Recent Submissions

  • Disproportionality in NHS Disciplinary Proceedings

    Archibong, Uduak E.; Kline, R.; Eshareturi, Cyril; McIntosh, Bryan (2019-04-01)
    This article investigates the representation of black, Asian and minority ethnic staff in NHS disciplinary proceedings. The study involved an in-depth knowledge review and analysis of literature on the representation of black, Asian and minority ethnic staff in NHS disciplinary proceedings from 2008 to 2017, as well as semi-structured interviews with 15 key stakeholders. Participants were stakeholders from both primary and secondary care and included equality and diversity leads, human resource professionals, NHS service managers, representatives of trade unions and health professional regulatory council representatives. The knowledge review indicates that to date, black, Asian and minority ethnic staff are disproportionately represented in NHS disciplinary proceedings. Evidence gathered demonstrates the continuation of inappropriate individual disciplinary action and failure to address organisational shortcomings against black, Asian and minority ethnic members of staff. Overall, six factors were identified as underpinning the disproportionate representation of black minority ethnic staff in disciplinaries: closed culture and climate; subjective attitudes and behaviour; inconclusive disciplinary data; unfair decision making; poor disciplinary support; and disciplinary policy misapplication.
  • Disrupting disproportionality proceedings: The recommendations

    Archibong, Uduak E.; Kline, R.; Eshareturi, Cyril; McIntosh, Bryan (2019-06-02)
    An in-depth knowledge review and analysis of literature on the involvement of Black and Minority Ethnic (BAME) staff in NHS disciplinary proceedings from 2008 to 2017 as did 15 semi-structured interviews with key stakeholders. The research findings indicate that BME staff are disproportionately represented in NHS disciplinary proceedings, there is a continuation of inappropriate individual disciplinary action and a failure to address organisational shortcomings. Six factors emerged: closed culture and climate; subjective attitudes and behaviour; inconclusive disciplinary data; unfair decision making; poor disciplinary support and disciplinary policy mis-application were all identified as underpinning the disproportionate representation of BME staff in disciplinary procedures. Disciplinary policy needs streamlining and greater clarity needs to be achieved regarding the difference between disciplinary, capability and performance issues and to this respect we make several recommendations.
  • Towards a practice theory of goal setting: assessing the theoretical goal-setting of a leprosy organisation in Nigeria

    Ogbeiwi, Osahon (2020)
    Goal-setting is indispensable for effective healthcare management. Yet, literature evidence suggests many organisations worldwide do not know how to formulate ‘SMART’ goals. Evidence of how existing theories work in practice is scarce, and the practices in low-income countries are unknown. Therefore, this research explored how leprosy project goals were formulated to describe the theoretical practice framework of A leprosy-focused organisation in Nigeria. Using a case-study design, ten managers were interviewed individually concerning their goal-setting knowledge, experience and perspective; and documented goals of six projects were reviewed. A five-step constructionist thematic data analysis generated eleven theoretical frameworks from the concepts of the emergent core themes of ‘stakeholders’, ‘strategies’ and ‘statements.’ Further theorisation reduced them to one general framework. This revealed organisational goal-setting practice as a four-stage centre-led, top-down, beneficiary-focused and problem-based process. The stages were national preparation, baseline needs-survey, centralised goal formulation and nationalised planning. The outcome was the formulation of assigned, ‘non-SMART’ objective statements, which are then used for planning projects. Other theoretical models constructed included a Goal Effects Cycle, ‘SMARTA’ goal attributes and hierarchical criteria for differentiating goal-types. A theory developed from the goal-setting practice postulates that: ‘Assigned non-SMART goal formulation directly results from centralised goal-setting practice and is the predictor of unrealistic project planning.’ Therefore, I propose that goal statements will be ‘SMARTA’ and plans, more realistic and relevant if goal-setting is done collaboratively by all stakeholders at all stages of the process. Also, ‘Change-Beneficiary-Indicator-Target-Timeframe’ and ‘Change-Beneficiary-Location-Timeframe’ frameworks are recommended as templates for writing SMART objectives and aims respectively.
  • Why part-time nurses should be valued

    McIntosh, Bryan; Archibong, Uduak E. (2020-02)
    The article discusses how nurses are increasingly being valued as autonomous decision makers and co-ordinators of patient care. Topics include relating to the age of the dependent children, a woman's working hours and any successive career breaks, woman's career progression directly related to the school age of the dependent children, and children being inhibit and is driven in part by a determination to maintain traditional employment practices.
  • Logical goal-setting frameworks for leprosy projects

    Ogbeiwi, Osahon (2020)
    Introduction: Goal setting is a fundamental practice in the effective management of healthcare services worldwide. This study investigated the extent to which leprosy goal formulation in Nigeria is logical and SMART. Method: Document review of baseline problems, goal statements and goal attainments for 2016 in six leprosy projects using a customised logical framework matrix. Results: A total of 15 main problems, 6 aims, 19 objectives and 42 indicators were found. The goals were problem-based and logically linked, with a pattern of a single aim per project, multiple objectives per aim, and multiple indicators per objective. Goal statements specified only impact in 5/6 aims, and only outcome and terminal timeframe in 17/19 (89.5%) objectives. Only one objective stated all four SMART components of outcome, indicator, target and timeframe. While three (7.1%) indicators and two (10.5%) objectives were measurable, no target was attainable. Discussion: Goal-setting frameworks for leprosy projects should be problem based and logical according to best practice. That most leprosy objectives were not completely SMART is similar to the reported structure of objectives published by other health organisations globally.
  • The prevalence and predictors of loneliness in caregivers of people with dementia: findings from the IDEAL programme

    Victor, C.R.; Rippon, I.; Quinn, Catherine; Nelis, S.M.; Martyr, A.; Hart, N.; Lamont, R.; Clare, L. (2020)
    Objectives: To establish the prevalence of loneliness among family caregivers of people with dementia and to identify potential risk factors for loneliness. Methods: Using data from the baseline wave of the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort study, we examined loneliness in 1283 family caregivers of people with mild-to-moderate dementia living in Great Britain. Multinomial regression was used to examine the relative influence of a series of risk factors for caregiver loneliness. Results: Almost half, 43.7%, of caregivers reported moderate loneliness and 17.7% reported severe loneliness. Greater social isolation and increased caregiving stress were linked with both moderate and severe loneliness. Better quality of relationship with the person with dementia along with increased levels of well-being and life satisfaction were associated with a lower relative risk of reporting both moderate and severe loneliness. Discussion: This study examines the prevalence and predictors of loneliness in a large sample of family caregivers of people with dementia. Notably over two-thirds of caregivers in our sample reported feeling lonely. Interventions aimed at reducing caregiving stress and supporting meaningful relationships may go some way towards helping to reduce loneliness.
  • The co-development and feasibility-testing of an innovative digital animation intervention (DAISI) to reduce the risk of maternal sepsis in the postnatal period

    Haith-Cooper, Melanie; Stacey, T.; Bailey, F.; Broadhead-Croft, S. (2020-04)
    Introduction: Sepsis is one of the most common causes of mortality in postnatal women globally and many other women who develop sepsis are left with severe morbidity. Women’s knowledge of postnatal sepsis and how it can be prevented by simple changes to behaviour is lacking. Methods: This paper describes the co-development and feasibility testing of a digital animation intervention called DAISI (digital animation in service improvement). This DAISI is designed to enhance postnatal women’s awareness of sepsis and how to reduce their risk of developing the condition. We co-designed the digital animation over a six-month period underpinned by theory, best evidence and key stakeholders, translated it into Urdu then assessed its use, firstly in a focus group with women from different Black, Asian and Minority Ethnic (BAME) groups and secondly with 15 clinical midwives and 15 women (including BAME women). Following exposure to the intervention, midwives completed a questionnaire developed from the COM-B behaviour change model and women participated in individual and focus group interviews using similar questions. Results: The animation was considered acceptable, culturally sensitive and simple to implement and follow. Discussion: DAISI appears to be an innovative solution for use in maternity care to address difficulties with the postnatal hospital discharge process. We could find no evidence of digital animation being used in this context and recommend a study to test it in practice prior to adopting its use more widely. If effective, the DAISI principle could be used in other maternity contexts and other areas of the NHS to communicate health promotion information.
  • Interpreting trauma radiographs

    Hardy, Maryann L.; Barrett, Christine (2003-10)
    Background: Many accident and emergency clinicians regard the radiographic image as an extension of the clinical examination, as a provisional diagnosis, based on clinical signs and symptoms, can be confirmed or refuted by inspection of X-rays. However, the value of radiography in this context is not determined by the actual presence of trauma or pathology on the radiograph, but is dependent on the ability of a clinician to identify any trauma or pathology present. Traditionally, the responsibility for interpreting radiographic images within the accident and emergency environment in the United Kingdom (UK) has been with medical clinicians. However, expansion of the nursing role has begun to change the boundaries of professional practice and now many nurses are both requesting and interpreting trauma radiographs. Aim: To ascertain the ability of accident and emergency doctors and nurses to interpret trauma radiographs, and identify whether there is a consistent standard of interpretive accuracy that could be used as a measure of competence. Methods: A literature review was conducted using the Cochrane Library, Medline and CINAHL databases and the keywords radiographic interpretation, radiographic reporting, accident and emergency and emergency/nurse practitioner. Findings: The ability of accident and nursing doctors and nurses to interpret trauma radiographs accurately varies markedly, and no identified published study has established an appropriate level of accuracy that should be achieved in order to demonstrate satisfactory competence in the interpretation of radiographic images. Conclusions: Determining a measure of interpretive accuracy that can be used to assess ability to interpret radiographic trauma images is fraught with difficulties. Consequently, nurses may attempt to prove their skills by directly comparing their abilities to those of their medical colleagues. However, as a result of marked variation in the ability of senior house officers to interpret trauma radiographs, a similar ability does not automatically imply that a satisfactory level of ability has been achieved.
  • The immobilisation and restraint of paediatric patients during plain film radiographic examinations

    Graham, P.; Hardy, Maryann L. (2004-02)
    Purpose: The immobilisation and restraint of children to facilitate radiographic examination is a controversial issue that has been relatively ignored by radiography research. The aim of this study was to begin to fill this gap by providing a description of restraint used in a limited number of clinical sites in order to highlight any perceived need for training, policies or guidelines in the use of child immobilisation and restraint. Methods: A cross-sectional survey design using a postal questionnaire was adopted. One hundred and sixty-seven questionnaires were distributed to radiographers employed within six hospital Trusts. Results: A response rate of 83.2% (n=139/167) was achieved. Ninety-three percent (93.5%, n=130/139) of respondents indicated that restraining techniques were used although only 19.2% (n=25/130) had received specific training in safe restraining techniques and 7.9% (n=11/139) in distraction techniques as an alternative to restraint. A need for further guidance and support for clinical staff was evident with 73.3% (n=74/101) of respondents identifying a need for specific guidelines and 84.6% (n=110/130) indicating that further training opportunities were required. Conclusions: The use of restraint in paediatric plain film radiography is an apparently widespread practice and support for clinical radiographers through the development of training opportunities and practice guidelines are seen as essential in order to promote high quality paediatric radiography practices.
  • Requesting and interpreting trauma radiographs: a role extension for accident & emergency nurses

    Hardy, Maryann L.; Barrett, Christine (2003-10)
    Government supported expansion of the nursing role within Accident & Emergency (A&E) departments in the United Kingdom (UK) has begun to break down the traditional barriers to professional practice. Today, many nurses working within A&E departments are both requesting and interpreting radiographic examinations as part of their normal working practice. However, role expansion does not occur without increased responsibility. Unsatisfactory requests for radiography and inaccurate radiographic interpretation may result in inappropriate patient treatment, misuse of resources, patient recall and litigation. Nurses undertaking these role extensions need to ensure that their levels of knowledge and skill to perform the role are appropriate and adequately supported. This article summarises the results of a national questionnaire survey of A&E nurse managers that aimed to identify current working practices, including education, training and limitations to practice, with respect to the requesting and interpretation of trauma radiographs by A&E nurses.
  • Role extension and role advancement - Is there a difference? A discussion paper

    Hardy, Maryann L.; Snaith, Beverly (2006-11)
    The terms ‘extended’ and ‘advanced’ practice are commonly used to describe clinical practitioner roles. However, these terms have not been clearly defined within the context of modern radiography practice despite their fundamental importance to establishing the 4 tier structure, implementing Agenda for Change and promoting a coherent clinical radiography career structure. This paper discusses the terms ‘extension’ and ‘advancement’ in relation to radiography practice and, using evidence from the debates of other health professions, attempts to offer some clarity to the terminology, presenting one interpretation of its possible application to the radiographer role in the United Kingdom.
  • Accident and emergency radiography: A comparison of radiographer commenting and 'red dotting'

    Hardy, Maryann L.; Culpan, Gary (2007-02)
    Purpose: The College of Radiographers has called for ‘Red Dot’ schemes to evolve and has recommended the development of radiographer commenting. The implementation of a radiographer comment scheme assumes that radiographers previously participating in ‘red dot’ schemes have been accurately recognising radiographic abnormalities and are, therefore, able to comment upon, and describe, such radiographic appearances. Research evidence to support such an assumption is sparse. This study compares the ability of radiographers attending a short course on musculoskeletal trauma to ‘red dot’ and comment on A&E radiographic appearances. Methods: This study adopted a pre-test, post-test approach. One hundred and twenty one radiographers attending a short course on musculoskeletal trauma (Bradford Red Dot Course) were invited to undertake an assessment of their ability to recognise (‘red dot’) and describe (comment upon) radiographic abnormalities at the start and end of the short course. Results: One hundred and fifteen radiographers (n = 115/121; 95.0%) completed both the pre- and post-training assessments. Post-training mean scores per case improved on average by 9.8% [p = 0.012; 95% CI: 2.4, 17.1] for ‘red dots’ and 12.7% [p = 0.007; 95% CI: 3.8, 21.5] for commenting. However, the difference between mean ‘red dot’ and commenting scores remained similar with mean radiographer comment scores being 13.7% less than mean ‘red dot’ scores pre-training and 10.8% less post-training. Conclusions: The results of this study indicate that the accuracy of radiographer comments was significantly reduced when compared to the accuracy of ‘red dots’ for the same radiographic images. The clinical significance of these findings for departments wanting to move from a ‘red dot’ system to a radiographer commenting scheme is that without appropriate training and audit, the quality of service and assistance to the A&E department could be significantly reduced.
  • How to achieve advanced practitioner status: A discussion paper

    Snaith, Beverly; Hardy, Maryann L. (2007-05)
    Accepted definitions and descriptions of advanced practice offer generic ideals for the development of advanced radiographer practitioner roles. However, they fail to specify a development pathway necessary for a clinical practitioner to attain advanced practitioner status and lack of clarity persists around the definition of advanced practice within the context of radiography [Price R. Critical factors influencing the changing scope of practice: the defining periods. Imaging & Oncology 2005;June:6–11.]. This paper will consider the expectations of practitioner and advanced practitioner competencies within the context of radiography practice in the United Kingdom and suggest criteria for an advanced practice development pathway that may be adopted by individual radiographers, or their managers, to assist professional development within any imaging speciality.
  • How to achieve consultant practitioner status: A discussion paper

    Hardy, Maryann L.; Snaith, Beverly (2007-11)
    Non-medical consultant posts are a relatively new addition to the National Health Service (NHS) workforce, the role first being announced for nurses in 1998 followed by the Allied Health Professions in 2000. They have been described as multidimensional positions that encompass the four core functions of consultant practice: expert clinical practice; professional leadership and consultancy; practice and service development, research and evaluation; education and professional development. Consequently, the purpose of non-medical consultants is to promote and develop practice at the clinical, strategic and policy level. Despite the professional drive to develop consultant radiographer roles, by the end of 2005 only 15 were in post. One of the reasons for this poor appointment rate is the deficiency in suitably qualified and experienced candidates, a finding acknowledged to be an issue across all the non-medical professions. Further, the development of potential consultant practitioners has been hampered by the lack of clearly defined clinical and educational pathways. This paper acknowledges the limited published material available to radiographers wishing to advance to consultant positions. Yet while recognising the need to establish a true consultant career pathway underpinned by an appropriate education and research strategy, it explores the requirements of consultant practice, identifying some opportunities available to radiographers to develop appropriate consultant level skills.
  • The evaluation of compliance with iRefer guidelines for abdominal imaging and the impact of the normal abdominal radiograph on the clinical confidence and decision making of emergency clinicians

    Mowlem, P.J.; Gouveia, A.; Pinn, J.; Hardy, Maryann L. (2019-02)
    Introduction: Attendance of adult patients to the Emergency Department (ED) with acute abdominal pain is a frequent event. Abdominal X-ray imaging (AXR) is commonly the first line of investigation but previous studies have suggested that the AXR has no place in assessing acute abdominal pain because of its low diagnostic yield and limited contribution to direct clinical decision making. However, no evaluation of the impact of a negative AXR on the clinical confidence and decision making of emergency clinicians has been undertaken. This study aims to fill this gap. Method: A self-designed paper questionnaire was distributed to medical clinicians on ED placement at a single NHS trust in the South of England. The survey sought to explore the impact of the negative AXR on clinical confidence and decision making and compliance with iRefer guidelines for referring to alter-native imaging modalities (ultrasound and computed tomography) should the option to refer for AXR be restricted. Results: A total of 28 (n¼28/41; 68.3%) completed questionnaires were returned. Most clinicians(n¼18/28; 64.3%) indicated that negative AXR had little impact on their clinical decision making although a small majority (n¼10/18; 55.6%) acknowledged it provided greater clinical confidence in their decision making. Variable compliance with iRefer guidelines for referral to ultrasound and computed tomography was noted. Conclusion: Whilst the negative AXR did not impact on the clinical decision making of most ED clinicians,it did increase clinical confidence. Consequently, the AXR should remain a referral option in the workup for adult patients presenting with acute abdominal pain to the emergency department.
  • Using avatars in weight management settings: a systematic review

    Horne, M.; Hill, A.; Murells, T.; Ugail, Hassan; Irving; Chinnadorai, R.; Hardy, Maryann L. (2020-03)
    Background: Obesity interventions rely predominantly on managing dietary intake and/or increasing physical activity but sustained adherence to behavioural regimens is often poor. Avatar technology is well established within the computer gaming industry and evidence suggests that virtual representations of self may impact real-world behaviour, acting as a catalyst for sustained weight loss behaviour modification. However, the effectiveness of avatar technology in promoting weight loss is unclear. Aims: We aimed to assess the quantity and quality of empirical support for the use of avatar technologies in adult weight loss interventions. Method: A systematic review of empirical studies was undertaken. The key objectives were to determine if: (i) the inclusion of avatar technology leads to greater weight loss achievement compared to routine intervention; and (ii) whether weight loss achievement is improved by avatar personalisation (avatar visually reflects self). Results: We identified 6 papers that reported weight loss data. Avatar-based interventions for weight loss management were found to be effective in the short (4–6 weeks) and medium (3–6 months) term and improved weight loss maintenance in the long term (12 months). Only 2 papers included avatar personalisation, but results suggested there may be some added motivational benefit. Conclusions: The current evidence supports that avatars may positively impact weight loss achievement and improve motivation. However, with only 6 papers identified the evidence base is limited and therefore findings need to be interpreted with caution.
  • Artificial intelligence in diagnostic imaging: impact on the radiography profession

    Hardy, Maryann L.; Harvey, H. (2020-03)
    The arrival of artificially intelligent systems into the domain of medical imaging has focused attention and sparked much debate on the role and responsibilities of the radiologist. However, discussion about the impact of such technology on the radiographer role is lacking. This paper discusses the potential impact of artificial intelligence (AI) on the radiography profession by assessing current workflow and cross-mapping potential areas of AI automation such as procedure planning, image acquisition and processing. We also highlight the opportunities that AI brings including enhancing patient-facing care, increased cross-modality education and working, increased technological expertise and expansion of radiographer responsibility into AI-supported image reporting and auditing roles.
  • From embracing to managing risks

    Keen, J.; Nicklin, E.; Wickramasekera, N.; Long., A.; Randell, Rebecca; Ginn, C.; McGinnis, E.; Willis, S.; Whittle, J. (2018-11)
    Objective: To assess developments over time in the capture, curation and use of quality and safety information in managing hospital services. Setting: Four acute National Health Service hospitals in England. Participants: 111.5 hours of observation of hospital board and directorate meetings, and 72 hours of ward observations. 86 interviews with board level and middle managers and with ward managers and staff. Results: There were substantial improvements in the quantity and quality of data produced for boards and middle managers between 2013 and 2016, starting from a low base. All four hospitals deployed data warehouses, repositories where datasets from otherwise disparate departmental systems could be managed. Three of them deployed real-time ward management systems, which were used extensively by nurses and other staff. Conclusions: The findings, particularly relating to the deployment of real-time ward management systems, are a corrective to the many negative accounts of information technology implementations. The hospital information infrastructures were elements in a wider move, away from a reliance on individual professionals exercising judgements and towards team-based and data-driven approaches to the active management of risks. They were not, though, using their fine-grained data to develop ultrasafe working practices.
  • Quality and safety between ward and board: a biography of artefacts study

    Keen, J.; Nicklin, E.; Long, A.; Randell, Rebecca; Wickramasekera, N.; Gates, C.; Ginn, C.; McGinnis, E.; Willis, S.; Whittle, J. (2018-06)
    Background: There have been concerns about the quality and safety of NHS hospital services since the turn of the millennium. This study investigated the progress that acute NHS hospital trusts have made in developing and using technology infrastructures to enable them to monitor quality and safety following the publication in 2013 of the second Francis report on the scandal at Mid Staffordshire NHS Foundation Trust (The Mid Staffordshire NHS Foundation Trust Public Inquiry. Chaired by Sir Robert Francis QC. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. HC 898. London: The Stationery Office; 2013). Methods: A telephone survey of 15 acute NHS trusts in the Yorkshire and the Humber region, and a review of board papers of all acute NHS trusts in England for January 2015, were undertaken. The telephone survey was used to identify trusts for a larger field study, which was undertaken in four acute NHS trusts between April 2015 and September 2016. The methods included the direct observation of the use of whiteboards and other technologies on two wards in each trust, an observation of board quality committees, semistructured interviews and an analysis of the quality and safety data in board papers. Published sources about national and local agencies were reviewed to identify the trust quality and safety data that these agencies accessed and used. An interview programme was also undertaken with those organisations. The Biography of Artefacts approach was used to analyse the data. Findings: The data and technology infrastructures within trusts had developed over many years. The overall design had been substantially determined by national agencies, and was geared to data processing: capturing and validating data for submission to national agencies. Trust boards had taken advantage of these data and used them to provide assurance about quality and safety. Less positively, the infrastructures were fragmented, with different technologies used to handle different quality and safety data. Real-time management systems on wards, including electronic whiteboards and mobile devices, were used and valued by nurses and other staff. The systems support the proactive management of clinical risks. These developments have occurred within a broad context, with trusts focusing on improving the quality and safety of services and publishing far more data on their performance than they did just 3 years earlier. Trust-level data suggest that quality and safety improved at all four trusts between 2013 and 2016. Our findings indicate that the technology infrastructures contributed to these improvements. There remains considerable scope to rationalise those infrastructures.
  • A realist process evaluation of robot-assisted surgery: integration into routine practice and impacts on communication, collaboration and decision-making

    Randell, Rebecca; Honey, S.; Hindmarsh, J.; Alvarado, N.; Greenhalgh, J.; Pearman, A.; Long, A.; Cope, A.; Gill, A.; Gardner, P.; et al. (2017-06)
    Background: The implementation of robot-assisted surgery (RAS) can be challenging, with reports of surgical robots being underused. This raises questions about differences compared with open and laparoscopic surgery and how best to integrate RAS into practice. Objectives: To (1) contribute to reporting of the ROLARR (RObotic versus LAparoscopic Resection for Rectal cancer) trial, by investigating how variations in the implementation of RAS and the context impact outcomes; (2) produce guidance on factors likely to facilitate successful implementation; (3) produce guidance on how to ensure effective teamwork; and (4) provide data to inform the development of tools for RAS. Design: Realist process evaluation alongside ROLARR. Phase 1 – a literature review identified theories concerning how RAS becomes embedded into practice and impacts on teamwork and decision-making. These were refined through interviews across nine NHS trusts with theatre teams. Phase 2 – a multisite case study was conducted across four trusts to test the theories. Data were collected using observation, video recording, interviews and questionnaires. Phase 3 – interviews were conducted in other surgical disciplines to assess the generalisability of the findings. Findings: The introduction of RAS is surgeon led but dependent on support at multiple levels. There is significant variation in the training provided to theatre teams. Contextual factors supporting the integration of RAS include the provision of whole-team training, the presence of handpicked dedicated teams and the availability of suitably sized operating theatres. RAS introduces challenges for teamwork that can impact operation duration, but, over time, teams develop strategies to overcome these challenges. Working with an experienced assistant supports teamwork, but experience of the procedure is insufficient for competence in RAS and experienced scrub practitioners are important in supporting inexperienced assistants. RAS can result in reduced distraction and increased concentration for the surgeon when he or she is supported by an experienced assistant or scrub practitioner. Conclusions: Our research suggests a need to pay greater attention to the training and skill mix of the team. To support effective teamwork, our research suggests that it is beneficial for surgeons to (1) encourage the team to communicate actions and concerns; (2) alert the attention of the assistant before issuing a request; and (3) acknowledge the scrub practitioner’s role in supporting inexperienced assistants. It is beneficial for the team to provide oral responses to the surgeon’s requests. Limitations: This study started after the trial, limiting impact on analysis of the trial. The small number of operations observed may mean that less frequent impacts of RAS were missed. Future work: Future research should include (1) exploring the transferability of guidance for effective teamwork to other surgical domains in which technology leads to the physical or perceptual separation of surgeon and team; (2) exploring the benefits and challenges of including realist methods in feasibility and pilot studies; (3) assessing the feasibility of using routine data to understand the impact of RAS on rare end points associated with patient safety; (4) developing and evaluating methods for whole-team training; and (5) evaluating the impact of different physical configurations of the robotic console and team members on teamwork.

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