Maximising learning opportunities in handover

Handing over responsibility for patients has always been part of medical practice. Definitions emphasise transfer of responsibility to ensure patient safety and the available literature tends to follow this line (see box 1). Handover is much more than this, however. It is a key event where teams meet, have the opportunity to communicate, support each other and learn. This paper considers different ways of maximising learning opportunities in handover, with particular emphasis on the strengths and challenges of the paediatric environment. Alongside review of the best available evidence, many of the ideas discussed were generated from working with a group of 65 experienced paediatricians with particular experience and interest in medical education as part of the Royal College of Paediatrics and Child Health Paediatric Educators Programme. Formal handover has increased in importance and been embedded in practice with the transition from “on-calls” to “full-shift” rotas in an effort to comply with the European Working Time Directive1 in the United Kingdom (UK). Departments responsible for acute patient care have had to incorporate two or three handover sessions into every day to ensure patient problems and management plans are appreciated by the incoming medical team

Taming the Perfect Beast: the Monster as Romantic Hero in Contemporary Fiction

This thesis examines the contemporary phenomenon of the paranormal romance, as exemplified by Stephenie Meyer\u27s Twilight series. Although immensely popular, the series has drawn harsh criticism for its writing style and for the sexual politics portrayed in the novels. Readers of the series have been subjected to similar harsh criticism for enjoying these works in spite of the aforementioned issues. Careful examination of the books, however, reveals that the source of their popularity draws from several factors: the use of a narrative structure known as the Rebirth scenario, particularly popular in romance novels an inverted form of the traditional Beauty and the Beast narrative, in which the Beast is princely on the outside and bestial within, and in which the heroine is the one who undergoes transformation and a heroine who, through her apparent lack of empowerment, may actually empower her readers by functioning as an avatar with whom they are capable of fully identifying and sympathizing. Further, this thesis traces the historical formation of the paranormal romance through the multiple genres that have contributed to its development, and examines the social forces that may have made the popularity of both a flawed heroine such as Bella Swan and a dangerous hero such as Edward Cullen inevitable. The segregation of the romance novel away from other fiction, along with the customary way in which it is derogated as inferior to other genres, emerges as a crucial factor in how the novels have been interrogated by their detractors. As this derogatory treatment is often extended to the novels\u27 fans, this thesis further suggests some ways in which those critics concerned about female empowerment may wish to re-evaluate the novels, the genres from which they draw, and the benefits that many readers may actually gain from reading the

Taming the Perfect Beast: the Monster as Romantic Hero in Contemporary Fiction

This thesis examines the contemporary phenomenon of the paranormal romance, as exemplified by Stephenie Meyer\u27s Twilight series. Although immensely popular, the series has drawn harsh criticism for its writing style and for the sexual politics portrayed in the novels. Readers of the series have been subjected to similar harsh criticism for enjoying these works in spite of the aforementioned issues. Careful examination of the books, however, reveals that the source of their popularity draws from several factors: the use of a narrative structure known as the Rebirth scenario, particularly popular in romance novels an inverted form of the traditional Beauty and the Beast narrative, in which the Beast is princely on the outside and bestial within, and in which the heroine is the one who undergoes transformation and a heroine who, through her apparent lack of empowerment, may actually empower her readers by functioning as an avatar with whom they are capable of fully identifying and sympathizing. Further, this thesis traces the historical formation of the paranormal romance through the multiple genres that have contributed to its development, and examines the social forces that may have made the popularity of both a flawed heroine such as Bella Swan and a dangerous hero such as Edward Cullen inevitable. The segregation of the romance novel away from other fiction, along with the customary way in which it is derogated as inferior to other genres, emerges as a crucial factor in how the novels have been interrogated by their detractors. As this derogatory treatment is often extended to the novels\u27 fans, this thesis further suggests some ways in which those critics concerned about female empowerment may wish to re-evaluate the novels, the genres from which they draw, and the benefits that many readers may actually gain from reading the

Individuals with low back pain: how do they view physical activity?

Background. Recent guidelines for those with acute low back pain have advocated early resumption of normal activity and increased physical activity. Little is known about the relationship between low back pain and physical activity, and on the impact of that relationship on the promotion of increased levels of physical activity within a general practice population. Objectives. We aimed to explore associations between factors that influence changes in physical activity and the way individuals perceive and behave with their low back pain, and the impact of those perceptions and behaviour on physical activity. Methods. Twenty-seven informants were chosen using a purposive sample from a larger group of individuals who, because of their low back trouble, had been referred by their GPs to a community-based, single-blind, randomized controlled trial (RCT) at the University of York, which is evaluating the effectiveness and cost-effectiveness of a progressive exercise programme. Fifty-four interviews were conducted with this subgroup of the RCT; four informants were interviewed once, 19 twice and four of them three times. Interviews were transcribed and analysed using manual and computer-aided approaches. Results. Physical activity was perceived as (i) activities of daily living, (ii) activities causing breathlessness that they went out of the way to do and (iii) more competitive-type activity. The avoidance of physical activity and fear of pain returning were the two main factors directly associated with informants' backs and changes in physical activity. These two factors hindered increases in physical activity, even though the majority of informants believed strongly that being physically active helped ease their low back pain. Conclusions. When advocating that individuals with acute low back pain return to or increase physical activity, it is important that clinicians identify avoidance of physical activity and/or fear of pain at the earliest stage in order to tailor advice and reassurance appropriately. If avoidance of activity and fear of pain is identified and clinicians want to encourage patients to take up and sustain increased physical activity, they should explore issues of fear of pain, and avoidance of and confidence to do physical activities, in addition to other factors influencing physical activity

A randomised controlled trial comparing graded exercise treatment and usual physiotherapy for patients with non-specific neck pain (the GET UP neck pain trial).

Evidence supports exercise-based interventions for the management of neck pain, however there is little evidence of its superiority over usual physiotherapy. This study investigated the effectiveness of a group neck and upper limb exercise programme (GET) compared with usual physiotherapy (UP) for patients with non-specific neck pain. A total of 151 adult patients were randomised to either GET or UP. The primary measure was the Northwick Park Neck pain Questionnaire (NPQ) score at six weeks, six months and 12 months. Mixed modelling identified no difference in neck pain and function between patients receiving GET and those receiving UP at any follow-up time point. Both interventions resulted in modest significant and clinically important improvements on the NPQ score with a change score of around 9% between baseline and 12 months. Both GET and UP are appropriate clinical interventions for patients with non-specific neck pain, however preferences for treatment and targeted strategies to address barriers to adherence may need to be considered in order to maximise the effectiveness of these approaches

Randomised controlled trial of exercise for low back pain : clinical outcomes, costs and preferences

Objective: To evaluate effectiveness of an exercise programme in a community setting for patients with low back pain to encourage a return to normal activities. Design: Randomised controlled trial of progressive exercise programme compared with usual primary care management. Patients' preferences for type of management were elicited independently of randomisation. Participants: 187 patients aged 18-60 years with mechanical low back pain of 4 weeks to 6 months' duration. Interventions: Exercise classes led by a physiotherapist that included strengthening exercises for all main muscle groups, stretching exercises, relaxation session, and brief education on back care. A cognitive-behavioural approach was used. Main outcome measures: Assessments of debilitating effects of back pain before and after intervention and at 6 months and 1 year later. Measures included Roland disability questionnaire, Aberdeen back pain scale, pain diaries, and use of healthcare services. Results: At 6 weeks after randomisation, the intervention group improved marginally more than the control group on the disability questionnaire and reported less distressing pain. At 6 months and 1 year, the intervention group showed significantly greater improvement in the disability questionnaire score (mean difference in changes 1.35, 95% confidence interval 0.13 to 2.57). At 1 year, the intervention group also showed significantly greater improvement in the Aberdeen back pain scale (4.44, 1.01 to 7.87) and reported only 378 days off work compared with 607 in the control group. The intervention group used fewer healthcare resources. Outcome was not influenced by patients' preferences. Conclusions: The exercise class was more clinically effective than traditional general practitioner management, regardless of patient preference, and was cost effective

Exploiting opportunities for leadership development of surgeons within the operating theatre

AbstractIt is increasingly recognised that leadership skills are a key requirement in being successful in surgery, regardless of speciality and at all levels of experience and seniority. Where the emphasis was previously on technical ability, knowledge and diagnostic acumen, we now know that non-technical skills such as communication and leadership contribute significantly to patient safety, experience and outcomes, and should be valued.The operating theatre is a unique micro-environment which is often busier, noisier, more stressful and more physically demanding than the clinic or ward setting. As a result surgeons and their trainers, who are striving to develop leadership skills require an in-depth awareness of the challenges in this environment and the opportunities that arise from them to develop leadership effectively. This article outlines why leadership learning is so beneficial in the operating theatre, both for the team and the patient as well as what elements of daily routine activity such as the WHO checklist use, list-planning and audit can be exploited to transform the average busy operating theatre into a rich, learning environment for future leaders in surgery

Clinical Leadership: can the skills be learned by trainee paediatricians?

Aim: To explore whether paediatricians in training can develop leadership skills through participating in a specifically designed leadership development initiative. Methods: A systematic review was conducted to explore the healthcare leadership literature for empirical evidence of different approaches to leadership development. Informed by this review, and conceptualised by key leadership theories, a work-based leadership development initiative was established within a newly formed trainee committee in the London School of Paediatrics. 32 paediatric trainee participants were recruited, and a comparator group came from within the wider trainee population. The trainee group recruited to the leadership initiative were also offered the opportunity to use a multi-source feedback tool to support their learning. The impact of the leadership development initiative was evaluated using a mixed methods approach. A web-based self-assessment questionnaire was designed, validated and then used as a pre- and post-intervention (12-months) quantitative measure. In addition focus groups were run pre- and post-intervention and framework analysis was used to explore the qualitative data. Results: The systematic review highlighted small areas of empirical evidence around leadership development within medicine. The quantitative analysis demonstrated a significant increase in the participants’ self-assessment scores between the pre-intervention questionnaire and the post-intervention questionnaire. Additionally, paired t-tests demonstrated statistically significant increases in scores relating to ‘developing networks and building & maintaining relationships’ and ‘working within teams and encouraging contribution’. The qualitative analysis highlighted the importance of personal development, team-working and understanding the wider context of healthcare systems emerged as important themes. Conclusions: This work helps to strengthen the understanding that clinical leadership skills and capabilities can be learned by trainee paediatricians. The results are suggestive of the positive impact of the intervention on many of the individuals involved, and despite some methodological weaknesses, this thesis has generated new evidence that can be used to influence the design and planning of other leadership development initiatives in the future

Acupuncture for chronic neck pain: a pilot for a randomised controlled trial

Background: Acupuncture is increasingly being used for many conditions including chronic neck pain. However the evidence remains inconclusive, indicating the need for further well-designed research. The aim of this study was to conduct a pilot randomised controlled parallel arm trial, to establish key features required for the design and implementation of a large-scale trial on acupuncture for chronic neck pain. Methods: Patients whose GPs had diagnosed neck pain were recruited from one general practice, and randomised to receive usual GP care only, or acupuncture ( up to 10 treatments over 3 months) as an adjunctive treatment to usual GP care. The primary outcome measure was the Northwick Park Neck Pain Questionnaire (NPQ) at 3 months. The primary analysis was to determine the sample size for the full scale study. Results: Of the 227 patients with neck pain identified from the GP database, 28 (12.3%) consenting patients were eligible to participate in the pilot and 24 (10.5%) were recruited to the trial. Ten patients were randomised to acupuncture, receiving an average of eight treatments from one of four acupuncturists, and 14 were randomised to usual GP care alone. The sample size for the full scale trial was calculated from a clinically meaningful difference of 5% on the NPQ and, from this pilot, an adjusted standard deviation of 15.3%. Assuming 90% power at the 5% significance level, a sample size of 229 would be required in each arm in a large-scale trial when allowing for a loss to follow-up rate of 14%. In order to achieve this sample, one would need to identify patients from databases of GP practices with a total population of 230,000 patients, or approximately 15 GP practices roughly equal in size to the one involved in this study (i.e. 15,694 patients). Conclusion: This pilot study has allowed a number of recommendations to be made to facilitate the design of a large-scale trial, which in turn will help to clarify the existing evidence base on acupuncture for neck pain

Identifying factors that promote and limit the effective use of real-time patient experience feedback: a mixed-methods study in secondary care

Objectives: The Friends and Family Test (FFT) is commissioned by the National Health Service (NHS) in England to capture patient experience as a real-time feedback initiative for patient-centred quality improvement (QI). The aim of this study was to create a process map in order to identify the factors that promote and limit the effective use of FFT as a real-time feedback initiative for patient-centred QI. Setting: This study was conducted at a large London NHS Trust. Services include accident and emergency, inpatient, outpatient and maternity, which routinely collect FFT patient experience data. Participants: Healthcare staff and key stakeholders involved in FFT. Interventions: Semi-structured interviews were conducted on fifteen participants from a broad range of professional groups to evaluate their engagement with the FFT. Interview data were recorded, transcribed, and analysed for using deductive thematic analysis. Results: Concerns related to inefficiency in the flow of FFT data, lack of time to analyse FFT reports (with emphasis on high level reporting rather than QI), insufficient access to FFT reports and limited training provided to understand FFT reports for frontline staff. The sheer volume of data received was not amenable to manual thematic analysis resulting in inability to acquire insight from the free-text. This resulted in staff ambivalence towards FFT as a near real-time feedback initiative. Conclusions: The results state that there is too much FFT free text for meaningful analysis, and the output is limited to the provision of sufficient capacity and resource to analyse the data, without consideration of other options, such as text analytics and amending the data collection tool