Westminster REFRAME workshops for Guy’s and St Thomas’ Hospital staff: Evaluation report

Executive summary Introduction Being a doctor is often a highly rewarding career, but it can be a challenging role. The demands of the job can lead doctors to experience high stress levels and burnout, and put them at risk of psychiatric morbidity. Resilience training, by providing insight, self-regulation skills and time for reflection, may have the potential to mitigate distress and improve physician wellness. The Westminster REFRAME workshop is a half day, intensive resilience-training programme, originally designed for FY1 doctors to help them cope and perform safely and competently as professionals. The workshop, in a form now taught by a larger team of trainers, has been adapted for other medical staff. This report presents evaluation findings on the experiences and outcomes of the workshop for doctors at various stages of their career, as well as a small number of other hospital staff. Methods Westminster REFRAME workshops were put on for different groups of staff at Guy’s Hospital: speciality training (ST) 1+ doctors, consultants, the Junior doctors leadership group and other members of clinical staff. Generally, different groups were invited to particular workshops and the content was fine tuned slightly to be inclusive when membership was diverse. Workshops’ maximum capacity was 20. All attendees were invited to take part in the evaluation. Questionnaires were used to collect quantitative and qualitative data from participants at three time points: immediately prior the workshop (baseline), immediately after the workshop (post workshop), and two months after the workshop (follow-up). Outcome measures collected included perceived stress and positive well-being. Additionally, participants are asked to rate six statements about the workshop (e.g. ‘the workshop was useful to me’; ‘The ideas and concepts were communicated clearly’). Open-ended questions collected written data regarding participants’ experiences and perceptions of the workshop and any changes they had made as a result of attending. Key findings • Of the 68 doctors and health professionals attending a Westminster REFRAME resilience workshop, 63 completed baseline and post-workshop questionnaires, and 47 completed a follow-up questionnaire. • Participants reported elevated levels of stress at baseline. • Comparisons between baseline and 2-month follow-up questionnaires revealed a statistically significant improvement in both participant stress levels and well-being ratings. • Participant ratings of various aspects of the workshop presented a positive overall picture of participants’ experiences of the day: many responses rated different aspects of the workshop with the maximum scores of 4 and 5. • Ninety percent of participants said that the workshop was useful, with 8% unsure how useful the workshop had been and 2% reporting not finding it useful. Ninety-two percent of participants felt that that topics covered were useful for their work. The majority of participants said that they intended to use some of the techniques they had learnt on the workshop. • Participants valued having time to explore stress and resilience issues including sharing experiences of work stress with peers, practical demonstrations on stress management, and having time to reflect on stress and coping. • Participants reported wanting even more on practical solutions to manage stress in the workshop, some would have liked a longer session. • Ninety percent of participants reported that they intended to do at least one thing differently as a result of attending the workshop; 75% of those who completed a follow-up questionnaire had actually done something differently. Changes made included using breathing techniques learnt on the workshop, meditating, taking more breaks/time out, adopting a different mental approach to stress/stressful situations, increased reflection on stressful situations, improved communication with colleagues, and approaching certain work situations differently. • Changes resulted in participants reporting that they were calmer at work and home, more effective at work, taking work home with them less, or had more energy. • Over half of participants felt that their patients had benefited from their attending a resilience training workshop: doctors felt that being more calm and focussed (as a result of resilience techniques) led to improved interactions with patients and more efficient working. • The Westminster REFRAME website intended to support doctors to make changes, was rarely used by participants. Key reasons for not doing so included not being aware that it existed, lack of time, and having forgotten about it. • The new evaluation strategy (e.g. new evaluation procedures, reworked questionnaires) improved the questionnaire completion rate and provided more contextual data regarding how participants were experiencing the workshop. Participant quotes “Great people – course director (especially [anonymised]) and other consultants on the course. Good to meet and have time with other colleagues. Confirmation that my own speciality is better off than many others. Much less isolated and more team working.” “Good group size. Lecturers/facilitators experienced, calm and steered. Open/honest/non-judgemental. Experience sharing. V useful techniques and strategies put in clear way.” “Very practical, important information, useful and good to apply to everyday life.” “The relationship between my nervous system and thinking demonstrated to me.” “Better work life balance ensuring I do regular exercise, and don't work at weekends or on holiday.” “This has allowed me to become more focused. Work is work and personal life is separate. I used to find it very difficult not to take ongoing issues at work home and I think I am managing this better.” Conclusions The Westminster REFRAME workshop was generally well received by attending healthcare staff, suggesting that the workshop had been successfully adapted for a wider group of health professionals. Statistically significant improvements in both the stress and well-being scores of participants, along with self-reported behaviour change amongst a number of attendees, suggest that the workshop has the potential to improve staff resilience and well-being. However, findings should now be confirmed with a larger comparative study. Additional work to support and encourage behaviour change after the workshop may be useful, particularly additional promotion of the resilience website during and after the workshop. The new evaluation strategy was successful, it improved the questionnaire completion rate providing more reliable data on the workshop. Additionally, the inclusion of a stress measure was useful, as it identified doctors as being vulnerable to high levels of stress. The stronger qualitative element of the evaluation was helpful in providing data on how participants were using the information they had learnt on the course

Westminster REFRAME workshops for foundation year doctors 2016-2017: Evaluation report

Executive summary Introduction The Foundation Programme is the postgraduate medical training that UK medical graduates undertake after finishing medical school and prior to choosing a speciality training. It marks the move from medical school into employment as a medical professional. Whilst this is often an exciting and rewarding time, it is also a key transitional time which brings with it feelings of uncertainty, anxiety and unpreparedness. This period is reported as the most stressful in a junior doctor’s career. Resilience training has the potential to improve physician wellness by alleviating distress. The Westminster REFRAME workshop is a half day, intensive resilience-training event for Foundation Year 1 (FY1) doctors, which is designed to help them cope better with the personal and professional challenges of this demanding, transitional time. The workshop has been presented to FY1s at Guy’s and St Thomas’ Hospital since 2014, and this evaluation report, using a newly designed evaluation strategy to enhance questionnaire completion rates, presents findings for the 2016/7 cohort of doctors. Methods All FY1 doctors at Guy’s and St Thomas’ Hospital were asked to attend the course, and all attendees were invited to take part in the evaluation. Questionnaires were used to collect quantitative and qualitative data from participants at three time points: immediately prior the workshop (baseline), immediately after the workshop (post workshop), and two months after the workshop (follow-up). Outcome measures collected included perceived stress and positive well-being scales. Participants were also asked to rate six statements about the workshop (e.g. ‘the workshop was useful to me’; ‘The ideas and concepts were communicated clearly’). Open-ended questions sought participants’ experiences and perceptions of the workshop and any changes made as a result of attending. Key findings • Of the 52 FY1 doctors attending a Westminster REFRAME resilience workshop 49 completed baseline and post-workshop questionnaires, and 43 completed a follow-up questionnaire. • Participant ratings of different aspects of the workshop overall presented a positive impression of participants’ experiences of the day. Many responses rated various aspects of the workshop with the maximum scores of 4 and 5. • Two-thirds of participants said that the workshop was useful, with 21% unsure how useful the workshop had been and 11% reporting not finding it useful. Eighty-one percent of participants felt that topics covered were useful for their work. Over three-quarters of participants said that they intended to use some of the techniques they had learnt on the workshop. • Participants particularly liked learning tips and practical solutions to reduce stress and improve well-being and resilience; and reported wanting to have even more of this in the workshop. • Participants also valued sharing experiences of work stress with peers, having time to reflect on stress and coping, and learning about stress and resilience. • Eighty-five percent of participants reported that they intended to do at least one thing differently as a result of attending the workshop; 76% of those who completed a follow-up questionnaire had actually done something differently. Changes made included using breathing techniques learnt in the workshop, meditation, taking more breaks/time out, adopting a different mental approach to stress/stressful situations, increased reflection on stressful situations, and accepting help. • Changes resulted in participants reporting that they were managing stress more effectively, had improved focus/concentration, were able to think more clearly under stress, and had an improved work/life balance. • Just over half of participants felt that their patients had benefited from their attending resilience training, because the workshop had enabled them to carry out their jobs more effectively and/or communicate better with patients. • Participants reported high levels of stress at baseline. • Comparisons between baseline and 2 month follow-up questionnaires revealed stress levels and well-being ratings improved, but that this change was not statistically significant. • The Westminster REFRAME website intended to support FY1s to make changes was not used by participants. The main reasons for not doing so included not being aware that it existed, lack of time, and ‘forgot about it’. • The new evaluation strategy (e.g. new evaluation procedures, making participating in the evaluation mandatory, improved questionnaires) improved the questionnaire completion rate and provided more contextual data about how participants were experiencing the workshop. Participant quotes “Encouraged open discussion around issues of resilience. It was also nice to know that other people experience the same levels of stress, find out ways to deal with it.” P11 “Very much enjoyed breathing exercise and practising mindfulness techniques – found it very relaxing.” P20 “Great tips on how to manage the many common challenges of being a Dr in the NHS today.” P15 “The technique of slow breathing has helped me to calm down several times when I was under severe stress.” P32 “Very busy days with more jobs than time - expected to be in attendance on ward a lot, difficult to take time for breaks.” P20 “Introduced some calm into hectic days, clear my mind and focus on most important tasks.” P20 Conclusions The Westminster REFRAME workshop was generally well received by FY1 doctors. The workshop was able to instigate at least some behaviour change amongst a number of participants, who reported managing their well-being and stress differently as a result of attending the course. However, these changes did not translate into statistically significant changes in stress and well-being outcome measures. Additional work to support and encourage behaviour change after the workshop may be useful, particularly additional promotion of the resilience website during and after the workshop. The new evaluation strategy improved the questionnaire completion rate and provided more reliable data on the workshop’s impact. Inclusion of a stress outcome measure was useful, as it identified this group’s high perceived levels of stress. The stronger qualitative element of the evaluation was helpful in providing data on how participants were making use of what they had learnt on the course

ADN: An Information-Centric Networking Architecture for the Internet of Things

Forwarding data by name has been assumed to be a necessary aspect of an information-centric redesign of the current Internet architecture that makes content access, dissemination, and storage more efficient. The Named Data Networking (NDN) and Content-Centric Networking (CCNx) architectures are the leading examples of such an approach. However, forwarding data by name incurs storage and communication complexities that are orders of magnitude larger than solutions based on forwarding data using addresses. Furthermore, the specific algorithms used in NDN and CCNx have been shown to have a number of limitations. The Addressable Data Networking (ADN) architecture is introduced as an alternative to NDN and CCNx. ADN is particularly attractive for large-scale deployments of the Internet of Things (IoT), because it requires far less storage and processing in relaying nodes than NDN. ADN allows things and data to be denoted by names, just like NDN and CCNx do. However, instead of replacing the waist of the Internet with named-data forwarding, ADN uses an address-based forwarding plane and introduces an information plane that seamlessly maps names to addresses without the involvement of end-user applications. Simulation results illustrate the order of magnitude savings in complexity that can be attained with ADN compared to NDN.Comment: 10 page

An individualised yoga programme for multiple sclerosis: a case study

Purpose Despite the evidence that yoga is beneficial for people with multiple sclerosis (MS),substantial in-depth qualitative studies of yoga and MS, in particular individualized yoga programmes (IYP), are lacking. The aims of this paper are a) to conduct a case study on an IYP for one participant with MS in terms of their experience of yoga and how yoga affects their particular symptoms of MS and b) to better understand the unique and changing needs of someone with MS in the context of an IYP. Design and Method A qualitative case study design with data collected via a participant diary completed over the 24 week duration of IYP; an exit interview after the final IYP session, and weekly records completed by the yoga teacher. Data were analysed using thematic analysis. Findings Over the course of the IYP the female participant experienced an increased awareness of negative thoughts and feelings about MS and how it affected them and their body. As the programme progressed she began to work through these feelings and by the end of the programme reported experiencing improvements in muscle tone, strength,balance, psychological well-being and confidence. Conclusion Our findings highlight the importance of a programme individualized to meet the complex health and psychological needs of an individual with MS

Office Space Supply Restrictions in Britain: The Political Economy of Market Revenge

Office space in Britain is the most expensive in the world and regulatory constraints are the obvious explanation. We estimate the ‘regulatory tax’ for 14 British office locations from 1961 to 2005. These are orders of magnitude greater than estimates for Manhattan condominiums or office space in continental Europe. Exploiting the panel data, we provide strong support for our hypothesis that the regulatory tax varies according to whether an area is controlled by business interests or residents. Our results imply that the cost of the 1990 change converting commercial property taxes from a local to a national basis – transparently removing any fiscal incentive to permit local development – exceeded any plausible rise in local property taxes.Land use regulation; regulatory costs; business taxation; office markets

“We make something with the flower, but feel like I make with myself something”: The role of a community arts project supporting women who have experienced human trafficking

Human trafficking can have multiple adverse effects on a victim's mental and physical health. The study explored how a small UK community arts project was experienced by individuals post-trafficking and the impact it had on well-being. Community-based participatory research was employed to increase understanding the experiences of six female participants taking part in a community arts project. Data were analyzed using thematic analysis. Themes of Authentic Care, Building Confidence, and Creative Expression were developed. Findings suggest the community arts organization played a vital role in supporting women to build trust and social connections, as well as to feel valued. Artistic activities helped participants express individuality, had therapeutic benefits, and provided motivation, routine, and space from worries. The role of community arts organizations is important in supporting individuals in the context of limited post-trafficking services

Getting to the point? Rethinking arrows on maps

Maps help to form public opinion and build public morale. When the war is over, they will contribute to shaping the thought and action of those responsible for the reconstruction of a shattered world. Hence it is important in these times that the nature of the information they set forth should be well understood (Wright, Citation1942: 527). Maps form an essential part of the language used to communicate conflict. They are used to plan military operations and to indicate their consequences to a wider audience by providing the visual basis for articulating the movement of troops, displaced populations and shifting territories between competing powers. Consequently, mapmakers draw from a well-used toolbox of symbols and techniques to describe the dynamic nature of war in familiar ways. For those maps designed for public consumption, which is our focus here, these methods often include broad, swooping arrows for representing movements of troops and displaced people, starburst or explosion symbols for battles and the use of strong colours for changes in territory. In many respects, mapmakers working in the news media conformed to these established cartographic norms when they first responded to Russia’s invasion of Ukraine on 24th February 2022. However, unlike previous conflicts that have attracted global attention, their maps were subject to wider critique – particularly on social media – which brought into sharp focus the way that maps can communicate the consequences of war and prompted some cartographic innovation. The critique coalesced around two themes: first, how territory was being represented in terms of Russian gains (and therefore Ukrainian losses) during the first weeks of the conflict (see Fafinski, Citation2022); and second, how the huge exodus of Ukrainians from their country should be captured cartographically (see Cheshire, Citation2022). The latter, especially, prompted questions about the suitability of using arrows to indicate the flow of Ukrainian refugees to surrounding countries when arrows were being used simultaneously to indicate invading Russian troops. In this short paper, we aim to provide a critical examination of whether the arrow is fit for purpose in communicating the displacement of people as a direct result of conflict. Since arrows have become the go-to cartographic symbol for portraying movement, particularly as a result of war and other geopolitical events, we explore their origins and evolution on maps before discussing how arrows and their alternatives have been used in news media coverage of the war in Ukraine. We contend that critique and innovation is necessary for the development and use of more effective, and ultimately more appropriate, cartographic symbology

Evaluating the effects of planning policies on the retail sector: or do town centre first policies deliver the goods?

Few studies conceive of land as a productive factor but British land use policies may lower total factor productivity (TFP) in the retailing industry by (i) restricting the total availability of land for retail, thereby increasing space costs (ii) directly limiting store size and (iii) concentrating retail development on specific central locations. We use unique store-specific data to estimate the impact of space on retail productivity and the specific effects of planning restrictiveness and micromanagement of store locations. We use the quasi natural experiment generated by the variation in planning policies between England, Wales, Scotland and Northern Ireland to isolate the impact of town centre first policies. We find that TFP rises with store size and that planning policy directly reduces productivity both by reducing store sizes and forcing retail onto less productive sites. Our results, while they strictly only apply to the supermarket group whose data we analyse, are likely to be representative of supermarkets in general and suggest that since the late 1980s planning policies have imposed a loss of TFP of at least 20%

Atlas Men’s Well-being Programme: Evaluation Report

EXECUTIVE SUMMARY Background to the evaluation Men’s mental health and well-being is increasingly of concern. In England and Wales, the suicide rate is now almost four times higher for men (78%) than women (22%). Rates of diagnosis of men’s mental health problems do not capture distress among men well, as men may express distress in atypical ways (eg acting out, blunting emotions), suggesting that we need a deeper understanding of male experiences of distress and ‘men-friendly’ services to better help men. One such service, Atlas, was designed as a potential way of improving access to mental health services for men. Atlas was originated by Professor Damien Ridge, co-designed by Prof Ridge and Professor David Peters, and managed and governed by adapting University of Westminster Polyclinic guidelines, developed over 15 years. The Atlas Men’s Well-being Programme was designed to be ‘male sensitive’, to provide counselling and/or acupuncture for men suffering from stress or distress. Based at the Victoria Medical Centre (VMC), a busy NHS GP practice in central London, the pilot Programme ran from March 2013 until July 2014 for practice patients only. Our evaluation collected quantitative patient outcomes and qualitative data, to examine clinical changes in patients and their experiences of the Programme. In addition, interviews were conducted with a wide range of key stakeholders involved in the Programme. The aims of the interviews were to (a) understand the Programme from the perspectives of key stakeholders, and (b) improve the Programme early on by identifying any problems and feeding them back to the people who needed to know. Methods Questionnaires: All patients using the Atlas service were invited to take part in the evaluation. Questionnaires were used to collect predominantly quantitative data and were completed by patients prior to using the Programme as well as on finishing the Programme. Measures collected included anxiety, depression, perceived stress, positive well-being, physical health and outcomes for problems identified as most important by each individual patient. Open-ended questions collected written data regarding patient experience of the Atlas Programme. Interview data: Semi-structured interviews with 14 key stakeholders (including Atlas practitioners, VMC GPs, VMC administration staff and other VMC practice staff) were conducted five to six months into the Programme. In addition, narrative interviews were conducted with six men who used Atlas to provide deeper insights behind the numerical results. The narrative interviews provided an understanding of men’s distress and Atlas. All qualitative data were analysed using thematic analysis. Cost implications: Additional questions regarding patients’ employment and service use were collected on patient questionnaires (before and after engaging in Atlas services) and formed the basis for the cost implications analysis. Key findings • GPs played a key role in referring and encouraging men to attend Atlas. • Patients took a variety of routes through the service, using counselling and acupuncture in different combinations, according to their needs, in consultation with their GPs and practitioners. • Of the 107 patients using the Programme, 102 (95%) completed a pre-treatment questionnaire, and 82 (80%) of those went on to complete their post-treatment questionnaire. • Men said that they were attending the Programme to help reduce psychological and physical symptoms, promote positive mental states and relaxation, improve daily functioning, understand and manage their problems, talk things through, and deal with a range of specific issues affecting their lives such as work and relationships. • Comparisons between pre- and post-treatment revealed statistically significant improvements in anxiety, perceived stressed, positive well-being, physical health and patient-centred outcomes (ie problems rated as most important to each patient at the time of first attendance). • Overall there was no change in depression, but this is likely to be because a significant proportion of the men using the Programme were not initially identified as depressed. However, the sub-sample (n=50) of men who were at risk of depression (as identified using recommended cut-off scores on our depression scale) before using the Programme did experience a statistically significant improvement in depression post-treatment. • 78% of patients said that they felt better after their Atlas sessions, 13% reported no change and 4% felt a little worse. • Patients reported an improvement in their understanding and awareness of themselves and/or the situation that they found stressful, and found ways of coping with and managing their issues as a result of using the Programme. • Some patients described being able to talk to an objective professional as helpful, although challenging at times. Some patients wanted a more structured or directive approach to working with their problems than counselling could provide. • The unanimous opinion among stakeholders was that the Atlas Men’s Well-being Programme functioned well. Some minor challenges for professionals included pressures on scarce room space, a lack of clarity regarding which health professionals were able to refer to Atlas, and occasional difficulties for receptionists with appointment bookings. Some patients wanted to have more than their allocated six or 12 sessions. When the demand for the Programme allowed, practitioners were able to provide up to six additional sessions. • Professional stakeholders felt that having a male-only service sent an implicit message to men that validated their emotional needs and normalised the idea of getting help for stress/distress, and attuned practitioners and GPs to the emotional needs of men. Other stakeholders felt the Programme should also be available to women. In interviews, men said that it being a male-only service had not occurred to them (GP referral was the most likely route rather than the flyer) and was not of particular significance. However, many agreed there was an unmet need for male mental health services, and that having a male-only service may improve access for other men. • Often counselling was more acceptable to patients than acupuncture as a way of helping them with their mental health problems. However, the acupuncture service was well used and was reported to reduce stress, and patients evaluated it well. • Qualitative data suggested a synergy between counselling and acupuncture: Atlas practitioners considered that acupuncture might help patients to be more emotionally ‘open’ in counselling sessions, or that acupuncture could help relax patients after a challenging counselling session. Further research will be needed to explore this interaction. • Atlas reduces costs, when taking costs related to health and social care usage and lost employment into account; reductions in these costs exceeded the cost of the Atlas counselling and acupuncture sessions, with an average saving of nearly £700 per patient. Quotes from Atlas participants “It was great to have someone independent from the situation to talk to and get objective feedback from. The action of talking about issues is itself a therapeutic process and helps one understand.” P2 “A good blend of professional and approachable. I guess these things can be a little strange at the beginning (especially if you are not pre-disposed to talking about your issues such as I), but she made me feel comfortable early and established credibility and trust early too. This helped develop the relationship quickly, which in turn helped get maximum benefits from the conversations.” P2 “The realisation that I was suffering from serious stress, which I wasn’t addressing and how to stop that happening in the future. I got a much-needed sense of perspective and was able to see that things had become almost unbearable in terms of not communicating how I was feeling.” P109 “It helped understand the reasons behind thoughts and emotions I had been experiencing. This led to a better acceptance of my moods/worries.” P13 “Helped me to understand myself better – ideally what’s important to me, what makes me special, who I am. Helped to identify my strengths and what makes a brilliant person. It was the first step on the road to recovery.” P22 “[Acupuncture practitioner] found ways of exploring my depression which were helpful, even though I sought only treatment via acupuncture.” P79 Conclusions The evaluation demonstrates a hitherto under-investigated pathway by which men experiencing mental health problems can be identified in primary care and helped to talk about the problems that are concerning them, and/or receive physical therapy aimed at reducing stressed-related symptoms. Findings from this evaluation suggest that the Atlas Men’s Well-being Programme was helpful for stressed and distressed men, particularly in terms of reducing anxiety and stress and improving physical health, positive well-being and individual problems important to each patient. The Programme also promoted relaxation as well as better understanding and coping with problems. Consistent with previous research in this area, the study found that a ‘one size fits all’ approach is unlikely to be useful for men, and indeed men using Atlas had varying preferences and expressed diverse needs in relation to the Programme. We found that it is possible to effectively develop and deliver a primary care-based programme offering help to men for their mental and physical symptoms of stress and distress. Flexibility (timing and treatment options), the close involvement and encouragement of GPs, and high-quality branding appear to be important considerations when providing men’s mental health services. This evaluation highlighted the value of engaging GPs in encouraging stressed/distressed men to identify – and seek help for – mental health problems