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Conefrey C, Ochieng C, Hoffman C, Elliott D, Avery K, Bennett J, Blencowe N, Duff S, Kinross J, McNair A, Messenger D, Pullybank A, Singh B, King A, Squire SE, Blazeby J, Main B, Rooshenas L. Managing surgical demand when needs outstrip resource: qualitative investigation of colorectal cancer surgery provision in the first wave of the COVID-19 pandemic. Br J Surg 2022; 110:92-97. [PMID: 36336577 PMCID: PMC10364543 DOI: 10.1093/bjs/znac371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/29/2022] [Accepted: 10/09/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND At the onset of the COVID-19 pandemic, elective surgical provision was severely affected by the need for hospital reorganization to care for critically ill patients. In response, National Health Service (NHS) England issued national guidance proposing acceptable time intervals for postponing different types of surgical procedure. This study reports healthcare professionals' private accounts of the strategies adopted to manage the imbalance of demand and resource, using colorectal cancer surgery as a case study. METHODS Twenty-seven semistructured interviews were conducted with healthcare professionals between June and November 2020. A key informant sampling approach was used, followed by snowballing to achieve maximum regional variation across the UK. Data were analysed thematically using the constant comparison approach. RESULTS In the context of considerable resource constraint, surgical teams overcame challenges to continue elective cancer provision. They achieved this by pursuing a combination of strategies: relocating surgical services; prioritizing patients within and across surgical specialties; adapting patient treatment plans; and introducing changes to surgical team working practices. Despite national guidance, prioritization decisions were framed as complex, and the most challenging of the strategies to implement, both practically and emotionally. CONCLUSION There is a need to better support surgeons tasked with prioritizing patients when capacity exceeds demand.
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Affiliation(s)
- Carmel Conefrey
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cynthia Ochieng
- NIHR Bristol Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Christin Hoffman
- NIHR Bristol Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daisy Elliott
- NIHR Bristol Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kerry Avery
- NIHR Bristol Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joanne Bennett
- Department of General Surgery, Gloucestershire Royal Hospitals NHS, Gloucester, UK
| | - Natalie Blencowe
- NIHR Bristol Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Duff
- Department of Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Angus McNair
- NIHR Bristol Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
- Department of Gastrointestinal Surgery, North Bristol NHS Trust, Bristol, UK
| | - David Messenger
- Department of Coloproctology, University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | - Anne Pullybank
- Department of Surgery, North Bristol NHS Trust, Bristol, UK
| | - Baljit Singh
- Department of Colorectal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Anni King
- NIHR Bristol Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah E Squire
- Association of Coloproctology of Great Britain and Ireland Patient Liaison Group, Oxford, UK
- NHS Specialised Colorectal Clinical Reference Group, UK
| | - Jane Blazeby
- NIHR Bristol Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Barry Main
- Bristol Dental School, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Elliott D, Blencowe NS, Cousins S, Zahra J, Skilton A, Mathews J, Paramasivan S, Hoffmann C, McNair AG, Ochieng C, Richards H, Hossaini S, Scroggie DL, Main B, Potter S, Avery K, Donovan J, Blazeby JM. Using qualitative research methods to understand how surgical procedures and devices are introduced into NHS hospitals: the Lotus study protocol. BMJ Open 2021; 11:e049234. [PMID: 34862280 PMCID: PMC8647399 DOI: 10.1136/bmjopen-2021-049234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 10/05/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The development of innovative invasive procedures and devices are essential to improving outcomes in healthcare. However, how these are introduced into practice has not been studied in detail. The Lotus study will follow a wide range of 'case studies' of new procedures and/or devices being introduced into NHS trusts to explore what information is communicated to patients, how procedures are modified over time and how outcomes are selected and reported. METHODS AND ANALYSIS This qualitative study will use ethnographic approaches to investigate how new invasive procedures and/or devices are introduced. Consultations in which the innovation is discussed will be audio-recorded to understand information provision practice. To understand if and how procedures evolve, they will be video recorded and non-participant observations will be conducted. Post-operative interviews will be conducted with the innovating team and patients who are eligible for the intervention. Audio-recordings will be audio-recorded, transcribed verbatim and analysed thematically using constant comparison techniques. Video-recordings will be reviewed to deconstruct procedures into key components and document how the procedure evolves. Comparisons will be made between the different data sources. ETHICS AND DISSEMINATION The study protocol has Health Research Authority (HRA) and Health and Care Research Wales approval (Ref 18/SW/0277). Results will be disseminated at appropriate conferences and will be published in peer-reviewed journals. The findings of this study will provide a better understanding of how innovative invasive procedures and/or devices are introduced into practice.
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Affiliation(s)
- Daisy Elliott
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Natalie S Blencowe
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Sian Cousins
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Jesmond Zahra
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Anni Skilton
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Sangeetha Paramasivan
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Christin Hoffmann
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Angus Gk McNair
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
- North Bristol NHS Trust, Bristol, UK
| | - Cynthia Ochieng
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Hollie Richards
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Sina Hossaini
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Darren L Scroggie
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Barry Main
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Shelley Potter
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Kerry Avery
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Jenny Donovan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane M Blazeby
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Elliott D, Ochieng C, Jepson M, Blencowe NS, Avery KN, Paramasivan S, Cousins S, Skilton A, Hutchinson P, Jayne D, Birchall M, Blazeby JM, Donovan JL, Rooshenas L. 'Overnight, things changed. Suddenly, we were in it': a qualitative study exploring how surgical teams mitigated risks of COVID-19. BMJ Open 2021; 11:e046662. [PMID: 34135048 PMCID: PMC8210660 DOI: 10.1136/bmjopen-2020-046662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES COVID-19 presents a risk of infection and transmission for operating theatre teams. Guidelines to protect patients and staff emerged and changed rapidly based on expert opinion and limited evidence. This paper presents the experiences and innovations developed by international surgical teams during the early stages of the pandemic to attempt to mitigate risk. DESIGN In-depth, semistructured interviews were audio recorded, transcribed and analysed thematically using methods of constant comparison. PARTICIPANTS 43 participants, including surgeons from a range of specialties (primarily general surgery, otolaryngology, neurosurgery, cardiothoracic and ophthalmology), anaesthetists and those in nursing roles. SETTING The UK, Italy, Spain, the USA, China and New Zealand between March and May 2020. RESULTS Surgical teams sought to mitigate COVID-19 risks by modifying their current practice with an abundance of strategies and innovations. Communication and teamwork played an integral role in how teams adapted, although participants reflected on the challenges of having to improvise in real time. Uncertainties remained about optimal surgical practice and there were significant tensions where teams were forced to balance what was best for patients while contemplating their own safety. CONCLUSIONS The perceptions of risks during a pandemic such as COVID-19 can be complex and context dependent. Management of these risks in surgery must be driven by evidence-based practice resulting from a pragmatic and novel approach to collation of global evidence. The context of surgery has changed dramatically, and surgical teams have developed a plethora of innovations. There is an urgent need for high-quality evidence to inform surgical practice that optimises the safety of both patients and healthcare professionals as the COVID-19 pandemic unfolds.
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Affiliation(s)
- Daisy Elliott
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Cynthia Ochieng
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Marcus Jepson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Natalie S Blencowe
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Kerry Nl Avery
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Sangeetha Paramasivan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Cousins
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Anni Skilton
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK
| | - David Jayne
- Leeds Institute of Medical Research, Level 7 Clinical Sciences Building, St. James's University Hospital, Leeds, UK
| | - Martin Birchall
- Ear Institute, Faculty of Brain Sciences, University College London, London, UK
| | - Jane M Blazeby
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jenny L Donovan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Eli K, Ochieng C, Hawkes C, Perkins GD, Couper K, Griffiths F, Slowther AM. Secondary care consultant clinicians' experiences of conducting emergency care and treatment planning conversations in England: an interview-based analysis. BMJ Open 2020; 10:e031633. [PMID: 31964663 PMCID: PMC7044868 DOI: 10.1136/bmjopen-2019-031633] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine secondary care consultant clinicians' experiences of conducting conversations about treatment escalation with patients and their relatives, using the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process. DESIGN Semi-structured interviews following ward round observations. SETTING Two National Health Service hospitals in England. PARTICIPANTS Fifteen medical and surgical consultants from 10 specialties, observed in 14 wards. ANALYSIS Interview transcripts were analysed using thematic analysis. RESULTS Three themes were developed: (1) determining when and with whom to conduct a ReSPECT conversation; (2) framing the ReSPECT conversation to manage emotions and relationships and (3) reaching ReSPECT decisions. The results showed that when timing ReSPECT conversations, consultant clinicians rely on their predictions of a patient's short-term prognosis; when framing ReSPECT conversations, consultant clinicians seek to minimise distress and maximise rapport and when involving a patient or a patient's relatives in decision-making discussions, consultant clinicians are guided by their level of certainty about the patient's illness trajectory. CONCLUSIONS The management of uncertainty about prognoses and about patients' emotional reactions is central to secondary care consultant clinicians' experiences of timing and conducting ReSPECT conversations.
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Affiliation(s)
- Karin Eli
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Claire Hawkes
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Keith Couper
- Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Murtagh MJ, Minion JT, Turner A, Wilson RC, Blell M, Ochieng C, Murtagh B, Roberts S, Butters OW, Burton PR. The ECOUTER methodology for stakeholder engagement in translational research. BMC Med Ethics 2017; 18:24. [PMID: 28376776 PMCID: PMC5379503 DOI: 10.1186/s12910-017-0167-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 01/08/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Because no single person or group holds knowledge about all aspects of research, mechanisms are needed to support knowledge exchange and engagement. Expertise in the research setting necessarily includes scientific and methodological expertise, but also expertise gained through the experience of participating in research and/or being a recipient of research outcomes (as a patient or member of the public). Engagement is, by its nature, reciprocal and relational: the process of engaging research participants, patients, citizens and others (the many 'publics' of engagement) brings them closer to the research but also brings the research closer to them. When translating research into practice, engaging the public and other stakeholders is explicitly intended to make the outcomes of translation relevant to its constituency of users. METHODS In practice, engagement faces numerous challenges and is often time-consuming, expensive and 'thorny' work. We explore the epistemic and ontological considerations and implications of four common critiques of engagement methodologies that contest: representativeness, communication and articulation, impacts and outcome, and democracy. The ECOUTER (Employing COnceptUal schema for policy and Translation Engagement in Research) methodology addresses problems of representation and epistemic foundationalism using a methodology that asks, "How could it be otherwise?" ECOUTER affords the possibility of engagement where spatial and temporal constraints are present, relying on saturation as a method of 'keeping open' the possible considerations that might emerge and including reflexive use of qualitative analytic methods. RESULTS This paper describes the ECOUTER process, focusing on one worked example and detailing lessons learned from four other pilots. ECOUTER uses mind-mapping techniques to 'open up' engagement, iteratively and organically. ECOUTER aims to balance the breadth, accessibility and user-determination of the scope of engagement. An ECOUTER exercise comprises four stages: (1) engagement and knowledge exchange; (2) analysis of mindmap contributions; (3) development of a conceptual schema (i.e. a map of concepts and their relationship); and (4) feedback, refinement and development of recommendations. CONCLUSION ECOUTER refuses fixed truths but also refuses a fixed nature. Its promise lies in its flexibility, adaptability and openness. ECOUTER will be formed and re-formed by the needs and creativity of those who use it.
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Affiliation(s)
- Madeleine J. Murtagh
- Data2Knowledge (D2K) Research Group, School of Social and Community Medicine, University of Bristol, Bristol, UK
- Centre for Policy, Ethics and Life Sciences (PEALS), Newcastle University, Newcastle, UK
| | - Joel T. Minion
- Data2Knowledge (D2K) Research Group, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Andrew Turner
- Data2Knowledge (D2K) Research Group, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Rebecca C. Wilson
- Data2Knowledge (D2K) Research Group, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Mwenza Blell
- Department of Sociology, University of Cambridge, Cambridge, UK
| | - Cynthia Ochieng
- Data2Knowledge (D2K) Research Group, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Barnaby Murtagh
- Data2Knowledge (D2K) Research Group, School of Social and Community Medicine, University of Bristol, Bristol, UK
- Urban Cow Productions, London, UK
| | - Stephanie Roberts
- Data2Knowledge (D2K) Research Group, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Oliver W. Butters
- Data2Knowledge (D2K) Research Group, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Paul R Burton
- Data2Knowledge (D2K) Research Group, School of Social and Community Medicine, University of Bristol, Bristol, UK
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Hercik C, Cosmas L, Mogeni O, Wamola N, Kohi W, Ochieng C, Onyango C, Fields B, Mfinanga S, Montgomery J. A Diagnostic and Epidemiologic Investigation of Acute Febrile Illness (AFI) in Kilombero, Tanzania. Int J Infect Dis 2016. [DOI: 10.1016/j.ijid.2016.11.269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Ofula V, Ochieng C, Limbaso S, Wurapa E, Sang R, Obonyo M, Bii E. Laboratory confirmation of dengue-3 virus outbreak in Mandera, Northern Kenya, 2011. Int J Infect Dis 2012. [DOI: 10.1016/j.ijid.2012.05.919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Ryman TK, Wallace A, Mihigo R, Richards P, Schlanger K, Cappelier K, Ndiaye S, Modjirom N, Tounkara B, Grant G, Anya B, Kiawi EC, Ochieng C, Kone S, Tesfaye H, Trayner N, Watkins M, Luman ET. Community and Health Worker Perceptions and Preferences Regarding Integration of Other Health Services With Routine Vaccinations: Four Case Studies. J Infect Dis 2012; 205 Suppl 1:S49-55. [DOI: 10.1093/infdis/jir796] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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