Evolution of Cleft Lip and Palate Surgical Training in the UK: A Qualitative Study.

BACKGROUND: Although the United Kingdom (UK) cleft surgeons follow a similar training pathway, and cleft centers adhere to similar protocols regarding the timing of palate surgery and surgical technique, speech outcomes still vary between centers. OBJECTIVE: To explore the training experiences of consultant cleft lip and palate (CL/P) surgeons, performing a Sommerlad radical intravelar veloplasty (IVVP) and their approach to teaching others. DESIGN: An exploratory, qualitative approach was adopted to understand the views of UK cleft surgeons performing a Sommerlad radical IVVP and discuss what was important during training and upon qualifying as a consultant. METHOD: A semi-structured interview schedule was designed, interviews were conducted in-person or via videoconferencing, depending on preference and availability, with interested surgeons. The interviews were recorded, transcribed, and checked for accuracy. Analysis involved inductive thematic analysis. RESULTS: Fourteen cleft consultants from the UK participated (3F:11M). Seven of the consultants were trained in plastic surgery and four in maxillofacial surgery. Seven themes were identified from the thematic analysis. Three themes, namely Learning to perform palate repair, Teaching others to perform palate repair, and Ongoing learning as a consultant are discussed. CONCLUSIONS: Cleft palate repair is clearly a technically challenging procedure to learn and teach with the potential to cause harm if performed incorrectly. Positive changes have been made to improve exposure to palate surgery, encourage practice away from the patient, and increase supervised practical experience. The role of colleagues in providing mentorship and support appears invaluable. We provide some simple recommendations that may improve the training experience and ensure parity for all trainees.

Surgical Variation Between Consultant Surgeons Performing a Sommerlad Radical Intravelar Veloplasty.

BACKGROUND: Although cleft surgeons in the United Kingdom follow a similar training pathway, and cleft centers adhere to similar protocols regarding timing of palate surgery and surgical technique, speech outcomes still vary significantly between centers. OBJECTIVE: To explore if differences in technique exist between individual surgeons, performing a Sommerlad radical intravelar veloplasty (IVVP). DESIGN: An exploratory, qualitative approach was adopted to understand the views of UK cleft surgeons performing a Sommerlad radical IVVP for primary cleft palate repair and to discuss what was important in the adoption, adaptation, and evolution of this technique within their own practice. METHOD: A semistructured interview schedule was designed. Interviews were conducted in person or via videoconferencing, with interested surgeons. The interviews were recorded, transcribed, and checked for accuracy. Analysis involved inductive thematic analysis. RESULTS: Fourteen cleft consultants from the United Kingdom participated (3 females and 11 males). Seven of the consultants were trained in plastic surgery and 4 in oral and maxillofacial surgery. Eight themes were identified from the thematic analysis. One theme-Surgical Variation-is discussed. CONCLUSIONS: The findings provide insight into areas of variation seen within one surgical technique of cleft palate repair. These variations may have arisen to accommodate heterogeneity in the patient population or may have evolved in relation to different experiences of training or influences of colleagues. Further work is needed to explore the reasons for these differences in technique and to identify if any of these subtle differences contributed to variability in outcomes.

The Construal of Midwives by Pregnant Women with a Body Mass Index Greater Than or Equal to 30 kg/m2 (BMI ≥ 30 kg/m2 ): A Repertory Grid Study.

OBJECTIVE: To explore the construal of midwives by pregnant women with a body mass index greater than 30 kg/m2 (BMI ≥ 30 kg/m2 ). METHOD: Ten pregnant women with a BMI ≥ 30 kg/m2 were recruited from antenatal clinics at a maternity hospital in the North West of England. Each participant completed a repertory grid. The participants chose people to match roles including themselves, pregnant women, midwives of different BMIs and hypothetical elements. They also generated psychological constructs to describe them. RESULTS: Pregnant women with a BMI ≥ 30 kg/m2 construed themselves as vulnerable and self-conscious. Some women endorsed obesity-related stereotypes for themselves and felt responsible for their weight. The midwife with a BMI 18 < 30 kg/m2 was considered to be most similar to the ideal midwife, while the midwife with a BMI ≤ 18 kg/m2 was construed as having an undesirable interpersonal style. The midwife with a BMI ≥ 40 kg/m2 was often construed as sharing similar experiences to the pregnant women with a BMI ≥ 30 kg/m2 , such as struggling with the psychological consequences of a raised BMI. Some women construed the midwife with a BMI 30 < 40 kg/m2 in a positive way, whereas others viewed it as sharing similar feelings about weight as the midwife with a BMI ≥ 40 kg/m2 . CONCLUSIONS: The pregnant women with a BMI ≥ 30 kg/m2 in this study described perceptions of themselves and the midwives responsible for their care, which may affect their engagement and satisfaction with services. Pregnant women with a BMI ≥ 30 kg/m2 should be involved in service development activities to ensure the structure of services and the language used by midwives are acceptable and do not confirm weight-related stereotypes. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Pregnant women with a BMI ≥ 30 kg/m2 construe themselves as vulnerable and self-conscious and perceive themselves responsible for their weight. Pregnant women with a BMI ≥ 30 kg/m2 construe midwives with a low BMI as having an undesirable, cold, interpersonal style. Midwives with a raised BMI are construed as similar to the women, because they share the uncomfortable psychological consequences of a raised BMI. The nature of pregnant women's construal may affect their engagement and satisfaction with maternity services and midwifery care.

The attitudes of pregnant women and midwives towards raised BMI in a maternity setting: A discussion of two repertory grid studies.

OBJECTIVES: Weight-related stereotypes may have a detrimental impact on interactions between midwives and pregnant women with a body mass index (BMI) outside the recommended range of 18-30kg/m2. This paper explores the reciprocal construal of midwives and pregnant women with a raised BMI and considers the clinical implications of these constructs. PARTICIPANTS: Ten pregnant women with a BMI≥30kg/m2 and 11 midwives and from an inner city maternity service were recruited. INTERVENTION: Participants provided information that allowed for the creation of a repertory grid; generating psychological constructs (perceptions or attitudes) identifying similarities and differences between pregnant women and midwives across a BMI range. FINDINGS: Midwives were extremely conscious of being perceived as judgemental. They construed all pregnant women as anxious and vulnerable, but attributed characteristics such as "less health-conscious" and "complacent" to those with a raised BMI. The ideal pregnant woman and ideal midwife were typically construed as more likely to have a BMI of 18-30kg/m2. Pregnant women with a BMI≤18kg/m2 were construed as lacking warmth. While midwives differentiated between the elements based on role, the pregnant women construed the elements according to their BMI. Similarly, they construed those with a BMI≤18kg/m2 as having an undesirable personality, and acknowledged weight-related stereotypes for those with a raised BMI. CLINICAL IMPLICATIONS: It is possible these constructs impact on the way midwives care for and interact with women. Midwives may be supported through reflective clinical supervision and communication skills training to reduce the perceptions of stigma experienced by women with a raised BMI. It may be beneficial to involve pregnant women with a raised BMI in service development to ensure services meet their needs.

Women's experiences of their pregnancy and postpartum body image: a systematic review and meta-synthesis.

BACKGROUND: Pregnancy-related physical changes can have a significant impact on a woman's body image. There is no synthesis of existing literature to describe the intricacies of women's experiences of their body, and relevant clinical implications. METHODS: Four electronic databases were searched in February 2014 using predefined search terms. English-language, qualitative studies published between January 1992 and December 2013 exploring pregnancy and postpartum body image were included. Following quality appraisal, 17 papers were synthesised using the interpretive thematic synthesis approach within a social constructionist framework. RESULTS: Three themes were highlighted: "Public Event: 'Fatness' vs. Pregnancy", "Control: Nature vs. Self", and "Role: Woman vs. Mother". Women perceived the pregnant body to be out of their control and as transgressing the socially constructed ideal, against which they tried to protect their body image satisfaction. Women perceived the physical manifestation of the mothering role as incongruent to their other roles as a wife or partner, or working woman. Body dissatisfaction dominated the postpartum period. CONCLUSIONS: Women's perception of their pregnancy body image is varied and depends on the strategies they use to protect against social constructions of female beauty. Women have unrealistic expectations for their postpartum body, highlighting this as an area where women need better support. Attending to women's narratives about their pregnant body may identify at-risk women and provide an opportunity for health professionals to provide support to either address or accept body image dissatisfaction. Clinical communication training may enable health professionals to explore body image concerns with women and guide them in identifying ways of accepting or reducing any dissatisfaction.