I currently hold the post of Reader in Healthcare Workforce Organisation and Wellbeing in the School of Health Sciences at the University of Surrey. I have worked in Health Services Research since 1997, following completion of a Psychology degree at Swansea University. My academic career began at Imperial College London (1997-2002) followed by Kings College London (2002-2017).
My main research interests are improving the wellbeing of the NHS workforce and assessing and improving multidisciplinary team working in healthcare teams. In relation to the wellbeing of NHS staff, I have conducted national cohort studies of mental health in hospital consultants, and worked alongside Professor Jill Maben (also at University of Surrey) in the recent national evaluation of Schwartz Center Rounds in the UK, funded by the NIHR. My work in relation to multidisciplinary teams led to the development of a cancer multidisciplinary team assessment and feedback tool (named MDT-FIT) that won QiC Oncology Digital Innovation of the Year in 2016.
My main research interests are improving the wellbeing of the NHS workforce, and assessing and improving multidisciplinary teamwork in healthcare (particularly where two or more specialisms are required to come together e.g. for multimorbidity).
Indicators of esteem
London Research for Patient Benefit (RfPB) Funding Committee member: January 2016 - current
Center Rounds as an organisational
innovation to improve staff well-being
in England, 2009?2015, BMJ Open 7 e014326 BMJ Publishing Group
Schwartz Center Rounds (?Rounds?) are a
multidisciplinary forum in which healthcare staff within
an organisation discuss the psychological, emotional
and social challenges associated with their work in a
confidential and safe environment. Implemented in
over 375 North American organisations, since 2009,
they have been increasingly adopted in England. This
study aimed to establish how many and what types of
organisations have adopted Rounds in England, and to
explore why they did so.
Public healthcare organisations in England.
Participants: Secondary data analysis was used to
map and profile all 116 public healthcare organisations
that had adopted Rounds in England by July 2015.
Semistructured telephone interviews were conducted
with 45 Round coordinators within adopting
The rate of adoption increased after a major
national report in 2013. Rounds were typically adopted in
order to improve staff well-being. Adopting organisations
scored better on staff engagement than non-adopters;
among adopting organisations, those performing better
on patient experience were more likely to adopt earlier.
Most adoption decision-making processes were
straightforward. A confluence of factors?a generally
favourable set of innovation attributes (including low
cost), advocacy from opinion leaders in different
professional networks, active dissemination by change
agents and a felt need to be seen to be addressing staff
well-being?initially led to Rounds being seen as ?an idea
whose time had come?. More recent adoption patterns
have been shaped by the timing of charitable and other
agency funding in specific geographical areas and
sectors, as well as several forms of ?mimetic pressure?.
The innate attributes of Rounds,
favourable circumstances and the cumulative impact of a
sequence of distinct informal and formal social
processes have shaped the pattern of their adoption in
Lymphedema is a common consequence of breast cancer treatment requiring life-long treatment to reduce
symptoms and prevent complications. Evidence to inform the optimal decongestive lymphedema treatment
package is lacking.
To identify the effect of decongestive lymphedema treatment on excess arm volume or patient-centered
outcomes for women presenting within either 12 months or mean 9 months of developing arm lymphedema
following breast cancer treatment.
Types of participants: women who received lymphedema treatment within either 12 months or mean 9
months of developing unilateral breast cancer-related arm lymphedema.
Types of intervention: any decongestive lymphedema treatment delivered with the purpose of reducing arm
lymphedema, compared to another form of lymphedema treatment (whether self or practitioner
administered), placebo or no treatment.
Types of outcomes: clinical outcome was excess arm volume; patient-centered outcomes were health
related quality of life, arm heaviness, arm function, patient-perceived benefit and satisfaction with treatment.
Types of studies: experimental study designs were eligible, including randomized and non-randomized
controlled trials, quasi-experimental, prospective and retrospective before and after studies.
A three-step search strategy was utilized to find published and unpublished studies. The search identified
studies published from inception of each database to 6th July 2016. Reference lists were scanned to identify
further eligible studies.
Studies were critically appraised using appropriate standardized critical appraisal instruments from The
Joanna Briggs Institute.
Details describing each study and treatment results regarding outcomes of interest were extracted from
papers included in the review using appropriate standardized data extraction tools from The Joanna Briggs
Due to heterogeneity in included studies, results for similar outcome measures were not pooled in statistical
meta-analysis. A narrative and tabular format was used to synthesize results from identified and included
Seven studies reporting results for outcomes of interest were critically appraised and included in the review:
five randomized controlled trials and two descriptive (uncontrolled) studies. Reported outcomes included
excess arm volume (five studies), health-related quality of life (three studies), arm heaviness (one study),
arm function (two studies) and patient-perceived benefit (two studies). There was some evidence that
decongestive treatments were effective for women presenting within either 12 months or mean 9 months
of developing breast cancer-related arm lymphedema, but the wide range of data prevented comparison of
treatment findings which limited our ability to answer the review questions.
Weak evidence (grade B) for the impact of decongestive lymphedema treatment on women with early
lymphedema (i.e. less than 12 months duration of BCRL symptoms) did not allow any conclusions to be
drawn about the most effective treatment to be offered when these women first present for treatment.
Findings provided no justification to support change to current practice.
Future primary research needs to focus on the most effective treatment for women when they first present
with lymphedema symptoms, e.g. treatment provided within 12 months of developing symptoms. Studies
should be adequately powered and recruit women exclusively with less than 12 months duration of BCRL
symptoms, provide longer follow-up to monitor treatment effect over time, with comparable treatment
protocols, outcome measures and reporting methods.
Cardiac disease is associated with adverse outcomes in pregnancy and is the leading cause of indirect maternal death in the United Kingdom (UK) and internationally. National and international guidelines recommend women should receive care from multidisciplinary teams; however evidence is lacking to inform how they should be operationalised.
To describe the composition and processes of multidisciplinary care between maternity and cardiac services before, during and after pregnancy for women with cardiac disease, and explore clinicians? (cardiologists, obstetricians, nurses, midwives) and women?s experiences of delivering/receiving care within these models.
Mixed-methods comprising case-note audit, interviews and observation.
Two inner-city National Health Service (NHS) maternity units in the south of England serving similar obstetric populations, selected to represent different models of multidisciplinary team care.
Women with significant cardiac disease (either arrhythmic or structural, e.g. tetralogy of fallot) who gave birth between June 1/st 2014 and 31/st May 2015 (audit/interviews), or attended an multidisciplinary team clinic (obstetric/cardiac) during April 2016 (observation).
A two-phase sequential explanatory design was undertaken. A retrospective case-note audit of maternity and medical records (n/=/42 women) followed by interviews with a sub-sample (n/=/7 women). Interviews were conducted with clinicians (n/=/7) and observation of a multidisciplinary team clinic in one site (n/=/8 women, n/=/4 clinicians).
The interests and expertise of individual clinicians employed by the hospital trusts influenced the degree of integration between cardiac and maternity care. Integration between cardiac and maternity services varied from an ad-hoc ?collaborative? model at Site B to an ?interdisciplinary? approach at Site A. In both sites there was limited documented evidence of individualised postnatal care plans in line with national guidance. Unlike pathways for risk assessment, referral and joined care in pregnancy for women with congenital cardiac disease, pathways for women with acquired conditions lacked clarity. Midwives at both sites were often responsible for performing the initial maternal cardiac risk assessment despite minimal training in this. Clinicians and women?s perceptions of ?normality? in pregnancy/birth, and its relationship to ?safe? maternity care were at odds.
The limited evidence and guidance to support multidisciplinary team working for pregnancy in women with cardiac disease ? particularly those with acquired conditions ? has resulted in variable models and pathways of care. Evidence-based guidance regarding the operationalisation of integrated care between maternity and cardiac services ? including pathways between local and specialist centres ? for all women with cardiac disease in pregnancy is urgently required.
To estimate prevalence and explore potential causes and consequences of compassion satisfaction and compassion fatigue in UK emergency medicine consultants.
A sequential mixed-methods design. Cross-sectional e-survey to all UK NHS emergency medicine consultants (n=1317) including Professional Quality of Life (ProQOL) (compassion satisfaction/fatigue), followed by interviews with consultants scoring above (n=6) and below (n=6) predefined ProQOL thresholds.
681 (52%) consultants responded. Most (98%) reported at least ?average? compassion satisfaction. Higher scores were associated with type of workplace (designated trauma centres faring better) and number of years worked as a consultant (gradually worsen over time, except 20?years onwards when it improves). Consultants with lower (worse) compassion satisfaction scores were more likely to report being irritable with patients or colleagues and reducing their standards of care (a third reported these behaviours at least monthly) and were more likely to intend to retire early (59% had such plans). Key features distinguishing ?satisfied? from ?fatigued? interviewed consultants included having strategies to deal with the high work intensities associated with their role and having positive views of the team within which they worked. The degree of variety in their roles and the ability to maintain empathy for their patients were also distinguishing features between these groups.
Findings support an urgent review of workforce and resources in emergency medicine and suggest that a multifactorial approach to identification, prevention and treatment of occupational stress in the workforce is required that considers individual, job and organisational factors, particularly those that impact on perceived control and support at work.
Despite numerous publications stating the importance of multidisciplinary care for women with pre-existing medical conditions, there is a lack of evidence regarding structure or processes of multidisciplinary working, nor impact on maternal or infant outcomes. This study aimed to evaluate the implementation of guidelines for multidisciplinary team (MDT) management in pregnant women with pre-existing diabetes or cardiac conditions. These conditions were selected as exemplars of increasingly common medical conditions in pregnancy for which MDT management is recommended to prevent or reduce adverse maternal and fetal outcomes.
National on-line survey sent to clinicians responsible for management or referral of women with pre-existing diabetes or cardiac conditions in UK National Health Service (NHS) maternity units. The survey comprised questions regarding the organisation of MDT management for women with pre-existing diabetes or cardiac conditions. Content was informed by national guidance.
One hundred seventy-nine responses were received, covering all health regions in England (162 responses) and 17 responses from Scotland, Wales and Northern Ireland. 132 (74%) related to women with diabetes and 123 (69%) to women with cardiac conditions. MDT referral was reportedly standard practice in most hospitals, particularly for women with pre-existing diabetes (88% of responses vs. 63% for cardiac) but there was wide variation in relation to MDT membership, timing of referral and working practices. These inconsistencies were evident within and between maternity units across the UK. Reported membership was medically dominated and often in the absence of midwifery/nursing and other allied health professionals. Less than half of MDTs for women with diabetes met the recommendations for membership in national guidance, and although two thirds of MDTs for women with cardiac disease met the core recommendations for membership, most did not report having the extended members: midwives, neonatologists or intensivists.
The wide diversity of organisational management for women with pre-existing diabetes or cardiac conditions is of concern and merits more detailed inquiry. Evidence is also required to support and better define the recommendations for MDT care.
meetings (MDMs), and test criterion validity, inter-rater reliability/agreement and describe performance.
Design: Clinicians and experts in teamwork used a mixed-methods approach to develop and refine the tool. Study 1 observers rated pre-determined optimal/sub-optimal MDM film excerpts and Study 2 observers independently rated video-recordings of 10 MDMs.
Setting: Study 2 included 10 cancer MDMs in England.
Participants: Testing was undertaken by 13 health service staff and a clinical and non-clinical observer.
Main Outcome Measures: Tool development, validity, reliability/agreement and variability in MDT performance.
Results: Study 1: Observers were able to discriminate between optimal and sub-optimal MDM performance
(P d 0.05). Study 2: Inter-rater reliability was good for 3/10 domains. Percentage of absolute agreement was high (e80%) for 4/10 domains and percentage agreement within 1 point was high for 9/10 domains. Four MDTs performed well (scored 3+ in at least 8/10 domains), 5 MDTs performed
well in 6?7 domains and 1 MDT performed well in only 4 domains. Leadership and chairing of the meeting, the organization and administration of the meeting, and clinical decision-making processes all varied significantly between MDMs (P d 0.01).
Conclusions: MDT-MOT demonstrated good criterion validity. Agreement between clinical and nonclinical
observers (within one point on the scale) was high but this was inconsistent with reliability coefficients and warrants further investigation. If further validated MDT-MOT might provide a useful mechanism for the routine assessment of MDMs by the local workforce to drive improvements in MDT performance.
The optimal management of patients with breast cancer (BC) requires the expertise of specialists from different disciplines. This has led to the evolution of multidisciplinary teams (MDTs), allowing all key professionals to jointly discuss individual patients and to contribute independently to clinical decisions. Data regarding BC MDTs in different regions and countries are scarce.
The investigators of a large global phase III adjuvant BC trial being conducted by the Breast International Group were invited to respond to a questionnaire about the extent, structure, and function of BC MDTs.
One hundred and fifty-two responses from 39 countries were received, and remarkable differences were noted in different geographic regions. Sixty-five percent of the respondents from eastern Europe, 63% from western Europe, 35% from Asia, and 25% from South America declared that MDT was a mandatory part of BC care in their country. Ninety percent of the respondents from Europe stated their MDTs met weekly, compared with only half of the respondents from Asia.
This survey is perhaps the first large-scale effort to collect information regarding BC MDTs from different parts of the world and provides objective information of frequency, composition, function, and working mechanism of BC MDTs.
Multidisciplinary teams (MDTs) are the standard means of making clinical decisions in surgical oncology. The aim of this study was to explore the views of MDT members regarding contribution to the MDT, representation of patients? views, and dealing with disagreements in MDT meetings?issues that affect clinical decision making, but have not previously been addressed.
Responses to open questions from a 2009 national survey of MDT members about effective MDT working in the United Kingdom were analyzed for content. Emergent themes were identified and tabulated, and verbatim quotes were extracted to validate and illustrate themes.
Free-text responses from 1,636 MDT members were analyzed. Key themes were: (1) the importance of nontechnical skills, organizational support, and good relationships between team members for effective teamworking; (2) recording of disagreements (potentially sharing them with patients) and the importance of patient-centered information in relation to team decision making; (3) the central role of clinical nurse specialists as the patient?s advocates, complementing the role of physicians in relation to patient centeredness.
Developing team members? nontechnical skills and providing organizational support are necessary to help ensure that MDTs are delivering high-quality, patient-centered care. Recording dissent in decision making within the MDT is an important element, which should be defined further. The question of how best to represent the patient in MDT meetings also requires further exploration.
We construct validated the instrument to evaluate assessor learning curves and the feasibility and interrater reliability of MTB-MODe for assessing the decision making process using video recorded multidisciplinary tumor board meetings.
Materials and Methods
Multidisciplinary tumor boards are becoming standard practice for managing cancer internationally but no standards have been agreed on to assess the efficacy of such teams. The MTB-MODe tool assesses the process of multidisciplinary tumor board decision making by standardized observation (1 to 5 anchored scales) of the quality of information presented at the multidisciplinary tumor board as well as board member contributions to the case review. We assessed 683 multidisciplinary tumor board case discussions using MTB-MODe in a multiphase study, including 332 cases (9 urology boards) by 1 urologist in vivo and 224 cases (6 urology boards) by 2 urologists in vivo. The instrument was refined and subsequently used to rate 127 video recorded case discussions (5 tumor types) by a total of 8 multidisciplinary tumor boards.
Good interrater reliability was achieved in vivo and at the video recorded multidisciplinary tumor board meetings (ICC e0.70). MTB-MODe scores were higher in cases that resulted in a decision than in cases in which no decision was made (mean ± SD 2.54 ± 0.47 vs 2.02 ± 0.65, p d0.001).
A standardized method to assess the quality of multidisciplinary tumor board discussions can enhance the quality of cancer care and the ability of the boards to self-evaluate performance, thus, promoting good practice. Video recordings offer a feasible, reliable method of assessing how multidisciplinary tumor boards work.
Using data from a national survey, this study aimed to address whether the current model for multidisciplinary team (MDT) working is appropriate for all tumour types.
Patients and methods:
Responses to the 2009 National Cancer Action Team national survey were analysed by tumour type. Differences indicate lack of consensus between MDT members in different tumour types.
One thousand one hundred and forty-one respondents from breast, gynaecological, colorectal, upper gastrointestinal, urological, head and neck, haematological and lung MDTs were included. One hundred and sixteen of 136 statements demonstrated consensus between respondents in different tumour types. There were no differences regarding the infrastructure for meetings and team governance. Significant consensus was seen for team characteristics, and respondents disagreed regarding certain aspects of meeting organisations and logistics, and patient-centred decision making. Haematology MDT members were outliers in relation to the clinical decision-making process, and lung MDT members disagreed with other tumour types regarding treating patients with advanced disease.
This analysis reveals strong consensus between MDT members from different tumour types, while also identifying areas that require a more tailored approach, such as the clinical decision-making process, and preparation for and the organisation of MDT meetings. Policymakers should remain sensitive to the needs of health care teams working in individual tumour types.
Cancer multidisciplinary teams (MDTs) are established in many countries but little is known about how well they function. A core activity is regular MDT meetings (MDMs) where treatment recommendations are agreed. A mixed methods descriptive study was conducted to develop and test quality criteria for observational assessment of MDM performance calibrated against consensus from over 2000 MDT members about the ?characteristics of an effective MDT?.
Eighteen of the 86 ?Characteristics of Effective MDTs? were considered relevant and feasible to observe. They collated to 15 aspects of MDT working covering four domains: the team (e.g. attendance, chairing, teamworking); infrastructure for meetings (venue, equipment); meeting organisation and logistics; and patient-centred clinical decision-making (patient-centredness, clarity of recommendations). Criteria for rating each characteristic from ?very poor? to ?very good? were derived from literature review, observing MDMs and expert input. Criteria were applied to 10 bowel cancer MDTs to assess acceptability and measure variation between and within teams. Feasibility and inter-rater reliability was assessed by comparing three observers.
Observational assessment was acceptable to teams and feasible to implement. Total scores from 29 to 50 (out of 58) highlighted wide diversity in quality between teams. Eight teams were rated either ?very good/good? or ?very poor/poor? for at least three domains demonstrating some internal consistency. ?Very good? ratings were most likely for attendance and administrative preparation, and least likely for patient-centredness of decision-making and prioritisation of complex cases. All except two characteristics had intra-class correlations of e0.50.
This observational tool (MDT-OARS) may contribute to the assessment of MDT performance. Further testing to confirm validity and reliability is required.
Multidisciplinary team (MDT) working is well established as the foundation for providing cancer services in the UK and elsewhere. A core activity is the weekly meeting (or case conference/tumor boards) where the treatment recommendations for individual patients are agreed. Evidence suggests that the quality of team working varies across cancer teams, and this may impact negatively on the decision-making process, and ultimately patient care. Feedback on performance by expert observers may improve performance, but can be resource-intensive to implement. This proof of concept study sought to: develop a structured observational assessment tool for use by peers (managers or clinicians from the local workforce) and explore its usability; assess the feasibility of the principle of observational assessment by peers; and explore the views of MDT members and observers about the utility of feedback from observational assessment.
For tool development, the content was informed by national clinical consensus recommendations for best practice in cancer MDTs and developed in collaboration with an expert steering group. It consisted of ten subdomains of team working observable in MDT meetings that were rated on a 10-point scale (very poor to very good). For observational assessment, a total of 19 peer observers used the tool (assessing performance in 20 cancer teams from four hospitals). For evaluation, telephone interviews with 64 team members and all peer observers were analyzed thematically.
The tool was easy to use and areas for refinement were identified. Peer observers were identified and most indicated that undertaking observation was feasible. MDT members generally reported that observational assessment and feedback was useful, with the potential to facilitate improvements in team working.
This study suggests that observation and feedback by peers may provide a feasible and acceptable approach to enhance MDT performance. Further tool refinement and validation is required.
The PELICAN Multidisciplinary Team Total Mesorectal Excision (MDT-TME) Development Programme aimed to improve clinical outcomes for rectal cancer by educating colorectal cancer teams in precision surgery and related aspects of multidisciplinary care. The Programme reached almost all colorectal cancer teams across England. We took the opportunity to assess the impact of participating in this novel team-based Development Programme on the working lives of colorectal cancer team members.
The impact of participating in the programme on team members' self-reported job stress, job satisfaction and team performance was assessed in a pre-post course study. 333/568 (59%) team members, from the 75 multidisciplinary teams who attended the final year of the Programme, completed questionnaires pre-course, and 6-8 weeks post-course.
Across all team members, the main sources of job satisfaction related to working in multidisciplinary teams; whilst feeling overloaded was the main source of job stress. Surgeons and clinical nurse specialists reported higher levels of job satisfaction than team members who do not provide direct patient care, whilst MDT coordinators reported the lowest levels of job satisfaction and job stress. Both job stress and satisfaction decreased after participating in the Programme for all team members. There was a small improvement in team performance.
Participation in the Development Programme had a mixed impact on the working lives of team members in the immediate aftermath of attending. The decrease in team members' job stress may reflect the improved knowledge and skills conferred by the Programme. The decrease in job satisfaction may be the consequence of being unable to apply these skills immediately in clinical practice because of a lack of required infrastructure and/or equipment. In addition, whilst the Programme raised awareness of the challenges of teamworking, a greater focus on tackling these issues may have improved working lives further.
(i) To synthesise the evidence-base for Schwartz Center Rounds® (Rounds) to assess any impact on healthcare staff and identify key features; (ii) to scope evidence for interventions with similar aims, and compare effectiveness and key features to Rounds.
Systematic review of Rounds literature; scoping reviews of comparator interventions (Action Learning Sets; After Action Reviews; Balint Groups; Caregiver Support Programme; Clinical Supervision; Critical Incident Stress Debriefing; Mindfulness-Based Stress Reduction; Peer Supported Storytelling; Psychosocial Intervention Training; Reflective Practice Groups; Resilience Training).
PsychINFO, CINAHL, MEDLINE, and EMBASE, internet search engines; consultation with experts.
Empirical evaluations (qualitative or quantitative); any healthcare staff in any healthcare setting; published in English.
The overall evidence base for Rounds is limited. We developed a composite definition to aid comparison with other interventions from 41 documents containing a definition of Rounds. Twelve (ten studies) were empirical evaluations. All were of low/moderate quality (weak study designs including lack of control groups). Findings showed the value of Rounds to attenders, with a self-reported positive impact on individuals, their relationships with colleagues and patients, and wider cultural changes. The evidence for the comparative interventions was scant and also low/moderate quality. Some features of Rounds were shared by other interventions, but Rounds offer unique features including being open to all staff and having no expectation for verbal contribution by attenders : Evidence of effectiveness for all interventions considered here remains limited. Methods that enable identification of core features related to effectiveness are needed to optimise benefit for individual staff members and organisations as a whole. A systems approach conceptualising workplace wellbeing as arising from both individual and environmental/structural factors, and comprising interventions both for assessing and improving the wellbeing of healthcare staff, is required. Schwartz Rounds could be considered as one strategy to enhance staff wellbeing.
Schwartz Center Rounds® (Rounds) were introduced into the UK in 2009 to support health-care staff to deliver compassionate care, something the Francis report (Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013) identified as lacking. Rounds are organisation-wide forums that prompt reflection and discussion of the emotional, social and ethical challenges of health-care work, with the aim of improving staff well-being and patient care.
How, in which contexts and for whom Rounds participation affects staff well-being at work, increases social support for staff and improves patient care.
(1) A scoping review of Rounds literature and comparison with alternative interventions; (2) mapping Rounds providers via a survey, telephone interviews and secondary data; (3) a two-wave survey of (i) new attenders/non-attenders in 10 sites to determine the impact on staff engagement and well-being; and (ii) interviews with Rounds attenders, non-attenders, facilitators, clinical leads, steering group members, board members and observations in nine case study sites to (4) describe experiences and (5) test candidate programme theories by which Rounds ?work? (realist evaluation).
(1) International literature (English); (2) all Rounds providers (acute/community NHS trusts and hospices) at 1 September 2014 (survey/interview) and 15 July 2015 (secondary data); (3) 10 survey sites; and (4 and 5) nine organisational case study sites (six of which also took part in the survey).
(1) Ten papers were reviewed for Rounds and 146 were reviewed for alternative interventions. (2) Surveys were received from 41 out of 76 (54%) providers and interviews were conducted with 45 out of 76 (59%) providers. (3) Surveys were received from 1140 out of 3815 (30%) individuals at baseline and from 500 out of 1140 (44%) individuals at follow-up. (4 and 5) A total of 177 interviews were conducted, as were observations of 42 Rounds, 29 panel preparations and 28 steering group meetings.
(1) The evidence base is limited; compared with 11 alternative interventions, Rounds offer a unique organisation-wide ?all staff? forum in which disclosure/contribution is not essential. (2) Implementation rapidly increased between 2013 and 2015; Rounds were implemented variably; challenges included ward staff attendance and the workload and resources required to sustain Rounds; and costs were widely variable. (3) There was no change in engagement, but poor psychological well-being (12-item General Health Questionnaire) reduced significantly (p
Rounds outcomes relied on self-report, fewer regular attenders were recruited than desired, and it was not possible to observe staff post Rounds.
Rounds offer unique support for staff and posi
Cancer is diagnosed and managed by multidisciplinary teams (MDTs) in the UK and worldwide, these meet regularly in multidisciplinary team meetings (MDMs) to discuss individual patient treatment options. Rising cancer incidence and increasing case complexity has increased pressure on MDMs. Streamlining discussions has been suggested as a way to enhance efficiency and ensure high quality discussion of complex cases.
Secondary analysis of quantitative and qualitative data from a national survey of 1,220 MDT members regarding their views about streamlining MDM discussions.
The majority of participants agreed that streamlining discussions may be beneficial although variable interpretations of ?streamlining? were apparent. Agreement levels varied significantly by tumour type and occupational group. The main reason for opposing streamlining were concerns about the possible impact on the quality and safety of patient care. Participants suggested a range of alternative approaches for improving efficiency in MDMs in addition to the use of treatment protocols and pre-MDT meetings.
This work complements previous analyses in supporting the development of tumour specific guidance for streamlining MDM discussions considering a range of approaches. The information provided about the variation in opinions between MDT for different tumour types will inform the development of these guidelines. The evidence for variation in opinions between those in different occupational groups and the reasons underlying these opinions will facilitate their implementation. The impact of any changes in MDM practices on the quality and safety of patient care requires evaluation.
Schwartz Center Rounds® (henceforce Rounds) were developed in the United States (US) in 1995 to provide a regular, structured time and safe place for staff to meet to share the emotional, psychological and social challenges of working in healthcare. Rounds were adopted in the United Kingdom (UK) in 2009 and have been subsequently implemented in over 180 healthcare organisations. Using Rounds as a case study, we aim to inform current debates around maintaining fidelity when an intervention developed in one country is transferred and implemented in another.
Interpretive design using nine qualitative interviews (UK = 3, US = 6) and four focus groups (UK: Focus group 1 (4 participants), Focus group 2 (5 participants; US: focus group 1 (5 participants) focus group 2 (2 participants) with participants involved in Rounds design and implementation, for example, programme architects, senior leaders, mentors and trainers. We also conducted non-participant observations of Rounds (UK = 42: USA = 2) and training days (UK = 2). Data were analysed using thematic analysis.
We identified four core and seven sub-core Rounds components, based upon the US design, and seven peripheral components, based on our US and UK fieldwork. We found high core component fidelity and examples of UK adaptations. We identified six strategies used to maintain high fidelity during Rounds transfer and implementation from the US to UK settings: i) having a legal contract between the two national bodies overseeing implementation, ii) requiring adopting UK healthcare organisations to sign a contract with the national body, iii) piloting the intervention in the UK context, iv) emphasising the credibility of the intervention, v) promoting and evaluating Rounds, and vi) providing implementation support and infrastructure.
This study identifies how fidelity to the core components of a particular intervention was maintained during transfer from one country to another by identifying six strategies which participants argued had enhanced fidelity during transfer of Rounds to a different country, with contractual agreements and legitimacy of intervention sources key. Potential disadvantages include limitations to further innovation and adaptation.
Background: Increasing numbers of UK women have overweight or obese BMIs when they become pregnant, or gain excessive weight in pregnancy, increasing their risk of adverse outcomes. Failure to manage postnatal weight is linked to smoking, non-healthy dietary choices, lack of regular exercise, and poorer longer-term health. Women living in areas of higher social deprivation are more likely to experience weight management problems postnatally.
Objectives: To assess feasibility of conducting a definitive RCT to determine effectiveness of lifestyle information and access to a commercial weight management group focusing on self-monitoring, goal setting and motivation to achieve dietary change commencing 8 to 16 weeks postnatally to achieve and maintain weight management and positive lifestyle behaviours.
Design: A randomised two arm feasibility trial, with a nested mixed-methods process evaluation.
Setting: A single centre in an inner city setting in the south of England
Participants: Women with BMIs>25kg/m2 at antenatal booking and women with normal BMIs (18.5kg/m2) at antenatal booking who developed excessive gestational weight gain as assessed at 36 weeks gestation.
Feasibility objectives: Recruitment, retention, acceptability of study processes and identification of relevant economic data. The proposed primary outcome was difference between groups in weight 12 months postnatally, expressed as % weight change and weight loss from antenatal booking. Other proposed outcomes included assessment of diet, physical activity, smoking, alcohol, body image, maternal esteem, mental health, infant feeding and NHS costs.
Results: Most objectives were achieved. 193 women were recruited, 98 allocated to the intervention and 95 to the control. High follow up rates (>80%) were achieved to 12 months. A possible 8.8% benefit in weight change at 12 months compared with booking BMI was found among intervention women, compared with control (4.2% compared to 13.0% p=0.062) , 47% of whom attended at least one weight management session, with low risk of contamination between groups. Greatest benefit was among women who attended 10+ sessions. Barriers to attending sessions included opportunity, capability and motivation issues. Data collection tools were appropriate to support economic evaluation in a definitive trial, and economic modelling is feasible to quantify resource impacts and outcomes not directly measurable within a trial.
Limitations: The study only recruited from one site. It was not possible to recruit women with normal BMIs who developed excessive pregnancy weight gain.
Conclusion: It was feasible to recruit and retain women with overweight or obese BMIs at pregnancy commencement to a trial of postnatal weight management plus standard care compared to standard care only, and collect relevant data to assess outcomes. Approaches to recruit women with normal BMIs who gain excessive gestational weight need to be considered. Commercial weight management groups could support women?s weight management as assessed at 12 months postnatally, with likely greater benefit from attending 10+ sessions. Process evaluation findings highlighted importance of providing more information about the intervention on study allocation, extended duration of time to commence sessions following birth, and extended number of sessions offered to enhance uptake and retention.
Future work: Results support the conduct of a future effectiveness RCT.
A high BMI during and after pregnancy is linked to poor pregnancy outcomes, and contributes to long-term maternal obesity, hypertension and diabetes. Evidence of feasible, effective postnatal interventions is lacking. This randomised controlled trial will assess the feasibility of conducting a future definitive trial to determine effectiveness and cost effectiveness of lifestyle information and access to Slimming World®(Alfreton, UK) groups for 12 weeks commencing from 8 to 16 weeks postnatally, in relation to supporting longer-term postnatal weight management in women in an ethnically diverse inner-city population.
Women will be recruited from one maternity unit in London. To be eligible, women will be overweight (BMI 25?29.9 kg/m²) or obese (BMI e30 kg/m²) as identified at their first antenatal contact, or have a normal BMI (18.5-24.9 kg/m2) at booking but gain excessive gestational weight as assessed at 36 weeks gestation. Women will be aged 18 and over, can speak and read English, expecting a single baby and will not have accessed weight management groups in this pregnancy. Women will be randomly allocated to standard care plus lifestyle information and access to Slimming World®(Alfreton, UK) groups or standard care only. A sample of 130 women is required.
Feasibility trial objectives reflect those considered most important inform a decision about undertaking a definitive future trial. These include estimation of impact of lifestyle information and postnatal access to Slimming World®(Alfreton, UK) on maternal weight change between antenatal booking weight and weight at 12 months post-birth, recruitment rate and time to recruitment, retention rate, influence of lifestyle information and Slimming World®(Alfreton, UK) groups on weight management, diet, physical activity, breastfeeding, smoking cessation, alcohol intake, physical and mental health, infant health, health-related quality of life 6 and 12 months postnatally. An embedded process evaluation will assess acceptability of study processes and procedures to women.
Ethics/dissemination. London?Camberwell St Giles Research Ethics Committee, reference: 16/LO/1422. Outcomes will be disseminated in peer reviewed journals and presentations at national and international conferences.
Trial registration number: ISRCTN 39186148
Protocol version number: v7, 13/08/17
Trial sponsor: King?s College London
Strengths and limitations of this study
" Postnatal interventions may be more effective than antenatal interventions at supporting weight management among women with higher BMIs but evidence is needed.
" This feasibility trial will assess if women with high BMIs at pregnancy commencement or have normal BMIs but gain excessive gestational weight would be prepared to be randomised to standard care plus Slimming World®(Alfreton, UK) groups offered from 8 to 16 weeks postnatally, or to standard care only.
" Women will only be recruited from one study site, however the site provides maternity care to a population with wide diversity. The intervention is available UK-wide.
" Blinding of study participants and assessors is not possible.
A high BMI during and after pregnancy is linked to poor pregnancy outcomes and contributes to
long-term maternal obesity, hypertension, and diabetes. Evidence of feasible, effective postnatal interventions is
lacking. This randomised controlled trial will assess the feasibility of conducting a future definitive trial to determine
effectiveness and cost-effectiveness of lifestyle information and access to Slimming World® (Alfreton, UK) groups for
12 weeks commencing from 8 to 16 weeks postnatally, in relation to supporting longer-term postnatal weight
management in women in an ethnically diverse inner city population.
Women will be recruited from one maternity unit in London. To be eligible, women will be
overweight (BMI 25?29.9 kg/m2) or obese (BMI e 30 kg/m2) as identified at their first antenatal contact, or have a
normal BMI (18.5?24.9 kg/m2) at booking but gain excessive gestational weight as assessed at 36 weeks gestation.
Women will be aged 18 and over, can speak and read English, expecting a single baby, and will not have accessed
weight management groups in this pregnancy. Women will be randomly allocated to standard care plus lifestyle
information and access to Slimming World® (Alfreton, UK) groups or standard care only. A sample of 130 women is
Feasibility trial objectives reflect those considered most important inform a decision about undertaking a definitive
future trial. These include estimation of impact of lifestyle information and postnatal access to Slimming World®
(Alfreton, UK) on maternal weight change between antenatal booking weight and weight at 12 months postbirth,
recruitment rate and time to recruitment, retention rate, influence of lifestyle information and Slimming World®
(Alfreton, UK) groups on weight management, diet, physical activity, breastfeeding, smoking cessation, alcohol
intake, physical and mental health, infant health, and health-related quality of life 6 and 12 months postnatally.
An embedded process evaluation will assess acceptability of study processes and procedures to women.
London?Camberwell St Giles Research Ethics Committee, reference: 16/LO/1422. Outcomes
will be disseminated in peer-reviewed journals and presentations at national and international conferences.
Trial registration number: ISRCTN 39186148. Protocol version number: v7, 13 August 17. Trial
sponsor: King?s College London.
To assess feasibility of a future randomised controlled trial (RCT) of clinical and cost?effectiveness of lifestyle information and commercial weight management groups to support postnatal weight management to 12 months post?birth.
Two?arm feasibility trial, with nested mixed?methods process evaluation.
Inner?city unit, south England.
Women with body mass indices (BMIs) e25 kg/m2 at pregnancy booking or normal BMIs (18.5?24.9 kg/m2) identified with excessive gestational weight gain at 36 weeks of gestation.
Randomised to standard care plus commercial weight management sessions commencing 8?16 weeks postnatally or standard care only.
Feasibility outcomes included assessment of recruitment, retention, acceptability and economic data collation. Primary and secondary end points included difference between groups in weight 12 months postnatally compared with booking (proposed primary outcome for a future trial), diet, physical activity, smoking, alcohol, mental health, infant feeding, NHS resource use.
In all, 193 women were randomised: 98 intervention and 95 control; only four women had excessive gestational weight gain. A slightly greater weight change was found among intervention women at 12 months, with greatest benefit. Among women attending ten or more weight management sessions. There was >80% follow up to 12 months, low risk of contamination and no group differences in trial completion.
It was feasible to recruit and retain women with BMIs e25 kg/m2 to an intervention to support postnatal weight management; identification of excessive gestational weight gain requires consideration. Economic modelling could inform out?of?trial costs and benefits in a future trial. A definitive trial is an important next step.
A feasibility RCT of postnatal weight support showed women with BMIs e25 kg/m2 can be recruited and followed to 12 months postnatally.
Early initiation of breastfeeding and exclusive breastfeeding can reduce infant mortality.
Breastfeeding support interventions such as counselling may improve adherence to recommended practices. However, it is not known if these interventions work at the population level.
The aim of this study was to assess the relationship between early postnatal breastfeeding
support and recommended breastfeeding practices.
We pooled data from 11 Demographic and Health Surveys in Africa (n = 7), South East
Asia (n = 2), the Americas (n = 1), and Europe (n = 1) to analyse these associations at the population
We limited the data to the most recent live births in the two years before the survey,
including 41,431 births.
We fitted three multivariable logistic regression models to estimate the relationship between
early postnatal breastfeeding support (a newborn postnatal check within an hour of birth plus counselling
and observation of breastfeeding within two days) and three breastfeeding outcomes (early initiation of
breastfeeding, absence of prelacteal feeding, and exclusive breastfeeding), adjusting for sociodemographic
characteristics and birth-related factors.
Early breastfeeding support was associated with a 24% increase (OR=1.24 95%CI=1.11,1.39) in
the odds of initiating breastfeeding within one hour of birth. No relationships were found between
breastfeeding support and prelacteal feeding in the first three days or exclusive breastfeeding at six
While postnatal breastfeeding counselling and observation may improve early initiation
of breastfeeding, impact is not persistent for longer term breastfeeding outcomes.
Implication for practice:
Improved training for breastfeeding support and an enabling policy environment
are required to improve breastfeeding practices for women and newborns.
Design: Concurrent mixed methods (qualitative dominant) process evaluation nested within a feasibility randomised controlled trial, comprising questionnaires and interviews at six and 12 months post-birth.
Setting: One National Health Service maternity unit in an inner city area in the south of England.
Participants: 98 postnatal women with BMIs>25kg/m2 (overweight/obese) at pregnancy commencement.
Intervention: Twelve week Slimming World® (SW) commercial group weight management programme, commencing anytime from 8 to 16 weeks postnatally.
Primary and secondary outcome measures: Data regarding uptake and retention from questionnaires and interviews conducted six and 12 months post birth, analysed thematically and mapped to the COM-B model.
Results: Barriers to SW uptake mostly concerned opportunity issues (e.g., lack of time or childcare support) though some women also lacked motivation, not feeling that weight reduction was a priority, and a few cited capability issues such as lacking confidence. Weight loss aspirations were also a key factor explaining retention, as were social opportunity issues, particularly in relation to factors such as the extent of group identity and relationship with the group consultant; and physical opportunity such as perceived support from and fit with family lifestyle. In addition, barriers relating to beliefs and expectations about the SW programme were identified, including concerns regarding compatibility with breastfeeding and importance of exercise. Women?s understanding of the SW approach, and capability to implement into their lifestyles, appeared related to level of attendance (dose-response effect).
Conclusions: Uptake and retention in commercial weight management programmes may be enhanced by applying behaviour change techniques to address the barriers impacting on women?s perceived capability, motivation and opportunity to participate.
Despite a reduction in overall maternal mortality in the United Kingdom (UK) during recent decades, maternal mortality rates over the previous six years have started to increase (Knight et al. 2019), and maternal deaths associated with pre-existing physical and/or psychological comorbidities are increasing nationally and globally (Nair et al. 2017). Surveillance data from the UK and Ireland suggests that most women who died during or following pregnancy in the period 2015 to 2017 had multiple health problems and/or additional complex social factors (Knight et al. 2019). This is mirrored in maternal mortality case reviews in other high-income countries including United States of America (USA) (Creanga et al. 2015), Australia (Australian Institute of Health and Welfare 2017) and New Zealand (Perinatal and Maternal Mortality Review Committee 2018).
Whilst maternal mortality rates in other high-income countries have also decreased over the past two decades, ranging from 3 to 12 deaths per 100,000 live births (WHO 2018a), severe maternal morbidity rates are increasing (Gellar et al. 2018), as a consequence of pre-existing and pregnancy related health problems, often reflecting multiple complex health and social needs. In the USA for example, overall severe maternal morbidity rates increased from 74 per 10,000 hospital births in 1998?99 to 163 in 2010?11 (Creanga et al. 2014). In the UK and Ireland more than two-thirds (68%) of the women who died during or after pregnancy in the triennial period 2014-2016 were known to have pre-existing medical problems (Knight et al. 2018). Conditions associated with increased maternal morbidity include obesity (Dudenhausen 2015, NHSE 2018a) diabetes (Coton et al. 2016, Feig et al. 2018) cardiac disease (Roos-Hesselink 2019) and severe mental illness (Estrin et al. 2019, Xu et al. 2014). Increasing numbers of women have physical and/or psychological comorbidities prior to becoming pregnant (Molyneaux et al. 2014, Ruhstaller et al. 2017, Kumpulainen 2018). These women are at greater risk of adverse pregnancy outcomes than women in the general pregnant population (Mhyre et al. 2011, Nair et al. 2015) and it is imperative that maternity policy acknowledges and addresses the impact of the changing health-profile of women to consider how to prevent or at least reduce maternal morbidity.
Methods: Interviews with 39 panellists, from nine case study sites, representing acute, community, mental health NHS trusts and hospices. Data were analysed using thematic analysis.
Results: Most panellists spoke positively about their experience of sharing their stories in Rounds. Reported impacts included increased emotional resilience and acceptance of past experiences; reduced negative assumptions about colleagues and increased approachability and trust increasing tolerance and compassion; a space to stop and think and to reframe negative patient experiences facilitating greater empathy, and emotional disclosure becoming more visible and normative helping change culture. The extent of panel preparation and audience characteristics (e.g. size, composition, and response to their stories) influenced panellist?s experiences and outcomes.
Conclusions: Rounds highlight the important role of disclosure and reflection through storytelling to support panellists with the emotional aspects of their work, providing a space for support with the emotional demands of healthcare, reducing the need for employees to be stoic. Panel participation also offers an important source of validation in organisations marked by scrutiny.