Professor Cath Taylor

Problem: Parents with learning disabilities are often disadvantaged and their needs not well understood in maternity services. Background: Despite a global vision to improve maternity care, current evidence

Background Organisational and individual barriers often prevent university students from seeking mental health support. Digital technologies are recognised as effective in managing psychological distress and as a source of health-related information, thus representing useful options to address mental health needs in terms of accessibility and cost-effectiveness. However, university students' experiences and perspectives towards such interventions are little known. Objectives We thus aimed to expand the existing base of scientific knowledge, focusing on this special population. Methods Data were from the qualitative component of “the CAMPUS study”, longitudinally assessing the mental health of students at the University of Milano-Bicocca (Italy) and the University of Surrey (UK). We conducted in-depth interviews and thematically analysed the transcripts using the framework approach. Results An explanatory model was derived from five themes identified across 33 interviews (15 for Italy, 18 for the UK). Students perceived that social media, apps, and podcasts could deliver relevant mental health content, ranging from primary to tertiary prevention. Wide availability and anonymity were perceived as advantages that make tools suitable for preventive interventions, to reduce mental health stigma, and as an extension of standard treatment. These goals can be hindered by disadvantages, namely lower efficacy compared to face-to-face contact, lack of personalisation, and problematic engagement. Individual and cultural specificities might influence awareness and perspectives on the use of digital technologies for mental health support. Conclusion Although considering some specific features, digital tools could be a useful instrument to support the mental health needs of students. Since personal contact remains crucial, digital tools should be integrated with face-to-face interventions through a multi-modal approach.

Background COVID-19 has led to rapid changes in healthcare delivery, raising concern that these changes may exacerbate existing inequalities in patient outcomes. Aim To understand how patients’ help-seeking experiences in primary care for colorectal cancer symptoms during COVID-19 were affected by their socioeconomic status (SES). Design and setting Qualitative semi-structured interviews with males and females across the UK, recruited using purposive sampling by SES. Method Interviews were carried out with 39 participants (20 higher SES; 19 lower SES) who contacted primary care about possible symptoms of colorectal cancer during COVID-19. Data were analysed using framework analysis followed by comparative thematic analysis to explore differences between groups. Results Three themes were identified with differences between SES groups: 1) how people decided to seek medical help through appraisal of symptoms; 2) how people navigated services; and 3) impact of COVID-19 on how patients interacted with healthcare professionals. The lower SES group expressed uncertainty appraising symptoms and navigating services (in terms of new processes resulting from COVID-19 and worries about infection). There was also potential for increased disparity in diagnosis and management, with other methods of getting in touch (for example, email or 111) taken up more readily by higher SES patients. Conclusion The findings suggest that COVID-19 exacerbated disparities between higher and lower SES participants. This study raises awareness around challenges in help seeking in the context of the pandemic, which are likely to persist (post-COVID-19) as healthcare systems settle on new models of care (for example, digital). Recommendations are provided to reduce inequalities of care.

Introduction Accurate and timely dispatch of emergency medical services (EMS) is vital due to limited resources and patients’ risk of mortality and morbidity increasing with time. Currently, most UK emergency operations centres (EOCs) rely on audio calls and accurate descriptions of the incident and patients’ injuries from lay 999 callers. If dispatchers in the EOCs could see the scene via live video streaming from the caller’s smartphone, this may enhance their decision making and enable quicker and more accurate dispatch of EMS. The main aim of this feasibility randomised controlled trial (RCT) is to assess the feasibility of conducting a definitive RCT to assess the clinical and cost effectiveness of using live streaming to improve targeting of EMS.Methods and analysisThe SEE-IT Trial is a feasibility RCT with a nested process evaluation. The study also has two observational substudies: (1) in an EOC that routinely uses live streaming to assess the acceptability and feasibility of live streaming in a diverse inner-city population and (2) in an EOC that does not currently use live streaming to act as a comparator site regarding the psychological well-being of EOC staff using versus not using live streaming.Ethics and disseminationThe study was approved by the Health Research Authority on 23 March 2022 (ref: 21/LO/0912), which included NHS Confidentiality Advisory Group approval received on 22 March 2022 (ref: 22/CAG/0003). This manuscript refers to V.0.8 of the protocol (7 November 2022). The trial is registered with the ISRCTN (ISRCTN11449333). The first participant was recruited on 18 June 2022.The main output of this feasibility trial will be the knowledge gained to help inform the development of a large multicentre RCT to evaluate the clinical and cost effectiveness of the use of live streaming to aid EMS dispatch for trauma incidents.Trial registration numberISRCTN11449333.

Introduction: Schwartz Rounds (“Rounds”) are a confidential group reflection forum, increasingly adopted to support pre-registration healthcare students. This realist review aims to understand what the available literature and key informant interviews can tell us about Rounds in this setting, asking what works, for whom, in what circumstances, and why? Methods: Published literature discussing Rounds in undergraduate settings were analysed using realist methods to describe how, for whom and in which contexts Rounds work. Four key informants were interviewed using realist methods, to further develop, test and refine a programme theory of Rounds in undergraduate settings. Results: We identified five core features and five contextual adaptations. Core: Rounds provide a reflective space to discuss emotional challenges; Rounds promote an open and humanised professional culture; Rounds offer role-modelling of vulnerability, enabling interpersonal connectedness; Rounds are impactful when focused on emotional and relational elements; Rounds offer reflective insights from a wide range of perspectives. Contextual adaptations: Rounds allow reflection to be more engaging for students when they are non-mandatory; perceptions of safety within a Round varies based on multiple factors; adapting timing and themes to students’ changing needs may improve engagement; resonance with stories is affected by clinical experience levels; online adaptation can increase reach but may risk psychological safety. Discussion: Schwartz Rounds are a unique intervention that can support healthcare students through their pre-registration education. The five “core” and five “contextual adaptation” features presented identify important considerations for organisations implementing Rounds for their undergraduates.

Background: Nurses, midwives and paramedics comprise over half the clinical workforce in the UK NHS and have some of the highest prevalence of psychological ill-health. This study explored why psychological ill-health is a growing problem and how we might change this. Methods: A realist synthesis involved iterative searches of within MEDLINE, CINAHL and HMIC, supplementary handsearching and expert solicitation. We used reverse chronological quota screening and appraisal journaling to analyse each source and refine our initial programme theory. A stakeholder group comprising nurses, midwives, paramedics, patients and public representatives, educators, managers and policy makers contributed throughout. Results: Following initial theory development from 8 key reports, 159 sources were included. We identified 26 CMOcs, with 16 explaining causes of psychological ill-health, and 10 explaining why interventions have not worked to mitigate psychological ill-health. These synthesised to five key findings: (1) it is difficult to promote staff psychological wellness where there is a blame culture; (2) the needs of the system often override staff psychological wellbeing at work; (3) there are unintended personal costs of upholding and implementing values at work; (4) interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; and (5) it is challenging to design, identify and implement interventions. Conclusions: Our final programme theory argues the need for healthcare organisations to rebalance the working environment to enable healthcare professionals to recover and thrive. This requires high standards for patient care to be balanced with high standards for staff psychological wellbeing; professional accountability to be balanced with having a listening, learning culture; reactive responsive interventions to be balanced by having proactive preventative interventions, and the individual focus balanced by an organisational focus.

Introduction Multi-disciplinary meetings (MDMs) have been the gold standard of cancer care in the UK since the 1990s. Our aim was to identify the views of UK Urology cancer multi-disciplinary team (MDT) members on ways to improve the functioning of MDMs and compare them with other specialities in order to manage the increasing demand on healthcare resources and enhance the care of complex cancer cases. Materials and Methods An analysis of data from two national surveys (2294 and 1258 MDT members respectively) distributed by Cancer Research UK, focussing on their views about cancer MDT meetings. Results The majority of Breast, Colorectal, Lung and Urology cancer teams felt that cancer MDMs could be improved in the following areas: time for MDM preparation in job plans, streamlining of patients, auditing MDT decisions and prioritising complex cases. With regards streamlining, 87% percent of Urology respondents agreed some patients could be managed outside a full MDT discussion. The support was lower in other specialities (Breast 75%, Colorectal 64%, Lung 78%). Discussion To facilitate decisions on which patients do require discussion, factors across all tumour types were identified as adding to case complexity, including rare tumour type, cognitive impairment and previous treatment failure. Conclusion This study confirms that Urology MDT members are supportive of a change in approach from reviewing all new cancer diagnoses to discussing complex cases with all others managed using a more protocolised pathway. The mechanism for how this is done and how the safety of patients is ensured requires further clarification.

ObjectivesTo evaluate the impact of the shift to virtual lung cancer multidisciplinary team meetings (MDTMs) in response to the COVID-19 pandemic, specifically in relation to the magnitude of information technology (IT) issues and distractions and MDT members’/managers’ perceptions and experiences of this shift.DesignA mixed methods study comprising real-time observations of IT issues/distractions within virtual MDTM case discussions held between April and July 2021 and qualitative data from interviews/surveys.SettingEight hospital organisations in Southern England.ParticipantsTeam members (respiratory physicians, surgeons, oncologists, radiologists, pathologists, palliative care professionals, nurses and MDT coordinators) and managers (n=190) across 8 local MDTs.ResultsMDTM observations (n=1664) highlighted significant variation between teams regarding IT functionality. IT issues and other distractions relating to the virtual MDTM format were observed 465 times affecting 20.6% of case discussions, most of which were audio issues (18.1%). Case discussions that had audio issues were, on average, 26 s longer (t(1652)=−2.77, p

Reliable measurement of newborn postnatal care is essential to understand gaps in coverage and quality and thereby improve outcomes. This study examined gaps in coverage and measurement of newborn postnatal care in the first 2 days of life. We analyzed Demographic and Health Survey data from 15 countries for 71,366 births to measure the gap between postnatal contact coverage and content coverage within 2 days of birth. Coverage was a contact with the health system in the first 2 days (postnatal check or newborn care intervention), and quality was defined as reported receipt of 5 health worker-provided interventions. We examined internal consistency between interrelated questions regarding examination of the umbilical cord. Reported coverage of postnatal check ranged from 13% in Ethiopia to 78% in Senegal. Report of specific newborn care interventions varied widely by intervention within and between countries. Quality-coverage gaps were high, ranging from 26% in Malawi to 89% in Burundi. We found some internally inconsistent reporting of newborn care. The percentage of women who reported that a health care provider checked their newborn's umbilical cord but responded "no" to the postnatal check question was as high as 16% in Malawi. Reliable measurement of coverage and content of early postnatal newborn care is essential to track progress in improving quality of care. Postnatal contact coverage is challenging to measure because it may be difficult for women to distinguish postnatal care from intrapartum care and it is a less recognizable concept than antenatal care. Co-coverage measures may provide a useful summary of contact and content, reflecting both coverage and an aspect of quality.

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.

Background The COVID-19 pandemic changed the way in which people were diagnosed and treated for cancer. We explored healthcare professional and patient perceptions of the main changes to colorectal cancer delivery during the COVID-19 pandemic and how they impacted on socioeconomic inequalities in care. Methods In 2020, using a qualitative approach, we interviewed patients (n = 15) who accessed primary care with colorectal cancer symptoms and were referred for further investigations. In 2021, we interviewed a wide range of healthcare professionals (n = 30) across the cancer care pathway and gathered national and local documents/guidelines regarding changes in colorectal cancer care. Results Changes with the potential to exacerbate inequalities in care, included: the move to remote consultations; changes in symptomatic triage, new COVID testing procedures/ways to access healthcare, changes in visitor policies and treatment (e.g., shorter course radiotherapy). Changes that improved patient access/convenience or the diagnostic process have the potential to reduce inequalities in care. Discussion Changes in healthcare delivery during the COVID-19 pandemic have the ongoing potential to exacerbate existing health inequalities due to changes in how patients are triaged, changes to diagnostic and disease management processes, reduced social support available to patients and potential over-reliance on digital first approaches. We provide several recommendations to help mitigate these harms, whilst harnessing the gains.

Background High rates of poor mental health in healthcare staff threatens the quality and sustainability of healthcare delivery. Multi-factorial causes include the nature and structure of work. We conducted a critical review of UK NHS (England) data pertaining to: doctors, nurses, midwives and paramedics. Sources of data Key demographic, service architecture (structural features of work) and well-being indicators were identified and reviewed by a stakeholder group. Data searching prioritized NHS whole workforce sources (focusing on hospital and community health services staff), which were rated according to strength of evidence. Findings Key differences between professions were: (i) demographics: gender (nursing and midwifery female-dominated, doctors and paramedics more balanced); age (professions other than doctors had ageing workforces); ethnicity (greater diversity among doctors and nurses); (ii) service architecture: despite net staffing growth, turnover and retention were problematic in all professions; 41.5% doctors were consultants but smaller proportions held high grade/band roles in other professions; salaries were higher for doctors; (iii) well-being: all reported high job stress, particularly midwives and paramedics; sickness absence rates for nurses, midwives and paramedics were three times those of doctors, and presenteeism nearly double. Growing points Sociocultural factors known to increase risk of poor mental health may explain some of the differences reported between professions. These factors and differences in service architecture are vital considerations when designing strategies to improve well-being. Areas timely for developing research Multi-level systems approaches to well-being are required that consider intersectionality and structural differences between professions; together with inter-professional national databases to facilitate monitoring.

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.

Background: Globally, Multidisciplinary Teams (MDTs) are considered the gold standard for diagnosis and treatment of cancer and other conditions, but variability in performance has led to demand for improvement tools. MDT-FIT (Multidisciplinary Team Feedback for Improving Teamwork) is an improvement programme developed iteratively with over 100 MDTs (>= 1100 MDT-members). Complex interventions are often adapted to context, but this is rarely evaluated. We conducted a prospective evaluation of the implementation of MDT-FIT across an entire integrated care system (ICS). Methods: MDT-FIT was implemented within all breast cancer MDTs across an ICS in England (n = 10 MDTs; 275 medical, nursing, and administrative members). ICS managers coordinated the implementation across the three stages of MDT-FIT: set up; assessment (self-report by team members plus independent observational assessment); team-feedback and facilitated discussion to agree actions for improvement. Data were collected using process and systems logs, and interviews with a purposively selected range of participants. Analysis was theoretically grounded in evidence-based frameworks for implementation strategies and outcomes. Results: All 10 MDTs participated in MDT-FIT; 36 interviews were conducted. Data from systems and process logs covered a 9-month period. Adaptations to MDT-FIT by the ICS (e.g., coordination of team participation by ICS rather than individual hospitals; and reducing time protected for coordination) reduced Fidelity and Adoption of MDT-FIT. However, the Acceptability, Appropriateness and Feasibility of MDT-FIT remained high due to embedding implementation strategies in the development of MDT-FIT (e.g., stakeholder engagement, interactive support). Conclusions: This is a unique and comprehensive evaluation of the multi-site implementation of a complex team improvement programme. Findings support the imperative of considering implementation strategies when designing such programmes to minimize potentially negative impacts of adaptations in "real world" settings.

Background Multidisciplinary Team Meetings (MDTMs), where treatment recommendations are discussed and agreed, are fundamental to effective cancer care. The increasing volume and complexity of caseloads has led to the need to transform MDTM pathways to improve efficiency and allow sufficient time for discussion of complex cases. Understanding of current functioning and inefficiencies is required to inform such transformation. Methods A mixed-methods observational study of all lung cancer MDTMs in one UK cancer network over 12 weeks (n=8 MDTs, 96 MDT meetings). Data were collected on meeting attendance and on each discussed case using a validated MDT tool. Semi-structured interviews were conducted with a range of MDT members and cancer service managers to gain understanding of perceived influences on the efficiency of MDTMs. Results 1671 case discussions were observed. Models of MDT working, including referral and diagnostic pathway management, varied within the network. Attendance was quorate in only 21% of the observed MDTMs, most often lacking palliative care specialists. Over a third (37%) of observed cases were repeat discussions pre-diagnosis. Treatment recommendations were agreed in 48% of case discussions but deferred for a quarter (24%) of discussed cases, most commonly due to awaiting results. Information about patients’ fitness for treatment and/or Performance Status score was available for 60% of cases discussed overall (30-75% by MDT). Interviews (n=56) identified addressing clinical and administrative workforce shortages, less reliance on the MDTM for pre-diagnostic decision-making and better availability of key clinical information about patients discussed in the MDTM as factors critical to improved MDT function. Conclusions Inefficiencies were prevalent in all MDTMs; improvements would require an individualised approach due to the variation in ways of working. Local, regional and national support is needed for lung MDTs to develop their diagnostic workforce and facilities, and clinical and administrative resource.

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.

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.

Introduction: COVID-19 restrictions introduced several changes in university academic and social experience. Self-isolation and online teaching have amplified students’ mental health vulnera-bility. Thus, we aimed to explore feelings and perspectives about the impact of the pandemic on mental health, comparing students from Italy and the UK. Methods: Data were from the qualitative portion of “the CAMPUS study”, longitudinally assessing mental health of students at the University of Milano-Bicocca (Italy) and the University of Surrey (UK). We conducted in-depth in-terviews and thematically analysed the transcripts. Results: The explanatory model was developed from four themes identified across 33 interviews: anxiety exacerbated by COVID-19; putative mechanisms leading to poor mental health; the most vulnerable subgroups; coping strategies. Generalised and social anxiety resulted from COVID-19 restrictions by being associated with loneliness, excessive time online, unhealthy management of time and space and poor communication with the university. Freshers, international students, and people on the extremes of the introversion/extroversion spectrum, were identified as vulnerable, while effective coping strat-egies included taking advantage of free time, connection with family and mental health support. The impact of COVID-19 was mostly related to academic issues by students from Italy, whereas to the drastic loss of social connectedness by the UK sample. Conclusions: Mental health support for students has an essential role, and measures that encourage communication and social connect-edness are likely to be beneficial.

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.

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.

Background Teamwork is essential for providing safe, effective and women-centred maternity care and several high profile investigations have highlighted the adverse conseqences of dysfuntional teamwork. Maternity teams may need support to identify the most relevant intervention(s) for improving teamwork. Objective To identify and describe current ‘off-the-shelf’ teamwork interventions freely or commercially available to support improvements to teamworking in UK maternity services and conduct a gap analysis to identify areas for future development. Design Rapid scoping review Methods A multi-component search process was used to identify teamwork interventions, comprising: (1) bibliographic database search (Medline, PsycINFO, CINAHL, MIDRS, NICE evidence research database); (2) identification of relevant policies and UK reports; and (3) expert input from key stakeholders (e.g., maternity service clinicians, managers, policymakers, and report authors). Data were extracted including the scope and content of each intervention and a gap analysis used to map interventions to the integrated team effectiveness model (ITEM) and structure level (macro, meso, micro) and results presented narratively. Findings Ten interventions were identified. Interventions were heterogeneous in their purpose and scope; six were classified as training courses, three were tools involving observational or diagnostics instruments, and one was a programme involving training and organisational re-design. Interventions were focused on teamwork in the context of obstetric emergencies (n=5), enhancement of routine care (n=4) or understanding workplace cultures (n=1). Users of interventions could vary, from whole organisations, to departments, to individual team members. All interventions focused on micro (e.g., team leadership, communication, decision-making, cohesion, and problem solving), with two also focused on meso aspects of teamwork (resources, organisational goals). Evidence for intervention effective on objective outcomes was limited. Conclusions Interventions that address key aspects of teamworking are available, particularly for improving safety in obstetric emergency situations. Most interventions, however, are focused on micro features, ignoring the meso (organisational) and macro (systems) features that may also impact on team effectiveness. Evidence-based team improvement interventions that address these gaps are needed. Such interventions would support team ownership of quality improvement, leading to improvements in outcomes for service users, staff and organisations.

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 Use of bystander video livestreaming from scene to Emergency Medical Services (EMS) is becoming increasingly common to aid decision making about the resources required. Possible benefits include earlier, more appropriate dispatch and clinical and financial gains, but evidence is sparse. Methods A feasibility randomised controlled trial with an embedded process evaluation and exploratory economic evaluation where working shifts during six trial weeks were randomised 1:1 to use video livestreaming during eligible trauma incidents (using GoodSAM Instant-On-Scene) or standard care only. Pre-defined progression criteria were: (1) ≥70% callers (bystanders) with smartphones agreeing and able to activate live stream; (2) ≥50% requests to activate resulting in footage being viewed; (3) Helicopter Emergency Medical Services (HEMS) stand-down rate reducing by ≥10% as a result of live footage; (4) no evidence of psychological harm in callers or staff/dispatchers. Observational sub-studies included (i) an inner-city EMS who routinely use video livestreaming to explore acceptability in a diverse population; and (ii) staff wellbeing in an EMS not using video livestreaming for comparison to the trial site. Results Sixty-two shifts were randomised, including 240 incidents (132 control; 108 intervention). Livestreaming was successful in 53 incidents in the intervention arm. Patient recruitment (to determine appropriateness of dispatch), and caller recruitment (to measure potential harm) were low (58/269, 22% of patients; 4/244, 2% of callers). Two progression criteria were met: (1) 86% of callers with smartphones agreed and were able to activate livestreaming; (2) 85% of requests to activate livestreaming resulted in footage being obtained; and two were indeterminate due to insufficient data: (3) 2/6 (33%) HEMS stand down due to livestreaming; (4) no evidence of psychological harm from survey, observations or interviews, but insufficient survey data from callers or comparison EMS site to be confident. Language barriers and older age were reported in interviews as potential challenges to video livestreaming by dispatchers in the inner-city EMS. Conclusions Progression to a definitive RCT is supported by these findings. Bystander video livestreaming from scene is feasible to implement, acceptable to both 999 callers and dispatchers, and may aid dispatch decision-making. Further assessment of unintended consequences, benefits and harm is required. Trial registration Trial registration: ISRCTN 11449333 (22 March 2022). https://www.isrctn.com/ISRCTN11449333

Schwartz Centre Rounds (Rounds), which originated in Boston, USA, are organisation-wide forums for healthcare staff which prompt reflection and discussion of the emotional, social or ethical challenges of healthcare work. Drawing on data from our UK National evaluation of Rounds we outline the unique features of Rounds as an organisational intervention, highlighting their differences to other wellbeing interventions and explain how Rounds work to influence organisational change and patient safety. As Rounds are open to all staff they are able to shine a spotlight on hidden organisational roles and staff groups, sparking greater insight and understanding of what peoples’ roles involve, resulting in reported reduced isolation and staff connection through sharing similar experiences. Rounds can help staff see and connect with the bigger picture of how the organisation functions helping to develop organisational cohesiveness and connectedness to the organisational mission and values and provide a space to process patient cases and learn from mistakes. Rounds can provide a counter-cultural space, allowing opportunities for staff to process and reflect upon difficult and satisfying aspects of their work as individuals, within teams and as an organisation. We reflect upon the challenges of implementing and sustaining Rounds including their evaluation and measuring organisational change resulting from Rounds provision.

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.

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 

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.

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.

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 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.

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.

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.

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.

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.

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: 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 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.

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.

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

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.

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 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.

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 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

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.

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 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 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.

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.

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.

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.

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 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 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 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.

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.

Background Nurses, midwives and paramedics are the largest collective group of clinical staff in the NHS and have some of the highest prevalence of psychological ill-health. Existing literature tends to be profession-specific and focused on individual interventions that place responsibility for good psychological health with nurses, midwives and paramedics themselves. Aim To improve understanding of how, why and in what contexts nurses, midwives and paramedics experience work-related psychological ill-health; and determine which high-quality interventions can be implemented to minimise psychological ill-health in these professions. Methods Realist synthesis methodology consistent with RAMESES reporting guidelines. Data sources First round database searching in MEDLINE ALL (via Ovid), CINAHL (via EBSCO) and HMIC (via Ovid), was undertaken between February-March 2021, followed by supplementary searching strategies (e.g., hand searching, expert solicitation of key papers). Reverse chronology screening was applied, aimed at retaining 30 relevant papers in each profession. Round two database searches (December 2021) targeted COVID-19-specific literature and literature reviews. No date limits were applied. Results We built on 7 key reports and included 75 papers in the first round (26 Nursing, 26 Midwifery, 23 Paramedic) plus 44 expert solicitation papers, 29 literature reviews and 49 COVID-19 focused articles in the second round. Through the realist synthesis we surfaced 14 key tensions in the literature and identified five key findings, supported by 26 Context Mechanism and Outcome configurations (CMOcs). The key findings identified that: 1) Interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; 2) It is difficult to promote staff psychological wellness where there is a blame culture; 3) The needs of the system often override staff wellbeing at work (‘serve & sacrifice’); 4) There are unintended personal costs of upholding and implementing values at work; and 5) It is challenging to design, identify and implement interventions to work optimally for diverse staff groups with diverse and interacting stressors. Conclusions Our realist synthesis strongly suggests the need to improve the systemic working conditions and the working lives of nurses, midwives and paramedics to improve their psychological wellbeing. Individual, one-off psychological interventions are unlikely to succeed alone. Psychological ill-health is highly prevalent in these staff groups (and can be chronic and cumulative as well as acute) and should be anticipated and prepared for, indeed normalised and expected. Healthcare organisations need to: 1) rebalance the working environment to enable healthcare professionals to recover and thrive; 2) invest in multi-level systems approaches to promoting staff psychological wellbeing; and use an organisational diagnostic framework such as the NHS England and NHS Improvement Health and Wellbeing framework to self-assess and implement a systems approach to staff wellbeing. Future work Future research should implement, refine and evaluate systemic interventional strategies. Interventions and evaluations should be co-designed with frontline staff and staff experts by experience, and tailored where possible to local, organisational and workforce needs. Limitations The literature was not equivalent in size and quality across the three professions and we did not carry out citation searches using hand searching and stakeholder / expert suggestions to augment our sample.

Objectives To evaluate the impact of the shift to virtual lung cancer multidisciplinary team meetings (MDTMs) in response to the COVID-19 pandemic, specifically in relation to the magnitude of information technology (IT) issues and distractions and MDT members’/managers’ perceptions and experiences of this shift. Design A mixed-methods study comprising real-time observations of IT issues/distractions within virtual MDTM case discussions held between April-July 2021 and qualitative data from interviews/surveys. Setting Eight hospital organisations in Southern England. Participants Team members (respiratory physicians, surgeons, oncologists, radiologists, pathologists, palliative care professionals, nurses and MDT coordinators) and managers (n=190) across eight local MDTs. Results MDTM observations (n=1664) highlighted significant variation between teams regarding IT functionality. IT issues and other distractions relating to the virtual MDTM format were observed 465 times affecting 20.6% of case discussions, most of which were audio issues (18.1%). Case discussions that had audio issues were, on average, 26 seconds longer (t(1652) = -2.77, p < .01). A total of 73 MDT members and managers participated in the survey and 41 participated in interviews, with all eight teams being represented. Increased flexibility, reduced travel time and easier real-time access to patient information were seen as the main advantages of virtual MDTMs. Views regarding the impact on relational aspects and communication differed. In line with observational findings, concerns were raised in relation to IT, including having inappropriate equipment, insufficient bandwidth (impairing image-sharing and video communication) and an overarching theme that virtual meeting platforms provided were not fit-for-purpose. Conclusions Despite the potential benefits of virtual MDTMs, IT issues can waste valuable MDTM time. If hospital organisations plan to continue virtual MDTMs, a functioning infrastructure is required, necessitating appropriate resource and investment.

Background: High rates of poor mental health in healthcare staff threatens the quality and sustainability of healthcare delivery. Multi-factorial causes include the nature and structure of work. We conducted a critical review of UK NHS (England) data pertaining to: doctors, nurses, midwives and paramedics. Sources of data: Key demographic, service architecture (structural features of work) and wellbeing indicators were identified and reviewed by a stakeholder group. Data searching prioritised NHS whole workforce sources (focusing on hospital and community health services staff), which were rated according to strength of evidence. Findings: Key differences between professions were: (i) Demographics: gender (nursing and midwifery female-dominated, doctors and paramedics more balanced); age (professions other than doctors had ageing workforces); ethnicity (greater diversity among doctors and nurses); (ii) Service architecture: despite net staffing growth, turnover and retention were problematic in all professions; 41.5% doctors were consultants but smaller proportions held high grade/band roles in other professions; salaries were higher for doctors; (iii) Wellbeing: all reported high job stress, particularly midwives and paramedics; sickness absence rates for nurses, midwives and paramedics were three times those of doctors, and presenteeism nearly double. Growing points: Socio-cultural factors known to increase risk of poor mental health may explain some of the differences reported between professions. These factors and differences in service architecture are vital considerations when designing strategies to improve wellbeing. Areas timely for developing research: Multi-level systems approaches to wellbeing are required that consider intersectionality and structural differences between professions; together with interprofessional national databases to facilitate monitoring.

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.

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.

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.