How did whistleblowing and the duty of candour get onto the agenda of the British national health service.

PURPOSE: This paper compares how the two interacting themes of "Whistleblowing" or "Speaking Up" and the duty of candour (DoC), which are both concerned with safety and quality improvement in health care, got onto the agenda of the British National Health Service (NHS). DESIGN/METHODOLOGY/APPROACH: It uses the approach of multiple streams and the methodology of interpretive content analysis in a deductive approach that focusses on both manifest and latent content. It examines official documents that discuss the DoC or whistleblowing or cognate terms in connection with the British NHS from 1999 to 2019. FINDINGS: The main conceptual finding, which mirrors many previous studies, is that it seems difficult to operationalise many of the sub-components of the multiple streams approach. The main empirical finding points to the "focusing event" of the Francis Report into the Mid Staffordshire Trust of 2013 and the importance of its Chair, Sir Robert Francis, as a policy entrepreneur. ORIGINALITY/VALUE: This is one of the first studies to focus on both issues of whistleblowing and the DoC and the first to compare them through the lens of the multiple streams approach. It has two main conceptual advantages over most previous studies in the field: it compares whistleblowing and the duty of candour rather than the dominant approach of a single case study and explores the different outcomes of failed as well as successful couplings of the streams.

What is a 'National' 'Health' 'Service'? A keyword analysis of policy documents leading to the formation of the UK NHS.

This paper explores the keywords of 'National', 'Health' and Service' in the road to the NHS in 1948. It uses a form of Qualitative Content Analysis to analyse key documents in the period leading to the 'Appointed Day' when the NHS was created in 1948. In terms of 'national', most documents favoured Local Authorities, with 'National' coming rather late in the day. For 'health', most of the documents 'talk' of a broad or 'positive' health, but they lack any specific details, and seem to focus on a narrower curative medical service. Finally, most proposals relating to 'service' are based on insurance and a '90% service', with the free and universal (100%) service arriving rather late in the period. Clearly, the three keywords could be combined in many ways, resulting in many possible types of NHS. However, bringing them together suggests that it was probably only with Beveridge onwards that the three keywords of national, health and service (citizenship) combined to form Bevan's NHS.

Modelling the Health Policy Process: One Size Fits All or Horses for Courses?

A range of conceptual models for understanding the policy process have been applied to the health policy process, largely in particular sub areas or policy domains such as public health. However, these contributions appear to offer different rationales and present different frameworks for understanding the policy process. This Editorial critically examines articles that explore the health policy process with models from wider public policy and from health policy. It can be seen that very few of the wider models have been applied in studies of the health policy process. Conversely, some models feature in studies of the health policy process, but not in the wider policy process literature, which suggests that literature on the health policy process is semi-detached from the wider policy process literature. There seem to be two very different future research directions: focusing on 'home grown' models, or taking greater account of the wider policy process literature. Does 'one size fit all' or is it 'horses for courses'?

An ultrasound-based radiomics model for survival prediction in patients with endometrial cancer.

PURPOSE: To establish a nomogram integrating radiomics features based on ultrasound images and clinical parameters for predicting the prognosis of patients with endometrial cancer (EC). MATERIALS AND METHODS: A total of 175 eligible patients with ECs were enrolled in our study between January 2011 and April 2018. They were divided into a training cohort (n = 122) and a validation cohort (n = 53). Least absolute shrinkage and selection operator (LASSO) regression were applied for selection of key features, and a radiomics score (rad-score) was calculated. Patients were stratified into high risk and low-risk groups according to the rad-score. Univariate and multivariable COX regression analysis was used to select independent clinical parameters for disease-free survival (DFS). A combined model based on radiomics features and clinical parameters was ultimately established, and the performance was quantified with respect to discrimination and calibration. RESULTS: Nine features were selected from 1130 features using LASSO regression in the training cohort, which yielded an area under the curve (AUC) of 0.823 and 0.792 to predict DFS in the training and validation cohorts, respectively. Patients with a higher rad-score were significantly associated with worse DFS. The combined nomogram, which was composed of clinically significant variables and radiomics features, showed a calibration and favorable performance for DFS prediction (AUC 0.893 and 0.885 in the training and validation cohorts, respectively). CONCLUSION: The combined nomogram could be used as a tool in predicting DFS and may assist individualized decision making and clinical treatment.

Comparing perspectives on organisational silence: an analysis of the Gosport inquiry.

PURPOSE: This paper examines different perspectives on the broad umbrella term of organisational silence. It identifies ten perspectives on organisational silence from the previous literature on inquiries into failings of British National Health Service providers. The purpose of this paper is to address these issues. DESIGN/METHODOLOGY/APPROACH: Using content analysis, it applies ten perspectives on organisational silence to the report of the inquiry into the Gosport Hospital. FINDINGS: There is some overlap between the perspectives in that they draw on the same authors, and stress similar issues. There is some evidence for most of the perspectives in the report, but some perspectives appear stronger than others. However, none of the perspectives seem to cover the full spectrum of behaviour and place differential emphasis on different processes. It is not clear whether all ten perspectives add independent analytical value. This suggests that some might be extended or combined with the umbrella term of organisational silence more fully opened. ORIGINALITY/VALUE: This is the first study in healthcare to review perspectives on organisational silence and apply them to a case study.

Learning lessons from the COVID-19 pandemic.

This study examines the literature on learning lessons from the coronavirus disease 2019 (COVID-19) pandemic to make a conceptual and empirical contribution. The conceptual contribution suggests a simplified policy transfer framework for learning lessons from the proliferation of approaches involving an expanding and confusing mix of hypotheses, questions, criteria, domains, constructs, factors and criteria. This is then used to review the literature of lessons from COVID-19. This fuses the three reasons for transfer failure and the context-mechanism- outcome configuration of realist approaches to suggest three simple criteria of informed transfer (outcomes); complete transfer (mechanisms); and appropriate transfer (context). The empirical contribution suggests that it is difficult to learn lessons from the existing literature. The conceptual framework suggests that lessons about successful transfer involve a clear idea of policy success, understanding how the policy instrument or mechanism links with success in the original context, and how 'fungible' it is to the new context. Put another way, the 'COVID lessons industry' may itself need to learn that lessons about policy transfer should be informed, complete and appropriate.

An MRI-based radiomics signature and clinical characteristics for survival prediction in early-stage cervical cancer.

OBJECTIVES: To investigate the prognostic role of magnetic resonance imaging (MRI)-based radiomics signature and clinical characteristics for overall survival (OS) and disease-free survival (DFS) in the early-stage cervical cancer. METHODS: A total of 207 cervical cancer patients (training cohort: n = 144; validation cohort: n = 63) were enrolled. 792 radiomics features were extracted from T2W and diffusion-weighted imaging (DWI). 19 clinicopathological parameters were collected from the electronic medical record system. Least absolute shrinkage and selection operator (LASSO) regression analysis was used to select significant features to construct prognostic model for OS and DFS. Kaplan-Meier (KM) analysis and log-rank test were applied to identify the association between the radiomics score (Rad-score) and survival time. Nomogram discrimination and calibration were evaluated as well. Associations between radiomics features and clinical parameters were investigated by heatmaps. RESULTS: A radiomics signature derived from joint T2W and DWI images showed better prognostic performance than that from either T2W or DWI image alone. Higher Rad-score was associated with worse OS (p < 0.05) and DFS (p < 0.05) in the training and validation set. The joint models outperformed both radiomics model and clinicopathological model alone for 3-year OS and DFS estimation. The calibration curves reached an agreement. Heatmap analysis demonstrated significant associations between radiomics features and clinical characteristics. CONCLUSIONS: The MRI-based radiomics nomogram showed a good performance on survival prediction for the OS and DFS in the early-stage cervical cancer. The prediction of the prognostic models could be improved by combining with clinical characteristics, suggesting its potential for clinical application. ADVANCES IN KNOWLEDGE: This is the first study to build the radiomics-derived models based on T2W and DWI images for the prediction of survival outcomes on the early-stage cervical cancer patients, and further construct a combined risk scoring system incorporating the clinical features.

The whistleblower stages model in British National Health Service Inquiries.

PURPOSE: This article applies the whistleblowing stages model to whistleblowing journeys as seen in British National Health Service (NHS) Inquiries. DESIGN/METHODOLOGY/APPROACH: It provides a qualitative analysis of Inquiry Reports since 2001, using Interpretive Content Analysis to allocate material to stages. FINDINGS: It is found that the Inquiry Reports show a wide variety of reporting mechanisms, but that most persons initially report internally. It seems to confirm recent suggestions that WB is often not a "one off" or simple and linear process, but a protracted process. While the simple stages model may be appropriate for individual "whistle-blowing incident" by a single whistleblower, it needs to be revised for the protracted process of raising concerns in a variety of ways by different people as shown in the Inquiry Reports. RESEARCH LIMITATIONS/IMPLICATIONS: The evidence is confined to the publicly available material that was presented in the Inquiry Reports. PRACTICAL IMPLICATIONS: It provides a template to apply to cases of whistleblowing, and provides some baseline material. ORIGINALITY/VALUE: This paper is one of the first to explore the whistleblowing stages model using qualitative material to one setting over time.

A prospective randomized controlled trial comparing two different treatments of intrauterine adhesions.

RESEARCH QUESTION: Intrauterine adhesions (IUA) are primarily caused by trauma to the endometrium, and hysteroscopy is presently the main treatment for IUA. However, high rates of post-operative adhesion re-formation remain a problem. In this study, the combination of an intrauterine device (IUD) with a Foley catheter and the balloon uterine stent were investigated to evaluate their efficacy in preventing adhesion re-formation and the subsequent reproductive outcomes in patients with moderate to severe adhesions. DESIGN: A prospective randomized controlled study was conducted in a university-affiliated hospital. A total of 171 women with Asherman's syndrome were initially recruited between August 2016 and December 2017 and were randomized to undergo either balloon uterine stent insertion or placement of a contraceptive IUD plus a Foley catheter after hysteroscopic adhesiolysis. Reduction of adhesion scores, incidence of adhesion re-formation, changes in menstrual flow and reproductive outcomes were analysed. RESULTS: A total of 118 participants were eligible for analysis. The American Fertility Society (AFS) scores were not significantly different between groups before hysteroscopic adhesiolysis. At the second-look hysteroscopy, the AFS scores and adhesion recurrence rates were significantly higher in the balloon uterine stent group compared with the combination group (P < 0.01 and P = 0.024, respectively). There were no statistically significant differences in pregnancy and live birth rates between the two groups. CONCLUSIONS: The combination of an IUD and a Foley balloon catheter had better efficacy in preventing adhesion re-formation than the balloon uterine stent alone; however, it did not produce better reproductive outcomes.

Resilience in inpatient palliative care nursing: a qualitative systematic review.

BACKGROUND: Nurses in inpatient palliative care are frequently exposed to death and dying in addition to common stressors found in other nursing practice. Resilience may mitigate against stress but remains ill-defined and under-researched in the specialist palliative care setting. OBJECTIVE: The aim of this systematic review was to understand resilience from the perspectives of inpatient palliative care nurses. DESIGN: A thematic synthesis of qualitative studies was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: Academic Search Ultimate, Cumulative Index to Nursing and Allied Health Literature, Medline Complete, PsycINFO and Scopus. REVIEW METHODS: The review stages were searching for relevant literature, selecting relevant papers, data extraction, critical appraisal and thematic synthesis. RESULTS: Eight studies revealed 10 subthemes, 3 descriptive themes and 1 analytical theme: resilience occurs when nurses incorporate stressful aspects of their personal or professional lives into a coherent narrative that enhances their ability to cope with the demands of their role. CONCLUSION: Palliative care nursing is more stressful if patients or situations remind nurses of personal experiences. Nurses cope better with adequate support; however, coping does not necessarily imply increased resilience. Resilience occurs when nurses cognitively process their experiences, articulate their thoughts and feelings into a coherent narrative, and construct a sense of meaning or purpose. Future research could explore how nurses understand resilience and how it could be enhanced in the palliative care inpatient setting. With resilience, nurses may remain in the profession longer and improve the quality of care when they do.

Whistleblowing over patient safety and care quality: a review of the literature.

PURPOSE: The purpose of this paper is to review existing research on whistleblowing in healthcare in order to develop an evidence base for policy and research. DESIGN/METHODOLOGY/APPROACH: A narrative review, based on systematic literature protocols developed within the management field. FINDINGS: The authors identify valuable insights on the factors that influence healthcare whistleblowing, and how organizations respond, but also substantial gaps in the coverage of the literature, which is overly focused on nursing, has been largely carried out in the UK and Australia, and concentrates on the earlier stages of the whistleblowing process. RESEARCH LIMITATIONS/IMPLICATIONS: The review identifies gaps in the literature on whistleblowing in healthcare, but also draws attention to an unhelpful lack of connection with the much larger mainstream literature on whistleblowing. PRACTICAL IMPLICATIONS: Despite the limitations to the existing literature important implications for practice can be identified, including enhancing employees' sense of security and providing ethics training. ORIGINALITY/VALUE: This paper provides a platform for future research on whistleblowing in healthcare, at a time when policymakers are increasingly aware of its role in ensuring patient safety and care quality.

Healthcare scandals and the failings of doctors.

PURPOSE: The purpose of this paper is to explore whether official inquiries are an effective method for holding the medical profession to account for failings in the quality and safety of care. DESIGN/METHODOLOGY/APPROACH: Through a review of the theoretical literature on professions and documentary analysis of key public inquiry documents and reports in the UK National Health Service (NHS) the authors examine how the misconduct of doctors can be understood using the metaphor of professional wrongdoing as a product of bad apples, bad barrels or bad cellars. FINDINGS: The wrongdoing literature tends to present an uncritical assumption of increasing sophistication in analysis, as the focus moves from bad apples (individuals) to bad barrels (organisations) and more latterly to bad cellars (the wider system). This evolution in thinking about wrongdoing is also visible in public inquiries, as analysis and recommendations increasingly tend to emphasise cultural and systematic issues. Yet, while organisational and systemic factors are undoubtedly important, there is a need to keep in sight the role of individuals, for two key reasons. First, there is growing evidence that a small number of doctors may be disproportionately responsible for large numbers of complaints and concerns. Second, there is a risk that the role of individual professionals in drawing attention to wrongdoing is being neglected. ORIGINALITY/VALUE: To the best of the authors' knowledge this is the first theoretical and empirical study specifically exploring the role of NHS inquiries in holding the medical profession to account for failings in professional practice.