevent them from accessing psychological services. Numerous studies have shown that rather than asking for help from other professionals such as counselling psychologists and therapists, doctors would rather turn to drugs and alcohol to cope with their psychological distress. Junior Doctors (JDs) specifically are at particular risk of mental ill-health but feel prevented by their profession from seeking psychological treatment. Little research has been conducted on this particular subject area focusing specifically on JDs. This study readdresses the empirical evidence available for the issue and informs more clearly how counselling psychology and related professions can provide a more effective service to this client group. A constructivist grounded theory approach using eight participants allowed for a detailed examination of the participants’ subjective experiences of the research phenomenon and the generation of new theory on the barriers which prevent JDs from accessing psychological help. Of the eight participants, seven were from an Asian background and one was of Caucasian origin. Further, seven were male with the remaining one participant being female. A core category was uncovered from the analysis of the data which apply to the research participants: psychosocial barriers to accessing psychological services by JDs. This core category was informed by three main themes: 1) medical identity 2) the development of coping strategies in the British medical culture, and 3) the unacceptability of difference. This core category and its themes make up the grounded theory of the research. In light of the findings it may be suitable to adapt the usual process of therapy and negotiate a more appropriate method of delivering psychological support to reduce barriers and to promote credibility and effectiveness of counselling psychology among this client group.

Background: Prescribing errors are the most frequent type of error in the medication use process. High risk medicines (HRMs) are a sub-class of medications that if used erroneously have potentially devastating consequences which defined by Institute for Safe Medication Practices (ISMP) as the drugs that bear a heightened risk of causing significant patient harm when they are used in error. Therefore, prescribing errors with HRMs are of concern to healthcare professionals that are responsible for ensuring mitigating patient safety. This thesis examines to what extent prescribing errors with HRMs in hospital occur, the causes of prescribing errors with HRMs and the differences to non-HRMs and the prescribing errors with HRMs during the on-call period. Method: The research adopted a mixed methods approach to explore prescribing errors with HRMs in hospitals and three studies were undertaken. The first study was a systematic review of the literature to explore the prevalence and incidence of prescribing errors with HRMs in hospitals. The second study was a secondary analysis of 59 existing interviews with foundation year doctors to explore the causes of prescribing errors with HRMs and compare them to those for non-HRMs reported in the same interviews. The third study was a qualitative study of the challenges of prescribing HRMs safely during the on-call period. This final study involved six focus groups with foundation year doctors (total participants number was 42). Results: Overall, findings demonstrated that there is paucity of studies that explored the prevalence of prescribing errors with HRMs and this literature showed inconsistency in definitions of prescribing errors, HRMs lists, severity scales and study methods (Study One). This resulted in a very wide range of prevalence of prescribing errors with HRMs. In terms of causes of prescribing errors with HRMs (Study Two), prescribing HRMs was considered a complex task for participants, especially those requiring dosage calculations, errors in the legal prescription requirements for controlled medications occurred with HRMs only and the on-call period was a particularly challenging period to prescribe safely especially with HRMs. In Study Three, the reasons found for this include the nature of the on-call period as a fast-paced environment, the methods of communication such as the bleep system, lack of accessibility to patient information and lack of plan from the primary team. Conclusions: HRMs form part of general medications, meaning they share similar traits, but the potentially devastating consequences of HRMs and the complicated task posed by prescribing them makes errors in their prescription profound. Therefore, HRMs need closer attention and more concern from healthcare professionals, researchers and policymakers. Such attention could result in a significant reduction in adverse outcomes and improved patient safety.

Background: Today, women constitute about half of medical students. However, women are still underrepresented in prestigious specialties such as surgery. Some suggest that this could be explained by women being more oriented towards work-life balance. Aim: The overall aim of this dissertation was to explore aspects of gender in work-life priorities, career plans, clinical experiences and negotiations of professional ideals among medical students and newly graduated doctors, all in a Swedish setting. Method: We based the analysis on data from two different sources: an extensive questionnaire exploring gender and career plans among medical students (paper I-III) and interviews with newly graduated doctors (study IV). In paper I, four classes of first- and final-year medical (N=507, response rate 85%) answered an open-ended question about their future life, 60% were women. We conducted a mixed methods design where we analyzed the answers qualitatively to create categories that could be analyzed quantitatively in the second stage. In paper II, five classes of final-year medical students  were included (N = 372, response rate 89%), and 58% were women. We studied their specialty preference and how they rated the impact that the motivational factors had for their choice. In order to evaluate the independent impact of each motivational factor for specialty preference, we used logistic regression. In paper III, final-year medical students answered two open-ended questions: “Can you recall an event that made you interested of working with a certain specialty?” and “Can you recall an event that made you uninterested of working with a certain specialty?”. The response rate was 62% (N = 250),  and 58% were women. The analysis was similar to paper I, but here we focused on the qualitative results. In paper IV, thematic interviews were conducted in 2014 and 2015. We made a purposeful sampling of 15 junior doctors, including nine women and six men from eight different hospitals. Data collection and analysis was inspired by constructivist grounded theory methodology. Results: When looking at the work-life priorities of medical students and junior doctors it is clear that both men and women want more to life than work in their ideal future. The junior doctors renounced fully devoted and loyal ideal and presented a self-narrative where family and leisure was important to cope and stay empathic throughout their professional lives. The specialty preferences and the highly rated motives for choosing them were relatively gender neutral. However, the gender neutrality came to an end when the final-year medical students described clinical experiences that affected their specialty preference. Women were more often deterred by workplace cultures, whereas men were more often deterred by knowledge area, suggesting that it is a male privilege to choose a specialty according to interest. Among the newly graduated doctors, another male privilege seemed to be that men were able to pass more swiftly as real doctors, whereas the women experienced more dissonance between their self-understanding and being perceived as more junior and self-doubting. Conclusions: The career plans and work-life priorities of doctors-to-be were relatively gender neutral. Both female and male doctors, intended to balance work not only with a family but also with leisure. This challenges the health care system to establish more adaptive and flexible work conditions. Gender segregation in specialty choice is not the result of gender-dichotomized specialty preferences starting in medical school. This calls for a re-evaluation of the understanding where gender is seen as a mere background characteristic, priming women and men for different specialties.