I am Professor of 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) to complete a national evaluation of Schwartz Center Rounds in the UK, funded by the NIHR. I am currently funded by NIHR to complete a realist synthesis aimed at understanding how to improve mental wellbeing in nurses, midwives and paramedics. 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. I am currently working with Surrey and Sussex Cancer Alliance to support and evaluate improvements to multidisciplinary team meetings across three tumour pathways.
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 - September 2020
Background It is the responsibility of healthcare regulators to ensure healthcare professionals remain fit for practice in healthcare settings. If there are concerns about an individual healthcare professional they may undergo a fitness to practice investigation. This process is known to be hugely stressful for doctors and social workers, but little is known about the impact of this experience on other professions. This study explores the experiences of registrants going through the process of being reported to the UK’s Health and Care Professions Council (HCPC) and attending fitness to practice (FTP) hearings. We discuss the implications of this process on registrants’ wellbeing and, from our findings, present recommendations based on registrants experiences. In doing so we articulate the structural processes of the HCPC FTP process and the impact this has on individuals. Methods This study uses semi-structured interviews and framework analysis to explore the experiences of 15 registrants who had completed the FTP process. Participants were sampled for maximum variation and were selected to reflect the range of possible processes and outcomes through the FTP process. Results The psychological impact of undergoing a FTP process was significant for the majority of participants. Their stories described influences on their wellbeing at both a macro (institutional/organisational) and micro (individual) level. A lack of information, long length of time for the process and poor support avenues were macro factors impacting on the ability of registrants to cope with their experiences (theme 1). These macro factors led to feelings of powerlessness, vulnerability and threat of ruin for many registrants (theme 2). Suggested improvements (theme 3) included better psychological support (e.g. signposting or provision); proportional processes to the incident (e.g. mediation instead of hearings); and taking context into account. Conclusions Findings suggest that improvements to both the structure and conduct of the FTP process are warranted. Implementation of better signposting for support both during and after a FTP process may improve psychological wellbeing. There may also be value in considering alternative ways of organising the FTP process to enable greater consideration of and flexibility for registrants’ context and how they are investigated.
Background: Evidence from a national clinical audit of early inflammatory arthritis (EIA) shows considerable variability between hospitals in performance, unexplained by controlling for case-mix. Objective: To explore the macro-level, meso-level and micro-level barriers and facilitators to the provision of good quality EIA care. Methods: A qualitative study within 16 purposively sampled rheumatology units across England and Wales. Quality was assessed in relation to 11 quality indicators based on clinical opinion, evidence and variability observed in the data. Data from semi-structured interviews with staff (1–5 from each unit, 56 in total) and an online questionnaire (n=14/16 units) were integrated and analysed using the framework method for thematic analysis using a combined inductive and deductive approach (underpinned by an evidence-based framework of healthcare team effectiveness), and constant comparison of data within and between units and its relationship with the quality criteria. Findings: Quality of care was influenced by an interplay between macro, meso and micro domains. The macro (eg, shared care arrangements and relationships with general practitioners) and meso (eg, managerial support and physical infrastructure) factors were found to act as crucial enablers of and barriers to higher quality service provision at the micro (team) level. These organisational factors directly influenced team structure and function, and thereby EIA care quality. Conclusions: Variability in quality of EIA care is associated with an interplay between macro, meso and micro service features. Tackling macro and meso barriers is likely to have a significant impact on quality of EIA service, and ultimately patient experience and outcomes.
Increasing numbers of women, particularly in high- and middle-income country settings, have poorer health at pregnancy commencement. This is due to a range of factors including older maternal age at first pregnancy, an increase in the numbers of women who have overweight or obese body mass index (BMI) at pregnancy commencement, and more women who have pre-existing mental and/or physical health problems. The most recent UK confidential enquiry into maternal deaths reported that two-thirds (68%) of the women who died in 2014–16 had pre-existing medical problems and 24% pre-existing mental health problems. More than a third (37%) of the women who died in this triennium had obese BMIs and 20% had overweight BMIs. Risk of maternal death was almost five-fold higher among women from black ethnic minority backgrounds compared with white women (RR 4.93; 95% CI 3.27–7.26). Maternal pre-existing mental and/or physical problems are associated with a range of adverse birth outcomes for the woman and her infant, including pre-eclampsia, gestational diabetes, preterm delivery, macrosomia, and stillbirth.2 Of concern is that some women may experience severe physical illness, for example sepsis or eclampsia, the signs and symptoms of which could lead clinicians to misdiagnose mental illness or, conversely, to miss severe mental health illness due to only considering a woman’s physical health. A wide range of mental and physical health problems could potentially lead to an adverse pregnancy outcome, a situation which may be compounded by a woman’s social needs. One condition currently raising concerns due to increased prevalence, risk of adverse pregnancy outcome, and life-long impacts on maternal and child health, is obesity. This chapter specifically considers mental and physical co-morbidity among women who have obese BMIs (BMI ≥30, Box 1) at pregnancy commencement. Some of the issues and practice recommendations described will be relevant for the management of a high-risk pregnancy due to other maternal co-morbidity, although it is important to note that ‘risk’ is a relative term. With tailored, planned multidisciplinary care, pregnant and postnatal women with mental and physical co-morbidity – and their infants – may remain well. Conversely, a woman who is initially well may develop health problems which could lead to poorer outcomes for herself or her infant, highlighting the importance of planned and effective antenatal, intrapartum and postnatal care.
Objectives: 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. Setting: 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 organisations. Results: 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’. Conclusions: 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 England.
Measuring an individual's experience of healthcare is complex, let alone when the experience concerns pregnancy, birth and postnatal care. Giving birth is a major life event, likely to be viewed in retrospect by women as a time of fluctuating physical and psychological health and well‐being, altered body image, and positive and negative views of support offered by those they come into contact with. Given the ebbs and flows of the pregnancy, birth and postnatal journey, providing ‘hard data’ to inform an objective measure of experience which also reflects the context, environment and quality of care, is not an easy task. Nevertheless, with increasing recognition of the importance of patient experience as a driving force for service improvement and resource allocation, knowing what contributes to a more (or less) positive experience is important. How, when and what to measure are important questions.
Background 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. Methods 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. Results 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. Conclusions 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.
Background Cancer multidisciplinary teams (MDTs) are well established worldwide and are an expensive resource yet no standardised tools exist to measure performance. We aimed to develop and test an MDT self-assessment tool underpinned by literature review and consensus from over 2000 UK MDT members about the “characteristics of an effective MDT.” Methods Questionnaire items relating to all characteristics of MDTs (particularly Leadership and Chairing; Teamworking and Culture; Patient-centred care; Clinical decision-making process; and Organisation and administration during meetings) were developed by an expert panel. Acceptability, feasibility and psychometric properties were tested by online completion of the questionnaire by 23 MDTs from 4 UK NHS Trusts followed by interviews with 74 team members including members from all teams and nonresponders. 10 of the MDTs also completed questionnaires that directly translated each characteristic to an item (for the five domains above) to test content validity. Results A total of 47 items were created, each rated for agreement on a 5-point scale. A total of 329 (52 %) of 637 team members completed the questionnaire, including representation from medical, nursing and clerical MDT members. Responses correlated well with domain-specific questionnaires (r > 0.67, p = 0.01), most domain-scales had acceptable internal consistency (Cronbach alpha > 0.60), and good item discrimination (majority of items r < 0.20). Team members were positive about its value. Conclusions Self-assessment of team performance using this tool may support MDT development.
Purpose 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. Results Good interrater reliability was achieved in vivo and at the video recorded multidisciplinary tumor board meetings (ICC ≥0.70). 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 ≤0.001). Conclusions 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.
Background 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. Methods 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. Results 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. Conclusion 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 participation of service users and the public in the development of clinical guidelines is increasingly valued in international guideline programmes. This paper extends the findings of Harding et al.'s (2010) exploration of the views of service users who participated in developing NICE mental health guidelines. This analysis considered the relative value of personal versus professional knowledge and experience, the barriers to service users contributing effectively in guideline development, the unspoken ‘rules’ concerning decision making, and issues of power and group dynamics. We combine these insights with observations from research in guideline development and with advances in the recovery movement and in the shared decision-making clinical model to suggest areas of improvement in guideline development, notably: translating evidence to recommendations, optimizing the acceptability of treatment recommendations to service users, and reconciling different types of knowledge.
Objectives: (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. Design: 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). Data Sources: PsychINFO, CINAHL, MEDLINE, and EMBASE, internet search engines; consultation with experts. Eligibility criteria: Empirical evaluations (qualitative or quantitative); any healthcare staff in any healthcare setting; published in English. Results: 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.
Objective To estimate prevalence and explore potential causes and consequences of compassion satisfaction and compassion fatigue in UK emergency medicine consultants. Methods 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. Results 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. Conclusions 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.
Women with chronic kidney disease have an increased risk of maternal and fetal complications in pregnancy. Pre-pregnancy counselling is recommended but the format of the counselling process and the experience of the patient have never been assessed. This study examines the experience of women with chronic kidney disease attending pre-pregnancy counselling and evaluates their pregnancy outcomes.
Background 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. Objectives How, in which contexts and for whom Rounds participation affects staff well-being at work, increases social support for staff and improves patient care. Design (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). Setting (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). Participants (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. Results (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
Objective: Schwartz Center Rounds (‘Rounds’) are multidisciplinary forum where healthcare staff come together to reflect upon the emotional impact of their work. A small number of staff (panellists) share experiences through stories to trigger reflection in audience members. Previous research has identified impacts associated with Rounds attendance but little is known about the experience and impact of Rounds from panellists’ perspectives. Drawing on interview data from a national evaluation of Rounds in the UK this study is the first to explore the role of disclosure and reflection through storytelling in Rounds specifically exploring panellists’ motivations, experience and reported impacts associated with panel participation. 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.
Neonatal mortality remains a significant health problem in low income settings. Low-cost essential newborn care (ENC) interventions with proven efficacy and cost-effectiveness exist but have not reached high coverage (≥90%). Little is known about the strategies used to implement these interventions or how they relate to improved coverage. We conducted a systematic review of implementation strategies and implementation outcomes for ENC in low- and low middle-income countries capturing evidence from five medical and global health databases from 1990-2018. We included studies of implementation of delayed cord clamping, immediate drying, skin-to-skin contact, and/or early initiation of breastfeeding implemented in the first hour (facility-based studies) or the first day (community-based studies) of life. Implementation strategies and outcomes were categorised according to published frameworks (Powell et al (2015): Expert Recommendations for Implementing Change (ERIC), Proctor et al (2013): Outcomes for Implementation Research). The relationship between implementation strategies and outcomes was evaluated using standardised mean differences and correlation coefficients. Forty-three papers met inclusion criteria. Interventions included community-based care/health promotion and facility-based support and health care provider training. Included studies used 3-31 implementation strategies, , though the consistency with which strategies were applied was variable. Conduct educational meetings was the most frequently used strategy. Included studies reported 1-4 implementation outcomes with coverage reported most frequently. Heterogeneity was high and no statistically significant association was found between the number of implementation strategies used and coverage of ENC. This review highlights several challenges in learning from implementation of ENC in low- and low middle-income countries, particularly poor description of interventions and implementation outcomes. We recommend use of UK Medical Research Council guidelines (2015) for process evaluations and checklists for reporting implementation studies. Improved reporting of implementation research in this setting is necessary to learn how to improve service delivery and outcomes and thereby reduce neonatal mortality.
Objectives: To understand the barriers and facilitators to uptake and retention of postnatal women randomised to a commercial group weight management intervention using the COM-B (Capability, Opportunity, Motivation - Behaviour) behaviour change model. 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.
Background: Evidence suggests patients delay reporting symptoms of neutropenic sepsis (NS) despite the risk to their life. This study aimed to elicit factors that contribute to delayed patient reporting of NS symptoms.Methods: A constructivist grounded theory study used observations of chemotherapy consultations (13 hours) and 31 in-depth interviews to explore beliefs, experiences and behaviors related to NS. Participants included women with breast cancer, their carers (partners, family or friends) and clinicians. An explanation for patient delays was developed through theoretical sampling of participants to explore emerging areas of interest and through constant comparison of data and their coding. This entailed iterative and concurrent data collection and analysis. Data were collected until saturation.Results: All patients who developed NS type symptoms delayed presenting to hospital (2.5 hours - 8 days), sometimes repeatedly. Moderators of delay included metastatic disease, bereavement, fatalism, religious beliefs and quality of relationships with clinicians. There was an interplay of behaviours between clinicians, patients and carers where they subconsciously conspired to underplay the seriousness and possibility of NS occurring. Conclusions: Findings have implications for health risk communication and development of holistic service models.
Background: Clinical assessment and management of sexual difficulties after gynecological cancer remain a neglected aspect of women’s rehabilitation. Aim: To develop and validate a patient-reported outcome measure of sexual well-being for women experiencing sexual consequences of cervical and endometrial cancer treatment for use in routine follow-up. Methods: This is a sequential mixed method study comprising (i) in-depth qualitative interviews (n¼21 of 118) to generate items regarding sexual consequences of cervical or endometrial cancer and treatment; (ii) questionnaire construction with 51 core items (all respondents) and 4 subsections (18e58 items), depending on the relationship status and whether or not participants were sexually active (SA/NSA); (iii) item refinement following cognitive debriefing (n¼13 of 21); (iv) validation of resultant items via postal survey (n¼788 women) and Rasch analysis; and (v) creation of brief (14-item) clinical screener. Women attending routine follow-up (3 months to 5 years) at 6 English cancer centers and members of 3 UK cancer patient websites, who met the study inclusion criteria, were invited to participate. Outcomes: The primary outcome of this study was the construction and initial psychometric testing of SWELLCE short and long form versions. Results: 21 women participated in interviews and 250 of 788 (32%) returned the postal survey (T1). 110 draft items were evaluated using cognitive testing (n¼13) to refine instrument design and test face validity, comprehension, and acceptability. Exploratory factor analysis of survey data (n¼250) produced an initial 6 domain structure as a guidance for the Rasch analysis. Subsequent Rasch analysis yielded a 3 domain structure: physical sexual function, sexual and relationship concerns, and sexual desire and sexual self-esteem, each satisfying Rasch model requirements within their respective SA (item pool ¼59) and NSA (item pool ¼53) categories, including the absence of local response dependency and all showing strict unidimensionality. The 3 subscales demonstrated good psychometric properties, external validity, and test-retest reliability. A valid Rasch short form of 14 items was created from the larger item pool. Clinical Implications: This PROM may assist clinicians to improve identification, discussion, and management of women who could benefit from sexual rehabilitation. Strengths & Limitations: Initial evaluation supports psychometric validity and reliability in the assessment of physical sexual function, sexual interest and sexual self-esteem, and sexual and relationship concerns in this study sample. However, given this study’s modest response rate (32%, n¼250), findings should be interpreted with caution. This PROM identifies sexual concerns in women who are sexually active or sexually non-active due to illness or treatment-associated sexual difficulties. Conclusion: Sexual Well-being after Cervical or Endometrial Cancer is a novel and psychometrically valid sexual well-being measure for clinical assessment of female sexual difficulties after cervical or endometrial cancer treatment.
Objective: To develop a tool for independent observational assessment of cancer multidisciplinary team 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. Intervention: None. 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 ≤ 0.05). Study 2: Inter-rater reliability was good for 3/10 domains. Percentage of absolute agreement was high (≥80%) 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 ≤ 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 widespread introduction of multidisciplinary team (MDT)-work for breast cancer management has in part evolved due to the increasing complexity of diagnostic and treatment decision-making. An MDT approach aims to bring together the range of specialists required to discuss and agree treatment recommendations and ongoing management for individual patients. MDTs are resource-intensive yet we lack strong (randomized controlled trial) evidence of their effectiveness. Clinical consensus is generally favorable on the benefits of effective specialist MDT-work. Many studies have shown the benefits of receiving treatment from a specialist center, and evidence continues to accrue from comparative studies of clinical benefits of an MDT approach, including improved survival. Patients’ views of the MDT model of decision-making (and in particular its impact on involvement in decisions about their care) have been under-researched. Barriers to effective teamwork and poor decision-making include excessive caseload, low attendance at meetings, lack of leadership, poor communication, role ambiguity, and failure to consider patients’ holistic needs. Breast cancer nurses have a key role in relation to assessing holistic needs, and their specialist contribution has also been associated with improved patient experience and quality of life. This paper examines the evidence for the benefits of MDT-work, in particular for breast cancer. Evidence is considered within a context of growing cancer incidence at a time of increased financial restraint, and it may now be important to reevaluate the structure and models of MDT-work to ensure that MDTs are an efficient use of resources.
Background 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. Objective 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. Inclusion criteria 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. Search strategy 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. Methodological quality Studies were critically appraised using appropriate standardized critical appraisal instruments from The Joanna Briggs Institute. Data extraction 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 Institute. Data synthesis 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 studies. Results 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. Conclusions 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.
IntroductionA 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. Methods/analysis: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 ≥ 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 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 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. 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:Trial registration number: ISRCTN 39186148. Protocol version number: v7, 13 August 17. Trial sponsor: King’s College London.
Background 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. Methods 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. Results 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. Conclusions 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 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. Objectives 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. Design Mixed-methods comprising case-note audit, interviews and observation. Setting 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. Participants 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). Methods 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). Results 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. Conclusion 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.
Background 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. Methods 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. Results 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. Conclusions 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.
Cancer care is increasingly delivered by multidisciplinary teams. Cath Taylor and colleagues argue that stronger evidence is needed of their effectiveness
Background: 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. Results: 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. Conclusions: 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.
Background: 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. Methods: 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. Results: 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. Conclusion: 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.
Background 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. Methods 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. Results 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. Conclusions 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.
In a survey of 1794 UK NHS hospital consultants 1308 (73%) responded. Psychiatric morbidity (General Health Questionnaire—12 score ⩾4) was present in 32% of responders, who were twice as likely to report drinking hazardous levels of alcohol, being irritable with patients and colleagues, reducing their standards of care and intending to retire early (all P
Informal carers provide important emotional support to patients having chemotherapy and assistance in monitoring and managing side‐effects. If they are inadequately supported in this, patient and carer morbidity may result. This study explored needs of informal carers supporting patients with cancer having chemotherapy. The study used a mixed methods approach. Carers of colorectal or lymphoma cancer patients at one comprehensive cancer centre participated. Questionnaire data informed semi‐structured interviews conducted with a subsample of respondents. Interviews were analysed using Framework analysis. Questionnaire data were analysed descriptively. Fifty‐nine informal carers were invited to participate; 48 returned the questionnaire (response rate 81%) and 13 were interviewed. Informal carers' needs for information about chemotherapy and its side‐effects were largely met although a third felt completely or somewhat unprepared to deal with particular symptoms experienced by patients at home. Many carers had unmet needs regarding financial support and their own needs as carers. Assertiveness was important to many caring roles, but it appeared difficult for informal carers to adopt when they were unsupported in this and their role was unrecognised by health professionals. Future research should develop interventions to systematically prepare carers for their carer role, improve carer involvement and ultimately improve patient outcomes.
Background 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”. Methods 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. Results 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 ≥0.50. Conclusions This observational tool (MDT-OARS) may contribute to the assessment of MDT performance. Further testing to confirm validity and reliability is required.
Objectives 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. Design Two‐arm feasibility trial, with nested mixed‐methods process evaluation. Setting Inner‐city unit, south England. Population Women with body mass indices (BMIs) ≥25 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. Methods Randomised to standard care plus commercial weight management sessions commencing 8–16 weeks postnatally or standard care only. Main outcomes 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. Results 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. Conclusion It was feasible to recruit and retain women with BMIs ≥25 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. Tweetable abstract A feasibility RCT of postnatal weight support showed women with BMIs ≥25 kg/m2 can be recruited and followed to 12 months postnatally.
Background Malawi has halved the neonatal mortality rate between 1990–2018, however, is not on track to achieve the Sustainable Development Goal 12 per 1,000 live births. Despite a high facility birth rate (91%), mother-newborn dyads may not remain in facilities long enough to receive recommended care and quality of care improvements are needed to reach global targets. Physical access and distance to health facilities remain barriers to quality postnatal care. Methods Using data We used individual data from the 2015–16 Malawi Demographic and Health Survey and facility data from the 2013–14 Malawi Service Provision Assessment, linking households to all health facilities within specified distances and travel times. We calculated service readiness scores for facilities to measure their capacity to provide birth/newborn care services. We fitted multi-level regression models to evaluate the association between the service readiness and appropriate newborn care (receiving at least five of six interventions). Results Households with recent births (n = 6010) linked to a median of two birth facilities within 5–10 km and one facility within a two-hour walk. The maximum service environment scores for linked facilities median was 77.5 for facilities within 5–10 km and 75.5 for facilities within a two-hour walk. While linking to one or more facilities within 5-10km or a two-hour walk was not associated with appropriate newborn care, higher levels of service readiness in nearby facilities was associated with an increased risk of appropriate newborn care. Conclusions Women’s choice of nearby facilities and quality facilities is limited. High quality newborn care is sub-optimal despite high coverage of facility birth and some newborn care interventions. While we did not find proximity to more facilities was associated with increased risk of appropriate care, high levels of service readiness was, showing facility birth and improved access to well-prepared facilities are important for improving newborn care.
Due to delivery of chemotherapy being mostly in ambulatory care settings, support of people with cancer relies heavily on caregivers (e.g. relatives). Whilst cancer caregiver research has been flourishing, there has been little focus on the specific experiences of caregivers of older people (>70yrs) with cancer, and little considerations of cultural influences on their experiences. This study explored caregiver experiences and outcomes in the geriatric oncology context in Switzerland.
More women with an increased risk of poor pregnancy outcome due to pre-existing medical conditions are becoming pregnant. Although clinical care provided through multi-disciplinary team (MDT) working is recommended, little is known about the structure or working practices of different MDT models, their impact on maternal and infant outcomes or healthcare resources. The objectives of this review were to consider relevant international evidence to determine the most appropriate MDT models of care to manage complex medical conditions during and after pregnancy, with a specific focus on pre-existing diabetes or cardiac disease in high income country settings.
Background: Evidence from a national clinical audit of Early Inflammatory Arthritis (EIA) shows considerable variability between hospitals in performance, unexplained by controlling for case-mix. Objective: To explore the macro, meso and micro level barriers and facilitators to the provision of good quality EIA care. Methods: A qualitative study within 16 purposively sampled Rheumatology Units across England and Wales. Quality was assessed in relation to 11 quality indicators based on clinical opinion, evidence and variability observed in the data. Data from semi-structured interviews with staff (1-5 from each unit, 56 in total) and an online questionnaire (n=14/16 units) were integrated and analysed using the Framework method for thematic analysis using a combined inductive and deductive approach (underpinned by an evidence-based framework of healthcare team effectiveness), and constant comparison of data within and between units and its relationship with the quality criteria. Findings: Quality of care was influenced by an interplay between macro, meso and micro domains. The macro (e.g. shared care arrangements and relationships with GPs) and meso (e.g. managerial support and physical infrastructure) factors were found to act as crucial enablers of and barriers to higher quality service provision at the micro (team) level. These organisational factors directly influenced team structure and function, and thereby EIA care quality. Conclusions: Variability in quality of EIA care is associated with an interplay between macro, meso and micro service features. Tackling macro and meso barriers is likely to have a significant impact on quality of EIA service, and ultimately patient experience and outcomes.
Background Healthcare work is known to be stressful and challenging, and there are recognised links between the psychological health of staff and high-quality patient care. Schwartz Center Rounds® (Rounds) were developed to support healthcare staff to re-connect with their values through peer reflection, and to promote more compassionate patient care. Research to date has focussed on self-report surveys that measure satisfaction with Rounds but provide little analysis of how Rounds ‘work’ to produce their reported outcomes, how differing contexts may impact on this, nor make explicit the underlying theories in the conceptualisation and implementation of Rounds. Methods Realist evaluation methods aimed to identify how Rounds work, for whom and in what contexts to deliver outcomes. We interviewed 97 key informants: mentors, facilitators, panellists and steering group members, using framework analysis to organise and analyse our data using realist logic. We identified mechanisms by which Rounds lead to outcomes, and contextual factors that impacted on this relationship, using formal theory to explain these findings. Results Four stages of Rounds were identified. We describe how, why and for whom Schwartz Rounds work through the relationships between nine partial programme theories. These include: trust safety and containment; group interaction; counter-cultural/3rd space for staff; self-disclosure; story-telling; role modelling vulnerability; contextualising patients and staff; shining a spotlight on hidden stories and roles; and reflection and resonance. There was variability in the way Rounds were run across organisations. Attendance for some staff was difficult. Rounds is likely to be a ‘slow intervention’ the impact of which develops over time. We identified the conditions needed for Rounds to work optimally. These contextual factors influence the intensity and therefore degree to which the key ingredients of Rounds (mechanisms) are activated along a continuum, to produce outcomes. Outcomes included: greater tolerance, empathy and compassion for self and others; increased honesty, openness, and resilience; improved teamwork and organisational change. Conclusions Where optimally implemented, Rounds provide staff with a safe, reflective and confidential space to talk and support one another, the consequences of which include increased empathy and compassion for colleagues and patients, and positive changes to practice.
Background: High coverage of care is essential to improving newborn survival; however, gaps exist in access to timely and appropriate newborn care between and within countries. In high-burden settings, health inequities due to social and economic factors may also impact on newborn outcomes. This study aimed to examine equity in co-coverage of newborn care interventions in low- and low middle-income countries in sub-Saharan Africa and South Asia. Methods: We analysed secondary data from recent Demographic and Health Surveys in 16 countries. We created a co-coverage index of five newborn care interventions. We examined differences in coverage and co-coverage of newborn care interventions by country, place of birth, and wealth quintile. Using multilevel logistic regression, we examined the association between high co-coverage of newborn care (4 or 5 interventions) and social determinants of health. Results: Coverage and co-coverage of newborn care showed large between- and within-country gaps for home and facility births, with important inequities based on individual, family, contextual, and structural factors. Wealth-based inequities were smaller amongst facility births compared to non-facility births. Conclusion: This analysis underlines the importance of facility birth for improved and more equitable newborn care. Shifting births to facilities, improving facility-based care, and community-based or pro-poor interventions are important to mitigate wealth-based inequities in newborn care, particularly in countries with large differences between the poorest and richest families and in countries with very low coverage of care.
Background Work stress and compassion fatigue are prevalent among healthcare staff and their negative effects on staff well-being and patient care are well-known. This paper reports on the implementation and evaluation of Schwartz Rounds® (Rounds) in UK healthcare organizations, predominantly part of the National Health Service (NHS). Rounds are one-hour, typically monthly, multidisciplinary forums during which clinical and nonclinical healthcare staff discuss the emotional and social demands of delivering patient care. The purpose of this research was to evaluate the effectiveness of Rounds attendance on the psychological distress, work engagement, compassion and self-reflection of healthcare staff. Methods We used a pre-post control design to assess the effect of Rounds attendance across 10 UK healthcare organizations. This design was most appropriate given the voluntary nature of Rounds and ensured the study had ecological validity. Self-reported data were collected from attenders and non-attenders at baseline and at eight-months follow-up. The outcomes were psychological distress, work engagement, compassion and self-reflection. Results During the 8 months’ study duration, regular attenders (N = 51) attended Rounds on average 4 times (2–8). Attenders showed a significantly greater decrease in psychological distress (as measured with the General Health Questionnaire (GHQ)) than non-attenders (N = 233; odds ratio of 0.197; 95% confidence interval (0.047–0.823)). However, Rounds attendance had no significant effect on work engagement, compassion and self-reflection. Conclusions Rounds attendance was linked to a 19% reduction in psychological distress adjusting for covariates. As an organization-wide intervention, Rounds thus constitute an effective, relatively low-cost intervention to assist staff in dealing with the demands of their work and to improve their well-being.
Improving management of type 1 diabetes in the UK: the Dose Adjustment For Normal Eating (DAFNE) programme as a research test-bed. A mixed-method analysis of the barriers to and facilitators of successful diabetes self-management, a health economic analysis, a cluster randomised controlled trial of different models of delivery of an educational intervention and the potential of insulin pumps and additional educator input to improve outcomes.
Introduction Multidisciplinary team (MDT) meetings have been the gold standard of cancer care in the UK since the 1990s. We aimed to identify the views of urology cancer MDT members in the UK on improving the functioning of meetings and compare them with those of other specialties to manage the increasing demand on healthcare resources and enhance the care of complex cancer cases. Methods We analysed data from 2 national surveys distributed by Cancer Research UK focusing on the views of 2,294 and 1,258 MDT members about cancer MDT meetings. Findings Most breast, colorectal, lung and urology cancer MDT members felt meetings could be improved in the following areas: time for meeting preparation in job plans, streamlining of patients, auditing meeting decisions and prioritising complex cases. Most urology respondents (87%) agreed some patients could be managed outside a full MDT discussion, but this was lower for other specialties (lung 78%, breast 75%, colorectal 64%). Conclusions To facilitate decisions on which patients require discussion in an MDT meeting, factors adding to case complexity across all tumour types were identified, including rare tumour type, cognitive impairment and previous treatment failure. This study confirms that urology MDT members are supportive of changing from reviewing all new cancer diagnoses to discussing complex cases but managing others with a more protocolised pathway. The mechanisms for how to do this and how to ensure the safety of patients require further clarification.
Cancer care is commonly managed by multidisciplinary teams (MDTs) who meet to discuss and agree treatment for individual patients. Patients do not attend MDT meetings but recommendations for treatments made in the meetings directly influence the decision-making process between patients and their responsible clinician. No research to-date has considered patient perspectives (or understanding) regarding MDTs or MDT meetings, though research has shown that failure to consider patient-based information can lead to recommendations that are inappropriate or unacceptable, and can consequently delay treatment.
Background: 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. Objective:The aim of this study was to assess the relationship between early postnatal breastfeeding support and recommended breastfeeding practices. Design/setting: 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 level. Participants: We limited the data to the most recent live births in the two years before the survey, including 41,431 births. Analysis: 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. Findings: 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 months. Key conclusion: 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.
Background 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. Methods Secondary analysis of quantitative and qualitative data from a national survey of 1,220 MDT members regarding their views about streamlining MDM discussions. Results 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. Conclusions 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.
Background Increasing numbers of UK women have overweight or obese body mass index scores 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 The objectives were to assess the feasibility of conducting a definitive randomised controlled trial to determine the clinical effectiveness and cost-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 8–16 weeks postnatally to achieve and maintain weight management and positive lifestyle behaviour. Design The design was a randomised two-arm feasibility trial with a nested mixed-methods process evaluation. Setting The setting was a single centre in an inner city setting in the south of England. Participants Participants were women with body mass index scores of ˃ 25 kg/m2 at antenatal ‘booking’ and women with normal body mass index scores (18.0–24.9 kg/m2) at antenatal booking who developed excessive gestational weight gain as assessed at 36 weeks’ gestation. Main outcome measures Recruitment, retention, acceptability of trial processes and identification of relevant economic data were the feasibility objectives. The proposed primary outcome was difference between groups in weight at 12 months postnatally, expressed as percentage weight change and weight loss from antenatal booking. Other proposed outcomes included assessment of diet, physical activity, smoking, alcohol consumption, body image, maternal esteem, mental health, infant feeding and NHS costs. Results Most objectives were achieved. A total of 193 women were recruited, 98 allocated to the intervention arm and 95 to the control arm. High follow-up rates (˃ 80%) were achieved to 12 months. There was an 8.8% difference in weight loss at 12 months between women allocated to the intervention arm and women allocated to the control arm (13.0% vs. 4.2%, respectively; p = 0.062); 47% of women in the intervention arm attended at least one weight management session, with low risk of contamination between arms. The greatest benefit was among women who attended ≥ 10 sessions. Barriers to attending sessions included capability, opportunity 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 trial recruited from only one site. It was not possible to recruit women with normal body mass index scores who developed excessive pregnancy weight gain. Conclusions It was feasible to recruit and retain women with overweight or obese body mass index scores at antenatal booking to a trial comparing postnatal weight management plus standard care with standard care only and collect relevant data to assess outcomes. Approaches to recruit women with normal body mass index scores 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 probable greater benefit from attending ≥ 10 sessions. Process evaluation findings highlighted the importance of providing more information about the intervention on trial allocation, extended duration of time to commence sessions following birth and extended number of sessions offered to enhance uptake and retention. Results support the conduct of a future randomised controlled trial.
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.
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.