To explore parents’ experiences of seeking health care for their children and instead being accused by healthcare professionals of Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT), being reported to Social Services, undergoing judiciary processing, and the impact of these events on family (dis)integration.Design: A qualitative study based on qualitative content analysis. Participants: Twelve parents in Sweden, mothers and fathers, seeking health care for their infants, encountering allegations of SBS/AHT, losing custody of their infants, and being subjected to a judiciary process, and finally regaining custody of their children. Data collection: In-depth interviews.An overarching theme ‘Fighting for protection of their child after being trapped by doctors’ and four sub-themes were developed to reflect the parents’ experiences, reactions and interpretations. The first sub-theme, ‘Being accused of injuring the child’, illuminated the shock experienced when seeking care and instead being accused of being a perpetrator. The second, ‘Chaos and powerlessness’, refers to the emotions experienced when losing custody of the child and being caught in the enforcement of legislation by the authorities. The third, ´The unified fight against the doctors’ verdict´, illustrates the parents’ fight for innocence, their worry for the lost child, and their support and resistance. The fourth, ‘The wounded posttraumatic growth’, describes the emotions, grief, panic, anxiety, and challenges in reuniting the family, but also the parents’ reflections on personal growth. Unanimously, they had experienced the authorities’ inability to reconsider, and expressed a deep mistrust of paediatric care.Being wrongly accused of child abuse and alleged SBS/AHT evoked emotions of intense stress, but parents endured because of a successful fight to regain custody of their child. However, the trauma had a long-term impact on their lives with residual posttraumatic stress symptoms and mistrust towards healthcare services and the authorities. The results provide important inferences for restoring system failures within child protection services. In the best interests of the child, correct diagnosis of infant abuse comprises the ethical principles of beneficence, non-maleficence and justice. Misclassification and missed cases of abuse, or wrongly accusing parents, can have severe consequences. Existing research has been focussed on barriers among doctors and nurses to detect and report suspected abuse, such as inadequate training, both a lack of and uncertainty within guidelines, a lack of support from authorities , 2, distThe diagnosis of shaken baby syndrome/abusive head trauma (SBS/AHT) has been described as within the “second wave of child protection”, characterized by developments in techno-science . The conCompared to other Western countries, Sweden has a lower incidence of Out-of-home care for infants . AdditioResearch is scant on parents’ experiences of when Social Services take their children into custody. One study from Australia reports questions of human rights abuse , and oneIn case of an eventual over-diagnosis of infant abuse, there is a need to listen to parents’ experiences of health and social care and of the judicial process related to alleged infant abuse to gain a patient/client perspective about possible inflicted harm in health and social care. To our knowledge, no study so far has addressed both mothers’ and fathers’ experiences of seeking health care for their infants and instead being accused of shaking their babies.The objective was to explore the experiences of parents who sought health care for their children yet were accused by healthcare professionals of SBS/AHT, then were subjected to inquiries by judicial and Social Services, and the impact of these events on family (dis)integration, whereby children were taken into custody and fathers were convicted, but later exonerated.The study design was qualitative, using qualitative content analysis , 25. ThiSweden has a long history of well-developed child welfare and child protection services, and, compared to other Western countries, a low and declining incidence of child abuse, apart from infant abuse, over the years, as illustrated by longitudinal data collected until 2009 . In 2007www.rffr.se) with an invitation to be interviewed and to participate in a qualitative study. Eight of those declined and 12 (6 mothers and 6 fathers) agreed. Events relating to the parents’ seeking health care yet being suspected of abuse had taken place during the years 2013 to 2017 and the selection criteria were: 1) all parents had been seeking health care for their infants; 2) all infants had been investigated according to a SBS/AHT-protocol with either findings of subdural haemorrhage, or radiologic findings indicative of abuse ; 3) a paediatrician had mandated a report of suspected abuse to Social Services; 4) all infants had been subjected to measures according to the Social Service Act or the Compulsory Act ; and 5) all parents had been interrogated by the police. In addition to meeting these criteria, almost all parents (10) had been arrested; one father was convicted of serious infant abuse in the District Court but found not guilty in the Court of Appeal; all charges against the parents according to the Social Service Act or Compulsory Act had finally been dropped; and all parents had, at the time of their interview, regained custody of their infants from Social Services, or were in the process of regaining custody of their infants.The research group contacted 20 parents (10 mothers and 10 fathers) through an informal internet peer support and advocacy group . One team member had experiences of providing peer support and advocacy group work related to this theme (GE). One team member had no previous research experience of this theme (ÅW).The informants were contacted by telephone, and were informed about the study aim and the interview process. The data collection took place from April 2017 to January 2019. Informed oral and written consent was obtained. The parents were interviewed by one of the authors (GE), an experienced clinical psychologist and psychotherapist. An interview guide was used, covering areas relating to their reason for seeking health care, the consultation, the professionals’ suspicion of abuse, the events that then followed, the parents’ reactions and coping strategies, and their present situation . Both thhttps://www.umu.se/institutionen-for-epidemiologi-och-global-halsa/forskning/open-code/).The interviews were transcribed verbatim. The transcripts were imported into the qualitative text software OpenCode .Two families had only had their first child (1 & 2), and four families already had older children before the event . Three of the parents were aged 25 to 29 years, and the others were aged 30 to 34 years at the time of the event. Three mothers had completed 12 years in school, and three more than 12 years. One father had completed nine years in school, one 12 years, and four had more than 12 years. Five of the infants were single born, and two were twins. Four were born pre-term. Infants’ ages at time of diagnoses of abuse were between 3 and 5 months. The families lived in six different counties in the catchment area of two different child protection teams within university hospitals.Based on the analysis, an overarching theme, ‘Fighting for the protection of their child after being trapped by doctors’, was developed to represent the underlying meaning of the experiences, reactions and interpretations of the parents’ trajectories when being accused of shaking their infants. The first subtheme, ‘Being accused of injuring the child’, reflects how they sought care for their infants but instead, their own care of their infant ended and they were accused of maltreatment. The second subtheme, ‘Chaos and powerlessness’, refers to the parents’ emotions when losing custody of the child and being caught in the enforcement of legislation by the authorities. The third subtheme, ‘The unified fight against the doctors’ verdict, illustrates their fight to prove their innocence, their worry for the lost child, and the support they received to resist. The fourth subtheme, ‘The wounded posttraumatic growth’, considers the emotions and reflections in the aftermath, such as grief, lasting mistrust and panic, challenges to reunite the family, and the authorities’ inability to reconsider, but also their growth, both personally and as a family. The results are also illustrated in The first sub-theme, ‘Being accused of injuring the child’, illuminated the shock when the parents sought care and instead were accused of being a perpetrator. The stories they told were about parents seeking help for emergency care relating to the condition of their young infants, or because they were worried about certain symptoms. They all described having had confidence with healthcare services. Gradually, or suddenly, they experienced a shift in their perception of the healthcare encounter; from a trustful consultation, to perceiving an agenda of distance, like the closing of a door. Their child was taken away for investigations they did not understand, and for which they were not provided an explanation. A creeping concern for what was going on, then not being listened to, which then evolved into panic, like being struck by lightning, occurred when they were then accused of having physically abused their child, having their child taken away, and being arrested.seeking care for their child included: concerns about skin lesions/rashes/bruises (3), being smaller in size, and having a lower weight gain than older siblings (1), vomiting and convulsions (1), agitation and crying, and other symptoms of pain from the baby (2). Some parents sought care several times, or explicitly asked for referral because of persistent worry that something was seriously wrong. The first level of care approached included the child care centre (2), primary care, and emergency care at a district, county or university hospital (4). In all cases, child protection doctors were consulted, either locally or at a university hospital.Reasons for not understanding the reason for extended investigations that continued, such as repeated radiology, ophthalmologic examinations and blood sampling. One couple expressed relief but then these extended investigations also increased their worry of their infant’s health; “Could it be a fatal disease?” (Mother3). None of those parents who were interviewed had been asked to provide consent for neuroimaging. Some parents were present during the neuroimaging, and experienced that the sedation provided to the infant was insufficient and that the infant eventually needed to be administered anaesthesia. Some were left alone while the child was taken for an x-ray and were never informed that neuroimaging had been done. None were informed that the siblings were also taken for extended x-rays or neuroimaging. The parents did not understand the reason for these procedures, nor did the doctors answer any of their questions. The infant was taken abruptly for the next investigation. “And why? It felt like we were not allowed to know the reasons … In hindsight we realized they were just following a standard protocol.” (Mother1).Initially, the families were well attended and their infants were examined appropriately. In some cases, the parents were reassured and told not to worry. At a certain stage the scene changed, for some, instantly on their arrival at the referral hospital, where the diagnosis of suspected abuse had already been determined, and for others, this occurred more gradually. A common experience was despair at not being listened to. They were not asked for their explanations or their interpretations of the findings obtained by a radiologist. “It is quite horrifying actually, it can be from x-ray images without having talked with the parents, to make a diagnosis without having met the patient” (Mother2). Repeatedly, families asked for extended investigation for diseases that later were actually proven to be the cause of the findings. “We were ignored when we suggested specific tests should be carried out on her, ‘No, but we have no time now’” (Father2).Soon the parents felt a closing door and the end of care. In several cases, the parents perceived that a child protection doctor led the investigations from a distance. The parents felt that nurses changed their attitude from being caring to being hostile, and some even made inappropriate innuendos. Once abuse was determined to be the sole cause, the momentum stopped and the doctors claimed that all possible investigations had been completed, while the parents desperately appealed to the doctors to make further investigations.In an instant, almost immediately at referral or after prolonged investigations, the healthcare professionals decided on a diagnosis of abuse. This decision-making process was perceived as 5)“I was trying to get the doctor to understand that I do not have mistreated children and tried to make them do a proper medical investigation […] that they needed to leave no stone unturned […] I was waiting all the time for when they had examined clearly and would discover that this is not abuse, coming to the conclusion that it is something with the skeleton that is not normal. They were so small and thin.” The parents experienced the decision to report them to Social Services as being surreal. “You can't really understand, it must have been the wrong paper, therefore, wrong children […] They must have confused the x-ray with someone else. This is not true!" (Mother1).After the doctors made their report, Social Services acted promptly to take the infants, and their siblings, into custody. The parents were called into a meeting, then asked to follow the doctors into a separate room where police and social workers suddenly entered. “Then two additional police officers entered and someone from Social Services; ‘Yes, you are arrested.’ I don't understand anything, I'm just sitting with my child in my arms and breaking down. […] the woman from Social Services says, ‘We are going to take your child into custody’” .6).The parents were separated and isolated with no contact with the outside world. The first interrogations were performed without the presence of legal representatives, and were harsh and brutal. They were told “We know that you are 100% guilty” and were subjected to intense pressure and questioning. “It wasn’t until after the police interrogation that I fully realized that we could be convicted in spite of our innocence. I was completely shocked when I realized how the system works” . The parents perceived that the police tried to antagonize them, fishing for evidence of partner abuse, and trying to persuade the mother to apply for custody.severance from their infant opening an abyss. “I felt like something had died in me, to be stripped of my own flesh and blood, it is not possible to describe the feeling you get, when we tried to have children for so long and then, they just take the child away from you” (Mother2).The loss of the child evoked emotions of fear, panic, despair and hopelessness, with the struggling against emotional breakdown were described. However, the parents also described an emerging inner strength. “This feeling of … overwhelming hopelessness … can't breathe” (Father4). “It was very difficult, I tried to stay strong. It was not an option to break down” (Mother5).Experiences of everything is turned against them. The parents perceived that the investigations, interrogations and statements were being interpreted to fit the doctors’ verdict. Unanimously, the parents experienced being denigrated by Social Services. If fathers or mothers did not show their emotions, this was turned against them. “You are in shock, not your usual self, but the doctors, nurses and social workers are sure that we are abusers and have their judging glasses on […] They described me page-up and page-down, as mentally disturbed. That I don't have any attachment to my children and being emotionless” (Mother5).The overwhelming experience was that censoring the infant’s record. “We demanded several times to have access to our child’s record, but were denied this as it was stated to be part of a secret investigation protocol” (Mother4). In several cases the lawyer had to request a copy of the child’s record by multiple court orders, section by section.The parents’ fight for their infants started after they had been released from custody. Soon they realized that the healthcare professionals were The third subtheme illustrates the parents’ fight for their innocence, their worry for the lost child, and their struggle to get their child back. The emotions of despair and worry for the child were transformed into controlled anger. This process was aided by social mobilization, attorneys and second opinions.desperate controlled anger. The parents’ experience of being innocent but accused of child abuse and understanding that you are guilty until proven otherwise provided the momentum to resist and defend their family. “My thought as a mom was never give up my child … We are right” (Mother2). The parents described having adopted a double-sided strategy; 1) one external world in the fight to keep up the façade, avoid showing anger, and avoid saying too much, and 2) one inner world of sorrow and despair. “Never show any aggression. Show heart, intelligence. If you show the slightest aggression, you lose” (Father1). The family who had to agree to be detained at the Social Services Investigative Custody Home for monitoring with their three children for 10 weeks described their experiences: “It was a bit like in the film, Life is Beautiful, with this father who is in a Nazi concentration camp with his son trying to create the idea that this is just for fun” (Mother3 & Father3).The false allegations evoked resistance. This emerged as a persistent worry for the child out-of-reach. The pain of being denied their ability to protect their child was almost unbearable. “We felt so sorry for her, we thought of her constantly” (Mother2 & Father2). One breastfeeding mother described how she was offered medication to stop breastfeeding when she was arrested. “Then I was mad and reacted in a way, saying ´Knock it off, we’ll get out of here and my child will be breast fed’” (Mother1).The parents had a mobilization through peer support and advocacy groups. All of the family members were full of anger and assisted by googling and gathering information and being a source of support at all visits with the authorities. Some moved into the homes of the accused to be nearby. The extended social network of the affected families was extremely important; friends, old colleagues, relatives who were social workers or police officers, past teachers, lawyers in their social network, and members of their church congregations. “My sisters are googling the whole night, and … checks the cell phone and the computer all the time. We're talking, I'm talking with several callers on the line. […] Mom and dad accompanied us to all the meetings” (Mother3).The parents’ extended family became united and worked hard in the fight; fathers and mothers, grandmothers and grandfathers, stepmothers and stepfathers, and siblings. This was experienced as “If we hadn't worked on this very hard and hadn’t had such support and the entire network and find this help through the RFFR. I mean where would you end up? In jail and the children would be in custody. Our daughter might come home then … but the twins would be gone, it is a fact” (Mother5). Many of the parents’ intuitive perceptions of the underlying medical conditions that contributed to the findings at the very start of the diagnostic process were confirmed by amassing second opinions and, as a result, the parents were exonerated in court.All of the participants described having gained support from the advocacy groups, including emotional and second opinion support, guidance on how to proceed, and the importance of continuously documenting the history and record of all encounters with Social Services. sudden disappearance of hope-eliciting professionals. One orthopedist commented on the newborn child’s diagnosis of rickets and the older child’s diagnosis as abused; ‘“But this is not correct. It must have been a wrong diagnosis with the previous child,’ [she said] … And she talked with us and we met with the child and she checked up a lot, and she was really on our side. Until one day when she had talked with child protection doctor in the university hospital, and all of a sudden she could not do anything because it was child abuse … so she turned into a really completely different person” (Mother4).One mother described an unpleasant and disturbing experience of the 1). Only one professional, a child care nurse, supported the parents in court. Some participants experienced attitudes of other professionals who understood their innocence, such as the police investigator, and prison officers, who suggested, “This is wrong, you shouldn’t be here” (Mother3 & Father3). Some participants experienced that social workers assured them, off the record, that they trusted them as parents and that they would push to get the children back promptly, but nothing happened.Several participants experienced that other doctors questioned the child protection doctor’s views, but none of them came to challenge the medical hierarchy, as one participant explained. “They are only servants, obey to the orders” . One mother feared that the forced separation would become embodied and would hurt the child later on. Parents who had several children and who had been separated from them for years experienced damaged attachment with difficulties in the family reunion. Parents reported feeling alienated from the child who re-entered the family; who is this, and how do I get to know the child? This feeling also influenced the parents’ attachment to the returning child by bringing out emotions of uncertainty, being overprotective and fear of making mistakes. “… the feeling is wrong, she will be somewhere in between […] It hurts so much. You are so afraid for it to be wrong […] She has missed her older siblings, they've missed her growing up … When I spend time with my children today, and I see that the other children directly in a second just take what they want and do what they feel. But it doesn't work for her. For even if she is mine, she is not mine” (Mother4).The participants, having had their children in Out-of-home care for months, or even for years, suffered in the ambiguous insight that the child is also attached to the foster parents. “He cries because he does not want to come here, and he cries when he leaves us” (Mother6).One consequence of the family reunion was Social Services did not support the family reunion after the judiciary decision, and that they delayed, and even opposed, the transition from having the most restrictive contacts during Out-of-home care to the family re-union. However, some families experienced that the foster families were very supportive in this transition, while others experienced mistrust, disappointment and denigration. Several parents expressed that they perceived that Social Services had a hidden agenda with the foster parents and had presumed that the Out-of-home care would be permanent. “We understood later that that Social Services had promised the foster family that our child would be placed there permanently” (Mother2 & Father2).The participants reported in most cases that authorities’ inability to reconsider, and received no apology and no support from healthcare or Social Services. An overwhelming experience described by the participants was that their families had been injured, that they had been through a terrible and horrifying trauma; an act of abuse by healthcare services. No doctors, no hospitals, none of those who had accused the parents of being abusers came back to them afterwards to support them. “Demolishing a wall, absolutely anyone can do. But they will not help to build it up again. When they have been wrong, or they don't want to admit they have been wrong. It becomes the prestige instead […] instead of, ‘We thought we didn’t do correctly,’ or ‘We didn’t know any better, but we have learned now’” (Father4).Because the parents had been exonerated, they experienced the Some social workers admitted their wrongdoings off the record, but Social Services offered neither an excuse nor support, the parents were simply told, “We have done nothing wrong”. Several participants expressed that they would have wished to have had supportive meetings with the authorities. Two of the families had registered complaints with the Health and Social Care Inspectorate (IVO), but only received the response that no wrongdoing had been identified. One father had fantasies of revenge, such as going public with the identity of the doctors who falsely accused them of abuse to warn other families. One family wanted to sue the perpetrating doctor through the courts.more courageous, compassionate and outspoken, having increased confidence, being more reflective and questioning more, getting more upset about injustices, being more empathetic, and less biased in their attitudes. “My mom said a very good thing to me a few months ago, she said, ‘When you were little you were always curious, you were fearless and whatever you wanted to find out or do, you went for it. Then something happened during your years in school … but now I recognize that spirit again.’ I'm less anxious, more brave and curious. I have no inhibitions in that sense now” (Father1).Many of the participants, both fathers and mothers, described how the experience had changed them positively; to be stigma of their experiences continued to pursue the participants. Some had changed workplace and domicile, to protect themselves and the child when they were grown up. A harrowing panic continued to haunt them, both in daily life and in nightmares. Several had endured depressive and anxiety symptoms, re-living the trauma repeatedly, for which they sought therapeutic support. Extreme focus was needed in order to manage the process, otherwise, “all the held back” emotions were opened up. “So I have had some setbacks … Everything catches up with you in the end. Yes, I tend to blend in and focus, but my feelings always catch up with me” (Father1). Emotions of panic hounded many of the participants. Just passing by the police station, the Social Services office or the hospital could evoke flashbacks of the trauma. Two families dismantled their doorbell afterwards in fear of intrusion. “I can still wake up at night, having flash-backs, wake up completely horror-struck … as soon as I see the Police station or the Social Services office, the panic is close […] When I hear motors running outside and I think they are coming to detain us” (Mother1).The The enduring loss of trust was very prevalent in the interviews. Unanimously a fear, for some, a phobia, of seeking health care for their children was expressed. “I still have a phobia of visiting doctors and hospitals with the children, I do not want it, you dare not go in with children. It falls over on you because I can’t do it, it is not possible. Well, I went to the allergologist with them, but then my stepfather accompanied me (Father5).loss of trust in healthcare services that they were terrified of having another child because of what they had been through and the fear that the authorities would take that child as well. One mother had even had an abortion because of this. “I carry a sadness that I, because I long so much for a small baby, but I dare not … I never want to go through this again” (Mother6).Several of the mothers expressed such a profound One mother made a decision to have another child despite reluctance from her husband and a huge fear from her mother-in-law that the newborn would also be taken into custody. The new child was born preterm, as was the first. The mother refused to leave the hospital until a proper investigation was completed, which the doctors finally did, and then came rushing in as severe osteopenia was revealed. As a result of her persistence, this mother regained custody of her older child who had erroneously been diagnosed as being abused when, in fact, the infant had suffered from bone fragility.The parents’ experiences of seeking health care for their infants and instead being accused of abuse are reflected in their narratives of shock, losing their infant and being caught in the hostility of the authorities. The descriptions of their experiences included a fight for survival against emotional breakdown and family disintegration by mobilizing inner forces, social support and second opinions to finally be exonerated from the allegations and regaining custody of their infants. The aftermath of these events, without any apology or support from the authorities, included feelings of sorrow and bereavement for the lost time with their child, challenges with family reunion, and long lasting post-traumatic emotions, such as anxiety, panic and distrust of the authorities, but also a sense of personal development in being more courageous and outspoken.Trustworthiness, the concept that the participants’ voices are heard, is the essence of qualitative content analysis , 25. It Nevertheless, we consider that our results might still have bearing on other parents who have experienced being falsely accused of abuse, and also for parents in general who are trying to care their best for their children.Four of seven infants were pre-term born. Prematurity is considered as a risk factor for maltreatment. HoweverThe trajectories described by our participants reveal the potential hazards of a child protection system that is characterized by proceduralization and technicalization in a climate of fear, mistrust and blame  that leaOur participants, when seeking care for their infants, instead experienced harm inflicted by healthcare services. The diagnostic error had disastrous consequences for the children and their parents. The parental experiences expressed in this study are in accordance with patients’ narratives in cases of diagnostic errors; ignorance of patients’ knowledge; and disrespect, manipulation and deception . Further“The Monstrous Perpetrator” is an underlying discriminatory stereotype often enmeshed by gender, race and class, and is often described in connection with SBS/AHT , 17. ThiSeverance from their infant opening an abyss and Persistent worry for the child out-of-reach and Grieving for the lost time with the child and damaged attachment.Loss was the overarching theme presented by Zeman (2004); the pain of the “physical separation”, “the loss of fantasy that they could protect their child”, and “the loss of the sense that their parenting experience had been normal” . These fThe “medical fact of abuse” presented by the doctors to the judiciary and Social Services reversed the burden of proof and placed an exceedingly severe strain on the participants. Such experiences, contrary to a normal court process, are shared by Hansen et al., who reported that “Families are guilty until proven innocent” . FurtherNoteworthy, several of our participants met professionals as doctors, police or social workers, who expressed to the interviewees that they perceived that this process could be erroneous. However, none of the participants experienced that those professionals were then willing to act to help the families and instead realigned themselves under the direction of an authoritative system. This illustrates a potential danger of a system working strictly according to guidelines under a leadership of often distant experts with little or no face-to-face meetings with the accused parents , not facMistrust in seeking health care is often described after a medical error . In the Our findings do show that the traumatic event of child custody loss did have long-lasting impacts on the parents’ lives, as previously shown . The emoAs this was a qualitative study, the longer-term consequences for the parents cannot be measured. A study by Wall-Wieler et al. (2018) indicates an increased risk of suicide attempts and completion among mothers after a child custody loss . The famSigns of Safety strategies when a report of suspected child abuse is received, to consider whether placements with relatives could be an alternative during the investigation [Our results, illustrating a system failure within child protection, have important clinical implications for the practice of reporting suspected abuse and avoiding false allegations. A techno-science that is dependent on a diagnostic procedure that lacks scientific support cannot be enrolled as the grounds for a fast decision to justify Out-home-care. Adequate training –3, 5 mustigation . None oftigation . FurtherTo conclude, being innocent but accused of SBS/AHT evoked emotions of intense stress but the parents survived because of a successful fight to regain custody of their child. However, the trauma had a long-term impact on their lives, as they still suffer from posttraumatic stress symptoms and a long-lasting mistrust towards healthcare services and other authorities. The results provide important inferences for the need to restore system failures in child protection services.S1 Appendix(DOCX)Click here for additional data file.


As they walked through the park, children shared thoughts regarding characteristics that may influence their visitation, park-based physical activity, and social interactions. Features that would encourage visitation included: challenging and interesting play equipment; a pond and water play area; trees/greenery and shade; and full-sized basketball courts. Features most valued for physical activity included: sports courts, ovals, and equipment; open space; trees to climb; and nature/rocks. Features most valued for social interaction included: a large size; playgrounds; and picnic areas. Children offer unique and important views. Park designers should consider inclusion of these features, when (re)developing parks to support children to lead healthy and active lives.Parks are places where children can interact with others and engage in physical activity in a natural setting. Park visits can enhance children’s social, mental, and physical health. It is therefore important to better understand how parks can be designed to ensure optimal use by children. This qualitative study explored children’s perceptions of park features that may influence their park visits, park-based physical activity, and social interaction. Qualitative walk-along interviews were completed with 30 children (mean age 9.7 years (SD 1.3), female  Parks are important locations for children to explore the natural environment, socialise with family and friends, engage in physical activity, and develop new skills such as fundamental motor skills , which aWhile access and proximity to parks and green space appear to be important determinants of park use among youth ,13,14,15Children have different needs in regard to park features than adolescents, adults, and older adults . ObservaSocial interaction is a key motivator for people to visit parks  and has Qualitative research can provide in-depth insights; however, the more traditional methods of individual or focus group interviews rely on children recalling past experiences. Conducting interviews while walking through the park  creates an interplay between the environment, the researcher, and the participant, which can help prompt in-depth discussion and facilitate contextual discussions about the park environment without relying on children to recall their previous park experiences . This meA deeper understanding of the needs of children and features that they believe will encourage park visitation, physical activity, and social interaction within parks is essential to help park designers create parks that encourage and enhance park visits and support active and social play for children . The aimThis research was part of a larger study (ProjectPARK) that examined park characteristics influencing park visitation, park-based physical activity, and social interaction among children, adolescents, and older adults. Following COREQ  guidelines , this quA researcher interviewed children whilst they both walked through one of nine urban public parks located in metropolitan Melbourne, Australia. The parks were located in areas of varying socioeconomic status , as defined by the Australian Bureau of Statistics Socioeconomic Index for Areas .n = 9); paths (n = 9); picnic tables (n = 9); barbecues (n = 8); playgrounds (n = 8); flying foxes (n = 7); toilets (n = 7); built shade (n = 7); basketball courts (n = 6); landscaping (n = 6); climbing structures (n = 5); sports ovals (n = 4); adventure playgrounds (n = 4); skate ramps (n = 3); cricket nets (n = 3); ropes course (n = 3); ponds (n = 2); water play area (n = 2); fitness equipment (n = 1); and table tennis tables (n = 1). All parks were open to the public at all times during the course of the study; none were fenced.To ensure that a range of potentially positive and negative park characteristics were observed during the interviews, the parks included in this study represented diversity in terms of size (1–30 ha), amenity, and condition. For example, across the nine parks the following characteristics were present: shady trees (n = 3); flyers posted at local venues such as cafes (n = 3); advertisements targeting parents of 8–12 year olds on Facebook (n = 3); emails distributed to staff at the University (n = 2); and in-park recruitment (n = 19). Parents of children recruited by means other than in-park recruitment, were sent study details and once they had agreed to participate, they and their child met the research team at one of the selected parks on a specified day and time. For in-park recruitment, research staff approached parents who were accompanying children who appeared to be 8–12 years. They explained the study and invited participation if their child met the age range criteria and was English speaking. Where possible, research staff attempted to recruit an even mix of boys and girls. Overall, 14 parents who were approached in the park declined participation. Recruitment continued until no new information was obtained. All parents and children (n = 30) provided written consent. Ethics approval was obtained from the Deakin University Human Ethics committee (HEAG-H 94_2017). Children aged 8–12 years were recruited via their parents using multiple methods (number recruited presented in parentheses for each) including: flyers handed out at shopping strips located close to each of the selected parks  interviewed the child whilst walking through the park together. The research staff completed training in qualitative data collection prior to conducting the interviews; they did not have existing relationships with any of the participants or report any biases or conflicts of interest. The interviews lasted between 7 and 20 min and were conducted in English. Voice recorders were worn by participants during the interview. At the start of the interview, children who had visited the park previously were asked why they visited that park, whereas those who had never visited the park were asked to describe things they may like to do during a visit to the park. All children were then asked to speak about what they liked and disliked within the park; what would make them want to be active or social here ; how they would change the park to make it better, and to make them want to be active or social; how being in this park made them feel; why they visit other parks (if they do); and to describe their ideal or perfect park. The researchers explained that there were no right or wrong answers and the children were the “experts”.Data from the survey were used to calculate descriptive statistics in Stata Statistical Software: Release 15 . Qualitative data from the walk-along interviews were transcribed verbatim and analysed using NVivo 12 . Data analysis was guided by a summative content analysis approach . A preliOverall, 30 interviews (2–5 interviews per park) were completed across the nine parks . The average age of participants was 9.7 years (SD 1.3), 53% were female, 40% owned a dog, and 73% had previously visited the park where the interview was conducted . A high Children stated that the main activities they either currently performed, or would be most likely to perform if they visited the park where the interview was conducted, were as follows: play on the playground; ride scooters; use the skate/BMX park; use the flying fox; be with friends; play soccer/cricket; walk around/relax; play tiggy (tag); play basketball; play in water play area; climb; or do school sport.Children reported that the most common reasons for visiting “other” parks were the attraction of particular playground equipment ; to use the skate park; to ride their bike; because the park was located close to home; they liked the trees/nature; and/or to have a barbecue. When one child, who was not a regular visitor to parks , was asked if they visit other parks they replied “Not really because there’s not many like really, really good parks near my area” .Well, they do have fences around their playgrounds, which feels a little bit safer and they have other equipment in the playground that these playgrounds don’t.I like that there’s sometimes a place with tonnes of trees that you can hide in and play in.I find that really fun.The words most commonly used when children described how they felt in the park were all positive and included happy, relaxed, excited, active, free, sporty, joyous, and comfortable.It makes me feel quite, almost active and adventurous.Well it makes me feel happy and it makes me feel like I want to go here more often. It makes me want to feel like to take all my friends here to play with them.Relaxing, it’s good to get out of the house, get some fresh air and exercise. Yeah it’s nice.When asked what they liked about the park, the most popular responses were playgrounds; trees/nature; climbing equipment; size; flying fox; basketball/netball courts; maintenance/aesthetics; walking/bike paths; grassy open spaces; skate parks; and sports ovals. In reference to the playground, they particularly liked the more challenging and “risky” equipment and having a variety of equipment.Probably the more risky things, the more risk taking things, not like full on dangerous, but they feel a little bit scary. A thrill.I like the swings. They go quite high….. and well everybody in my class likes them, because they race from over there to here.There’s like a lot of variety. Like it has monkey bars, the flying fox, slides.Nature was very important to many children. I like that it’s got lots of nature and greenery, and it’s really accessible to everyone. A lot of people can have fun here. Yeah. I love nature a lot. Nature is sort of like my number one thing in a park.I like the hill. With my friends I like rolling down and getting up straight away really dizzy and trying to run off.Yeah, the pond is very nice. I like it because it’s a little different, because if there was no pond in here, you could only see grass and trees. But then there’s a different element once you add the pond.I like trees, water, stones and flowers because it’s natural and it’s a nice place to be in, and not like all roads and concrete.Having a larger sized park, bike paths, and sport ovals were also features children liked.I like it because it’s big. So that it’s not like a tiny park, like a tiny bit, and there’s not much space or things to do there.I like there’s riding space and we can ride our bikes, scooters and roller blades.I like the ovals because you can play football and soccer and there’s just things to do there.When speaking about things they disliked, the main comments related to the playground equipment. They commented that the equipment was too small and not challenging or interesting enough and sometimes not well maintained. They also spoke about a general lack of amenities such as taps, toilets, and rubbish bins, too much empty space with not enough equipment or planting and overall poor maintenance in regards to the landscaping and presence of rubbish.Well I think I’d make the zip climb and the flying foxes a bit longer. Maybe the swings higher up from the ground because they’re a bit low.Like all the plants are really small and I like big plants that you can like play in and hide in and stuff.To encourage them to visit more often, children reported that they would add a water feature/pond with ducks and a water play area, improve maintenance , provide more trees nature/greenery and shade, have a skate bowl and full-sized basketball courts, and more water taps and bins.The main features that encouraged children to be active included: basketball/netball courts; open space and sports ovals; trees to climb and trees for hide and seek; nature/greenery/rocks; and playgrounds that are large and have things to run around on. Some children also spoke about being active when they visited the park with their dog.What would make you want to be active in this park?I only run around when I bring my dog. If I didn’t bring my dog, I would rather play tiggy with my friends and run around. Actually, I would like some more trees because when I play tiggy I get to go around the trees and stuff and play hide and seek.Respondent: So, what it is about this park that makes you want to be active?Maybe the forest area around here. I like running through it and the hill and the big open space to play soccer and run around on.Respondent: To encourage them to be more active, the children suggested having more sports courts, equipment  and ovals, bike/walking tracks, and large playgrounds.Maybe add a few more like basketball courts… so if one person is already playing in one of them you don’t have to wait, and you can just go to go to the next one really easily.How would you suggest changing this park to make you want to be more active here?Maybe a few more paths around.Respondent: OK, so if there were more paths, what would you do on the paths?Interviewer: You could do running or jogging, stuff like that.Respondent: Playgrounds; picnic and barbecue areas with sufficient shelter, tables, and chairs; facilities suitable for a range of ages; large size, basketball/netball courts; grassy open space areas; trees/nature; and sports equipment  were discussed as features that encouraged social interaction.What would make you want to meet up with your friends or family and be social?Well because it’s perfect scenery. Also, there’s lots of shade and lots of sun, and there’s lots of grassland where you can put your blanket for picnics and put it down and just eat. Or you could just get one of the benches.Respondent: Do you think your friends or family would want to come to this park with you?Yes, because like it’s a big space, and like if it’s my birthday I’ll invite a lot of people here, because it’s like fun for all ages.Respondent: Are there any ways you could change this park that would make you more likely to play with other friends you didn’t bring or make new friends?.Soccer balls because everyone could playRespondent: My school has this thing called a yarn circle. So, it’s basically [seats in a circle] where you sit around, and you can basically chat, or you can hop on the logs around the circle. It’s really fun, because you can just hang out with your friends, and it’s a place to relax or have fun.Not really because they’re not really interested in being active” . When one child, who was not a regular visitor to parks , was asked if they thought their friends would come to this park they replied, “When describing their “perfect” park, the following features emerged as being most important: playgrounds; green space/nature; large size; sports ovals, courts, and equipment; paths; water features; and things to climb. Overall, the most important feature of children’s “perfect park” mentioned by most children was a large adventure playground. Apart from it being high and large, children specified particular play equipment they wanted including long slides, large swings of all types including tyre and 360° swings, flying foxes, and monkey bars.A really big playground, like a big wooden structure with a high bit. It has lots of areas, and it’s like a maze, but it’s lifted off the ground. And there’s one part where it’s up really high and the playground has lots of pathways and stuff.I guess it would be sort of like this but maybe I’d make stuff bigger and probably higher off the ground because I love to climb.Nature emerged as a top priority in children’s “perfect” park. This included trees to climb and play hide and seek, flowers, water, rocks, and nature trails.Maybe there could be like a little place where it’s like a kind of like a trail that you can go and that shows you like around the park. Well they could have a little wildlife area, that you could see lots of cool plants and things. Because we have something like that at my school. Well it’s just that it’s unique and other parks don’t have it, that I know of. I think people like me would really enjoy it and seeing all the wildlife.Well it would probably have a pond, lots of trees, paths, and chairs obviously, flowers, and just like a lot of pathed areas. Not too much concrete, just stuff that makes it seem like a natural place.Yeah, and maybe even a kitchen garden, like volunteers could come and organise a club where they plant food. They come once or twice a week and they can just grow stuff and bring it home and everything.Grassy open spaces also emerged as being an important component of their “perfect park”.Well I really like more space for grass because I get to run around and play fetch with my dog.I think it should have quite a bit [green space] because that makes me feel really active and that I want to run all over it and stuff.Both girls and boys repeatedly spoke about having challenging equipment to climb such as ropes, climbing frames, and towers, as well as the provision of multiple full-sized courts such as basketball courts and sports ovals.It would definitely have like a big rope climbing area. I’d have quite a few climbing frames. Lots of climbing stuff. Yeah just more things to climb on. I’d put lots of big rocks in to climb around on.And how big would you want the climbing ropes to be?As high as possible. I’d love it like as high as they can go, to challenge myself.Respondent: Well maybe most of the things to climb on. Lots of monkey bars because I really like monkey bars and I’m good at doing lots of tricks.It absolutely must have steep [skate] ramps, a basketball court, and a scooter shop. It would be close to home and it would have a massive basketball court.Then all of this space would be saved for like I’d have a full-sized soccer pitch there, full-sized footy oval there, full-sized everything.Although mentioned less often, children also spoke about wanting a variety of features that suited people of all ages.Space for everyone to play with, like stuff. So, adults can have gym stuff, kids can have playground, and teenagers can have a skate park. And if they wanted to be sporty, like tennis courts, basketball courts, and golf.A lot of stuff that family can do together. Not just a playground for kids, maybe one that a family could join into, like an adventure park.Increasing children’s physical activity levels is a priority for public health . ConcurrChildren in this study typically visited parks at least once per week and were usually accompanied by parents, siblings, and friends. A key finding of this study was that the size, scale, and adventurousness of the playground are important for promoting visits, physical activity, and enjoyment. Additionally, results showed that children place value on nature as a location for play, particularly with friends, and the presence of friends was critical for encouraging park visitation. Overall, children had mostly positive things to say about spending time in the parks where the interviews were conducted. Even when children were asked about things they disliked about the park, they tended to report the scale of the playground equipment , rather than the absence of amenities or concerns regarding safety and cleanliness. These themes are distinct from those observed among other age groups, who more often report negative feelings and concerns towards the features and condition of parks and public open spaces ,43. Children repeatedly expressed the importance of playgrounds for encouraging visits, physical activity, and overall enjoyment. Survey responses from parents indicated that 70% of the children usually played on the playground during their park visits. Additionally, playgrounds were the most discussed feature throughout the interviews by a considerable margin and were particularly prevalent when children were asked to describe features they liked and their “perfect” park. This is consistent with previous research that has shown increases in park use and physical activity among children after playground upgrades ,44. ManyNature is also important for children, however unlike other populations, children see it as an opportunity for play, more so than for relaxation and social interaction. For example, children within this study referred to rolling down hills, hiding behind trees, and climbing on rocks. Children in the study also liked large open spaces so they could ride bikes, have fun, and play sports. This reinforces previous research that showed that the installation of a nature-based playground significantly increased visitation and park-based physical activity among children .Consistent with previous research that has found the presence of family and friends, unplanned encounters with others, and social functions to support park usage and park-based physical activity ,32, the Strengths of this study included the exploration of children’s views, which are often lacking yet provide invaluable insights , and theThis research comprises an early step in better understanding park features that influence visitation, social interaction, and physical activity from the child’s perspective. Overall, the findings suggest that children are drawn to parks that facilitate play, have elements of risk/adventure, and are large enough to allow for a variety of physical and social activities. Children viewed nature favourably, particularly when it allowed for exploration and active play. Neighbourhood parks can facilitate a variety of social and physical activities for children. However, when (re)developing parks, designers need to consider exactly what features are important to encourage children to visit and be active and social in the park and should involve children in the planning and design process.


In this paper, we report healthcare staff experiences of stress and burnout. (2) Methods: In total, 72 healthcare staff were interviewed from psychiatry, surgery, and emergency departments at an Australian public health service. The sample included doctors, nurses, allied health professionals, administrators, and front-line managers. Interview transcripts were thematically analyzed, with participant experiences interpreted against descriptors of burnout in Maslach’s Burnout Inventory and the International Statistical Classification of Diseases and Related Health Problems (ICD-11). (3) Results: Staff experiences closely matched the ICD-11 description of stress associated with working in an uncongenial workplace, with few reported experiences which matched the ICD-11 descriptors of burnout. (4) Conclusion: Uncongenial workplaces in public health services contribute to healthcare staff stress. While previous approaches have focused on biomedical assistance for individuals, our findings suggest that occupational health approaches to addressing health care staff stress need greater focus on the workplace as a social determinant of health. This finding is significant as organizational remedies to uncongenial stress are quite different from remedies to burnout. Since authors Freudenberger and Maslach ,2 publisResearch identifying how ‘burnout’ can overlap with other conditions, such as depression , has sugMaslach has described burnout as involving, “…Emotional exhaustion, depersonalization, and lack of personal accomplishment” (p. 192). The ICD-11 described burnout as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed” . The ICDThe aim of the research was to explore staff experiences of stress and burnout in a large health service. This research question was developed based on literature, which has highlighted the link between a challenging work environment and high rates of burned-out staff among, e.g., urgent care doctors ,13 and nThe design of this study involved qualitative analysis of a series of in-depth semi-structured interviews to explore staff perceptions of their workplace experiences. Interview questions were designed involving consultation with project stakeholders on the research focus. Researchers then collected data independently of stakeholder input. No data were collected during the research design stage of the project, only suggestions. The study was set in two urban hospitals in a single public health service in Australia located in one major city. This allowed data to be combined for analysis. Three clinical departments were sampled. Staff from psychiatry, surgery, and emergency departments provided a range of perspectives from clinical areas known for high acuity work.The participants included in the frontline ‘patient-facing’ staff include doctors, nurses, allied health professionals, administration and clerical staff, and front-line managers (such as nurse-managers who work on the ward). Patient-facing support services staff were excluded from the study because in one hospital these workers were employed by a private agency and not the health service directly. Participants were recruited using a combination of purposive and snowball sampling, where the researchers aimed to sample an entire team of patient-facing staff in the target departments. The process of recruitment involved an initial purposive approach using email introductions with the participant information statement attached that outlined the aims and protocol of the study, and in-person explanations of the study given pre-interview to confirm understanding. From the purposive approach, targeting staff in the psychiatry, emergency, and surgical departments, individuals were encouraged to tell their co-workers about the study and encourage others to participate. Individuals in the target departments were encouraged to discuss the study and the option of participating regardless of whether they had participated themselves.The study took a constructivist epistemology to the creation of knowledge from the subjective experiences and perceptions of individuals . In lineDue to the semi-structured, qualitative nature of the interview, participant responses varied based on their experiences and priorities. This approach was informed by studies that have illustrated the use of shorter questionnaires and analytical tools to identify the presence of burnout ,19, deriInterviews were conducted by two interviewers. One interviewer was a doctoral research student (MK), who designed the project, with a background in management interviewing techniques. The other interviewer was a psychiatric registrar, with a background in psychiatric interviewing techniques (KK). The two interviewers collaborated during transcription and coding to ensure overall consistency and to discuss assumptions prior to analysis. When participants from the psychiatry department were familiar with the psychiatrist interviewer, the doctoral research student conducted the interview to maintain objectivity, and ensure that all responses could be kept confidential. In other cases, participants felt more comfortable speaking to the psychiatrist interviewer. Interviews were conducted face-to-face with the interviewer with audio recording for accurate transcription. The researchers also recorded participant responses with rich descriptions, due to the nuances communicated by non-verbal communication such as extended pauses, sarcasm, and emphasis on specific words. Three participants declined to be recorded during the interview and their responses were written as field notes by the researcher. Interviews averaged approximately 40 min in duration, in a private location at the participant’s discretion . Participants volunteered knowing that there was no compensation. All interview transcripts were de-identified during transcription for participant confidentiality. Each participant was given the opportunity to review and edit their resulting transcript; the few transcripts which were returned to the researchers had only minor corrections.Data analysis was completed similar to steps presented in Braun and Clarke , in the The purpose of deductive thematic analysis was to identify themes and trends in the data relevant to the project and theoretical framework  based onThe process used to code documents was deductive and iterative, highlighting key words in the transcripts when they matched the ICD-11 theoretical framework of stress, burnout, depression, and anxiety. In the case of ‘anxiety’, key words such as ‘anxious’, ‘worried’, and ‘nervous’ would be highlighted and assigned to the main theme. When key words were not enough to qualify an anecdote (such as participant describing feeling ‘nervous’ and ‘stressed’), the context of the anecdote and the participant’s wider interview were considered before assigning a theme. The final assignation was based on ICD-11 guidelines with oversight from the consultant psychiatrist clinical site supervisor (PM). The transcripts were re-read and coded with a wider scope, incorporating quotes and anecdotes made by participants in relation to themes from the framework.The project was approved by the Health Service and La Trobe University Human Research Ethics Committees (HREC), registration number PRN: 0966. After receiving a participant information and consent form, all participants provided written informed consent prior to participating in the study. A withdrawal of consent form was provided to all participants in case they wished to no longer participate in the project. No participants withdrew their information. The research followed the consolidated criteria for reporting qualitative studies (COREQ) .De-identifying and collectively organizing participant transcripts was an essential requirement of the ethics approval. Without the ability to protect the identities of participants, the research project would not have been allowed to proceed due to the negative impacts that identification could have on participants. Variables such as age, gender, and years of service were divulged by participants, but were not recorded to preserve confidentiality. In addition to de-identifying individual transcripts, the researchers stored individual consent forms separately in a secure location in the researchers’ private office. Given the confidential nature of the data, the transcripts cannot be made available in open access.A total of 72 participants were interviewed, with 35 from psychiatry, 7 from surgery, 22 from emergency, and 8 from ‘other’ categories, such as those who worked across both surgical and emergency departments. Participants included doctors, nurses, and allied health professionals, as well as administration staff and line managers. See .In the psychiatric and emergency departments leaders  openly endorsed participation to their colleagues, encouraging volunteers to contact the researchers. As a result, in emergency and psychiatry, the researchers were able to sample several complete teams of patient-facing staff . Data from the surgery and ‘other’ departments were included for analysis due to thematically consistent responses. While direct representation of a population in the data sample is required for statistical analysis, the distinctive advantage of semi-structured interviews is that a theme can reach saturation from a comparatively small cohort ,23,24,25When participants were asked to describe ‘what work was like for them’, the majority of participants discussed experiences of stress, anxiety, and burnout. While many individuals used the term ‘burnout’, when asked to describe what burnout meant to them, only a small number of participants described burnout as the “end stage of chronic stress” defined by Maslach  and the When data collection was conducted and participant responses were compared with themes found in MBI and contemporary literature on burnout ,16, a ma“Got to a point…and that’s only been in the last few years…but it’s got to a point now where I was like…I can’t feel this miserable every day and be…a good person. Do a good job and do all the things I do like everyone else. … Been a bit up-and-down, to be honest…. I know it sounds ridiculous, being a [clinician] and everything, but you know…in my head, I was like “I was fine! Until this place happened.” And now, this place has happened. And now, you know, that’s it. I would say the only time I’ve got back to brilliant is when I’m not here. So, when I’m on holiday. And I’ve had two big holidays while I’ve been here. Thankfully my [period of leave] came in, so I had [a lot of time] off work. It was the best. I didn’t want to come back, obviously”.(participant 4)*participant pats their chest during the anecdote*. Going online and [obsessively] checking the [high] patient numbers. That’s what I started doing! But that’s not good for me. Like, *recounting, visibly anxious* oh my god, I’m going into this”.“…they were dropping me into some night shifts…and I was having palpitations. I could feel it there…like oh god I’m dreading…I was really dreading going in [which subsided once the participant began their shift] (participant 40)To illustrate the differences between participant anecdotes that fit the descriptions of burnout and those which did not, two examples from the data have been selected. Participant 4’s responses to interview questions matched the diagnostic and research criteria for burnout. Participant 40’s did not, matching more closely to descriptions of stress.Participant 40 described their experiences as ‘much better’ once they began their work routines; they felt more at-ease and less stressed. Participant 40 proceeded to describe how much they love their work, and how satisfying it was to connect with their patients. Participant 40 continued going to work because, “I still love my job! I love socializing, talking with patients…”, and because they derive a sense of deep satisfaction from providing high-quality, attentive care to patients. Like participant 40, most participants, including those who acknowledged significant stress, did not describe themselves or their co-workers as being ‘emotionally exhausted’, ‘depersonalized’, or ‘lacking feelings of personal accomplishment’. The lack of descriptors of this nature indicated to researchers that these experiences were not burnout. Instead, participants regularly described experiences of consistent, daily stress as a consequence of their working environment, consistent with data from organizational psychology research on the negative impact of uncongenial working environments ,26. In sParticipant 4’s experience differed from participant 40’s in many ways. Participant 40 appeared to experience anxiety, but this was largely anticipatory, as it evaporated once work began. In contrast participant 4 experienced anxiety and unhappiness that continued throughout work. They were also unable to detach from these sensations during weekends away from work, remaining focused on their experience of misery. These sensations only eased during prolonged holiday periods. This is congruent with evidence that one of the few known remedies for burnout discussed in literature is time away from the workplace where those suffering from burnout usually experience complete recovery from their symptoms ,27. This*participant rolls their eyes, emphasizing the word ‘basic’*.“…it’s almost like…you want to get something done for the benefit of patients and staff…and you’re happy to go to all the effort to prove why it’s needed and everything…but then it’s the continual…’oh, nobody knows’ or ‘you’ll have to speak to so-and-so somewhere up the ladder about that’, and you hit loads of dead-ends just trying to find out some very basic information” (participant 72)Participants who appeared to experience the most stress in the workplace were staff in the middle of the patient-facing hierarchy, i.e., those who were neither junior, nor senior staff in the team. These staff included registrar doctors and registered nurses. As their role carried a large amount of responsibility, often with little autonomy, these ‘middle’ staff members explained that, “There is a lot of responsibility in the workplace, a lot of stress…” (participant 12), and, “Why is this my responsibility to do …I brought [it] up with every single level of person… but it always used to come back to me, it was horrendous.” (participant 4). Many of the participants listed other stressors that impacted their long-term wellbeing, such as feeling unsafe at work, feeling like there was more work to do than people available to do it, and user-unfriendly systems for forms and issue resolution.*irritated*…There was a position being abolished … but there’s no money to reinstate the position now that it’s been cut, so the workload has to be absorbed by current staff. There’s no ‘fat’ in the system to absorb extra work anymore... So, we are all being provisioned to provide our services at a basic level, when we want to deliver silver or gold-standard care! When we can’t do that, that’s when the dissatisfaction comes in. *participant emphasizes the word ‘dissatisfaction’*. When you know you’re not delivering that standard, and there’s somebody out there hurting because you can’t, I feel concern for them...*participant looks upset by this disp-quote*”.“…I got a classic phone call the other day (participant 17)When asked to describe how these experiences made them feel, participants volunteered ‘fatigue’ and ‘frustration’ most frequently. Participants expanded on this, explaining that their frustrations mostly stemmed from systems and situations which prevented them from performing their job to their best ability;This was the main theme, with interview participants describing feeling stressed when they believed that they were not providing optimal quality of patient care. Those staff in the middle of the hierarchy, were more likely to describe this stress than more senior or junior staff.The researchers sought to explore the patient-facing staff experiences of stress and burnout in a large health service by comparing interview responses to MBI  and the The second theme suggested that stress was most common among patient-facing staff in the middle of the hierarchy, and this was largely a consequence of their perceived inability to provide the quality of care they felt they should be providing. These findings are consistent with current research that has found a relationship between episodes of missed care and powerlessness and stress among nurses .These themes led to the conclusion that the experiences of those interviewed was not burnout, but stress arising from uncongenial working conditions. Despite participants self-reporting that they perceived their experiences to be ‘burnout’, their own descriptions did not match the ICD-11 nor Maslach’s  descriptThe results of this study illustrated a case where participants suggested that they and their colleagues were suffering from burnout, but which in fact were stress responses to workplace factors, as also identified by Murtagh . DespiteWhile physical safety standards are well documented , the samWhile our analysis showed that the majority of participants in this project did not suffer from burnout, burnout remains the endpoint of long-term stressful experiences for an individual ,2,10. ThRather than developing strategies to bolster individual staff resilience to these uncongenial working conditions, a more sustainable and effective solution may be to remedy specific stressors present in the workplace. This will require accurate assessment of social factors and psychological stressors, in addition to physical workplace factors, in each public hospital for which policymakers and boards are responsible. To this end, the process of a staff-focused service review is highly recommended for the immediate future.Our results may be inconsistent with current literature on burnout due to targeting an infrequently sampled population or sampling a relatively small percentage of the overall number of staff working at the target health system. For context, the staff employed at the target health system number in the thousands, crossing a multitude of medical specialties, of which 72 participants were interviewed from three departments. However, by the end of the interviews no new themes emerged suggesting that data saturation had been achieved. There is potential for the participants of this study to experience work differently to those who have participated in other studies due to a variety of unique conditions present in this study’s target health system, some of which were identified in Kendrick and Bartram et al. . FurtherDue to the field of burnout being relatively new with diagnostic and measurement tools still undergoing revision and improvement , there iBurnout was rarely present despite participants self-reporting feeling burnt-out, or ‘witnessing’ burnout in their co-workers. This finding diverged from current literature on burnout in healthcare workers, which suggested a trend of high burnout rates across a range of cultural contexts ,4,18. ThThis unexpected finding and its interpretation led the authors to three potential conclusions: either (a) current studies on burnout are inaccurate and thus skewed towards confirmation-bias; (b) the target sample is a significant outlier that requires in-depth investigation as to the reasons why participant experiences do not match current trends of burnout; or (c) qualitative study has enabled greater depth in understanding the experiences of the staff that are not possible with existing quantitative burnout questionnaires ,21,23. T


In England, a significant proportion of people who take part in the national bowel cancer screening programme (BCSP) and have a positive faecal occult blood test (FOBt) result, do not attend follow-up colonoscopy (CC). The aim of this study was to investigate differences in intended participation in a follow-up investigation by diagnostic modality offered including CC, CT colonography (CTC) or capsule endoscopy (CE).We performed a randomised online experiment with individuals who had previously completed an FOBt as part of the English BCSP.Participants (n=953) were randomly allocated to receive one of three online vignettes asking participants to imagine they had received an abnormal FOBt result, and that they had been invited for a follow-up test. The follow-up test offered was either: CC (n=346), CTC (n=302) or CE (n=305). Participants were then asked how likely they were to have their allocated test or if they refused, either of the other tests. Respondents were also asked to cite possible emotional and practical barriers to follow up testing. Multivariable logistic regression models were used to investigate intentions.Intention to have the test was higher in the CTC group (96.7%) compared with the CC group . CTC was considered less ‘off-putting’  and less uncomfortable compared with CC . For those who did not intend to have the test they were offered, CE (39.7%) or no investigation (34.5%) was preferable to CC (8.6%) or CTC (17.2%).Alternative tests have the potential to increase attendance at diagnostic follow-up appointments. Use of a vignette design allowed us to investigate attitudes towards hypothetical scenarios which would be more difficult to carry out in a real-world setting.The use of comprehension checks after presenting vignettes ensured that participants engaged with materials and had an understanding of the tests they were presented.The study design presented a hypothetical scenario and so it is not possible to say if intentions would align with behaviours in real life.We only provided brief descriptions of the test which may have biased intentions.The online panel used in the survey had a very small number of Black, Asian and minority ethnic participants, and therefore, may not be representative of the UK population.Colorectal cancer (CRC) is the fourth most common cancer in the UK, accounting for 12% of all cancer diagnosis, and is the second-leading cause of cancer death.7 8et al reviewed the medical records of patients of 170 patients to identify patient factors associated with non-attendance at CC after a positive FOBt and found the most cited reason was ‘unwillingness to complete the test’.12Previous research point towards a range of psychological and practical factors which may influence decisions to have CRC screening.Some of these barriers may be directly or indirectly related to the nature of CC. CC involves inserting a long flexible tube with a tiny camera on the end into the anus in order to examine the bowel. If polyps  are found, they are removed during the procedure. The test requires the patient to restrict their diet, take a strong laxative and arrange for someone to take them home afterwards due to drowsiness caused by a sedative. After the procedure, most people will need to rest for the remainder of the day.13Considering the practical and emotional barriers which may inhibit someone from accepting the offer of further investigation via CC, it has been suggested that offering alternative tests, such as CT colonography (CTC) or capsule endoscopy (CE), may be more acceptable to patients.CTC and CE could be offered individuals who decline to have a CC after a positive FOBt, in the expectation that providing individuals with alternative choices increases their feeling of autonomy and intrinsic motivation.The present study aimed to evaluate whether offering different screening tests, such as CTC or CE, increases intentions to attend for further investigation, when compared with offering a CC.We performed a randomised online experiment with a survey company called: ‘Dynata’ . Potentially eligible men and women were invited to participate in the online experiment by Dynata, who invited them from their panel if they were: (1) aged 60–74 years and (2) lived in England. Potentially eligible men and women were informed that they would be rewarded with ‘Dynata points’, which they could exchange for money, or a donation to a charity, if they complete the survey.Individuals who agreed to participate in the survey were asked about their screening history, which was used to filter ineligible adults. Only individuals who had completed an FOBt previously, and received a normal result, were eligible to participate in the survey. We excluded participants who had previously had a CC, a previous diagnosis of CRC or had parts of their bowel removed. Once eligibility to participate had been established using these criteria, participants were then randomly allocated to one of three experimental conditions in which they were asked to read a hypothetical vignette see .10.1136/bmjopen-2019-035264.supp1Supplementary dataDepending on the condition individuals were allocated to, the vignette asked them to imagine that their next FOBt result was abnormal, and they were being invited for a follow-up test consisting of either CC, a CTC or a CE. Each vignette included a some images of the test, a short description about what happens before, during and after the test, and any risks associated with the offered test. After reading the information, participants were required to successfully answer a ‘comprehension check question’ about the test , to ensure they had understood the information. If answered incorrectly, the information about the test was presented again and the participant is provided with another opportunity to answer the question. Once the participant answered the comprehension check question correctly, they were asked about their intention to have the follow-up test. Details of the comprehension check questions can be found in the ’), using a four-point Likert scale, with response options: ‘definitely not’, ‘probably not’, ‘probably, yes’ and ‘definitely, yes’.On answering the comprehension check question correctly, participants were asked to indicate their intention to book an appointment , using a four-point Likert scale, with response options: ‘strongly agree’, ‘slightly agree’, ‘slightly disagree’ and ‘strongly disagree’. The barriers featured six emotional and four practical items, and were derived from previous surveys.Study participants who indicated that they would not (probably or definitely) have the offered follow-up test were presented with information about the other two tests and asked which of the three tests they would prefer (‘Which of the two tests would you prefer to have?’), with response options ‘CC’, ‘capsule endoscopy’, ‘CTC’ and ‘none of them’.et al,Numeracy skills were assessed by the question: ‘Which of the following numbers represents the biggest risk of getting a disease?’, with answer options ‘1/10’, ‘1/100’, ‘1/1000’ and ‘I don’t know’. This measure was adapted from Lipkus Details of the participant’s age, gender, ethnicity, employment status, education, car and home ownership were collected at the end of the survey. Ethnicity data were recoded as ‘White’ (White British or Other White Background) and Black, Asian and minority ethnic (BAME) due to the small numbers in each group. The three variables on education, car and home ownership were used to calculate a proxy measure for socioeconomic deprivation. One point was given to a participant if their household did not own a car or van, if they had no formal qualifications and if they did not own their own home.Sample size of this study was calculated prior to data collection based on the results of a soft launch. We calculated that we needed approximately 300 participants per condition to detect differences of at least 5 percentage points in proportion of intenders effect size between any of the three conditions, with a power of 80% and an alpha value of 0.05.30https://osf.io/fx69t/.Our primary outcome was intention to have the offered follow-up test after exposure to the allocated vignette. Our secondary outcomes were the responses to the perceived emotional and practical barrier questions. Descriptive statistics were used to report the sociodemographic characteristics of the study population. Univariable and multivariable logistic regression models were used to investigate the effect of offering alternative follow-up tests on participants’ intentions to have further investigations, as well as their perceived emotional and practical barriers of the test offered. Covariates that were included in the regression models were age, gender, ethnicity, deprivation score, employment status and numeracy. All statistical analyses were conducted using Stata/SE (V.15.1).The design of this study followed a direct question posed by representatives of Public Health England and was informed by previous research on this topic and close collaboration with experts involved in administering relevant tests (see Acknowledgments).In total, 1926 adults responded to the online invitation. Of these, 481 (25.0%) were excluded due to their age or medical history . A further 372 (19.3%) were excluded as they had never been invited for, or completed, an FOBt, and an additional 46 (2.4%) were excluded as they had previously received an abnormal FOBt result. Of the remaining 1027 adults who were eligible for inclusion, 953 (92.8%) completed the survey =6.64, p=0.036).A large majority (93.7%) intended to have their allocated test, although this was graded by ethnicity (61.5% vs 94.4%) and deprivation (2–3 markers: 87.9% vs 0 markers: 95.5%). The proportion of intenders was highest among those who were offered CTC, followed by those who were offered capsule, and finally those who were offered CC  study participants did not intend to have their offered follow-up test. Independently from the initial offer, most disinclined study participants would either choose CE  or none of the tests . A Fisher’s exact test demonstrated that preferences were not influenced by the initial random allocation (p=0.806).Those who were randomised to CTC were less likely to agree that the test is off-putting  or uncomfortable  than those who were offered a CC. Participants who were offered CE as a follow-up test were less likely to perceive the test as uncomfortable , embarrassing  or creating worries about the risks associated with the test  than those who were offered a CC .The table also shows that women were more likely to perceive the offered tests as off-putting , embarrassing  and causing worries about the risks  and results of the test .Higher deprivation was associated with worrying about the risks associated with the test  and numeracy was positively associated with being afraid of the results . Subgroup analysis did not reveal any significant interactions between these demographic variables and test allocation .10.1136/bmjopen-2019-035264.supp3Supplementary dataStudy participants who were offered CE, instead of CC, were less likely to think that they would not have the time to do the test . There were no other differences in practical barriers by test offered see . Health This study investigated whether offering alternative follow-up tests increases intention to undergo further investigation in the context of CRC screening. The results of our study show that, while the vast majority of individuals would accept any test, offering CTC instead of CC may increase acceptance of follow-up tests. Findings from our study suggest that this is due to individuals perceiving CTC as less ‘off-putting’ and ‘uncomfortable’ than CC. No differences were found in intention between those randomised to CE compared with CC despite CE appearing less uncomfortable, less embarrassing, causing less worry about the risks associated with the test and taking test time. However, for the small number of participants who did not intend to take the offered test, CE appeared to be the preferred test when presented with all options.et al and one in Italy, by Sali et al.et al found that CTC was more appealing than CE (7.4% vs 5.0% having the investigation) with no differences found in clinical outcomes. The authors concluded that those who refuse CC are difficult to recruit into the screening programme and that simply offering a different test is not effective. Sali et al also found that invitation to CTC was more preferable, but in comparison to CC (35.7% vs 14.1% attending). However, these trials were carried out in France and Italy and may not be generalisable to a UK population and the National Health Service (NHS) screening programme. Importantly, as these studies focused on patients who had already refused CC it looked at preferences in a preselected sample. This is reflected in the small sample sizes in both studies with only 50–100 participants in each comparison group, making it difficult to draw conclusions about the population-level benefits of offering alternative tests.The findings from this study are supported by two trials: one in in France, by Pioche Our study observed a lower likelihood of ethnic minorities to accept any follow-up test. This is supported by a recent systematic review which found that non-white participants were less likely to attend in 9 out of 10 studies investigating incomplete diagnostic follow-up after a positive bowel screening test While our study provides support that individuals perceive follow-up tests differently, we only offered one test at random. Future research should present all three tests to participants in a random order to analyse whether offering individuals the choice between different tests increases intentions.36Our study has several limitations. First, our study used hypothetical scenarios and non-representative online study samples. Although the vignettes were developed in collaboration with clinicians, it was not possible in the space available to fully explain the level of burden associated with each test which may have biased responses. For example, in the CE vignette we stated that after the procedure it was possible to return to normal daily activities, when in reality the patient may be required to take booster laxatives and will have to return another day to have the recording analysed. It is possible that CE emerged as the second most preferred test due to the relatively positive description of the procedure.Furthermore, the experiments lacked behavioural validation, in that they only measured intentions and choice in a hypothetical setting. The next step would be to test the effect of offering alternative follow-up tests under more ecologically valid conditions in a randomised controlled trial.A strength of our study is that we used comprehension checks to ensure that all study participants sufficiently engaged with the provided information about the follow-up test.While the results from this randomised online experiment show a high acceptance of the current practice of the NHS Bowel Screening Programme to invite individuals who have an abnormal FOBt result for a follow-up CC, our study also provides some evidence that offering CTC, instead of CC, may increase the total number of participants undertaking a follow-up test. Although CTC and CE are not currently endorsed as a screening modalites, our study provides some evidence that for high-risk and hard-to-engage groups, such as those who have a positive FOBt but refuse follow-up, offering alternative tests may increase intentions to engage with medical professionals and receive appropriate care.