Lessons from the Ashya King case

Children as voices and images for medicinal cannabis law reform

This article situates the movement for the legalisation of medicinal cannabis within the bigger picture of the impetus toward recreational cannabis legalisation. It describes the role played by children with epileptic syndromes in the medicinal cannabis law reform campaigns in the United Kingdom, and Queensland, New South Wales and Victoria in Australia. Noting the 'rule of rescue' and the prominence in media campaigns of children in Australian and English cases of parental disputation with clinicians about treatment for their children, it reviews whether paediatric epilepsy is a suitable test case for the legalisation of medicinal cannabis. Taking into account the vested commercial interests of Big Cannabis, the current medico-scientific knowledge of the efficacy of medicinal cannabis in controlling paediatric epileptic seizures, and issues of dignity, health privacy, and the enduring digital footprints of media coverage, the article commences discussion about the ethics of the media, parents, politicians and entrepreneurial doctors utilising parents' testimonials about the effects of medicinal cannabis as part of the cannabis law reform movement.

Scoping the literature on patient travel abroad for cancer screening, diagnosis and treatment

The incidence of cancer is on the rise globally. Under particular circumstances, patients are willing to travel abroad for healthcare treatments. We know relatively little however about patients travelling overseas for cancer-related screening, diagnosis and treatment. Where do patients go, for what treatments, what are their motivations, decision-making processes and treatment experiences? What do we know about patient safety and risk, and outcomes? More broadly, what are the ethical and legal implications? This review presents the first published assessment of what we term 'transnational oncology treatment', defined as patients travelling overseas or across borders for cancer screening, diagnosis and treatment. The review undertakes detailed search and retrieval of the literature, using an accepted scoping review method. We present a narrative review of existing knowledge and themes, identifying coverage and gaps. There is a five-fold agenda for future investigation: trajectories and itineraries; in depth focus on treatment decisions, experiences and outcomes; locating patient travel within wider health system analysis; exploration of professional perspectives and coordination; and situating travel within the context of health trade. Such an agenda is multidisciplinary and wide-ranging, encompassing epidemiology, health economics, health policy ethics, health politics, health management, and health policy.

Reducing healthcare conflict: outcomes from using the conflict management framework

OBJECTIVE

To test a new conflict management framework (CMF) to help staff identify and de-escalate conflict between staff and patients/families.

DESIGN

Before/after study that reports staff quality of life, frequency/severity of conflicts and qualitative interviews on using the framework. Data were collected from May 2017 to September 2017.

SETTING

A paediatric oncology department day-patient and 23-bed inpatient ward.

INTERVENTION

A two-stage CMF used by staff during daily handovers to identify and then manage conflict cases with families.

RESULTS

Staff found the CMFto be helpful in identifying and de-escalating conflicts. The number of conflicts reported decreased by 64% from baseline to follow-up. Communication regarding conflict identification improved. Reports of staff burn-out decreased between the two time-points (n=55 at baseline, n=31 at follow-up; p=0.001). Scores on compassion and secondary traumatic stress did not change.

CONCLUSIONS

The CMF substantially reduces the incidence of conflicts and is an acceptable approach for staff. Continued use of the framework would require it to be fully integrated into the working of the ward, which would need to include senior medical buy-in. Further refinements to the framework have been made and will be tested in four UK sites in 2018/2019.

Training paediatric healthcare staff in recognising, understanding and managing conflict with patients and families: findings from a survey on immediate and 6-month impact

BACKGROUND

Conflict is a recognised component of healthcare. Disagreements about treatment protocols, treatment aims and poor communication are recognised warning signs. Conflict management strategies can be used to prevent escalation, but are not a routine component of clinical training.

OBJECTIVE

To report the findings from a novel training intervention, aimed at enabling paediatric staff to identify and understand the warning signs of conflict, and to implement conflict resolution strategies.

DESIGN AND SETTING

Self-report measures were taken at baseline, immediately after the training and at 6 months. Questionnaires recorded quantitative and qualitative feedback on the experience of training, and the ability to recognise and de-escalate conflict. The training was provided in a tertiary teaching paediatric hospital in England over 18 months, commencing in June 2013.

INTERVENTION

A 4-h training course on identifying, understanding and managing conflict was provided to staff.

RESULTS

Baseline data were collected from all 711 staff trained, and 6-month follow-up data were collected for 313 of those staff (44%). The training was successful in equipping staff to recognise and de-escalate conflict. Six months after the training, 57% of respondents had experienced conflict, of whom 91% reported that the training had enabled them to de-escalate the conflict. Learning was retained at 6 months with staff more able than at baseline recognising conflict triggers (Fischer's exact test, p=0.001) and managing conflict situations (Pearson's χ² test, p=0.001).

CONCLUSIONS

This training has the potential to reduce substantially the human and economic costs of conflicts for healthcare providers, healthcare staff, patients and relatives.

Conflict in a paediatric hospital: a prospective mixed-method study

BACKGROUND

Conflict in healthcare is a well-recognised but under-examined phenomenon. Little is known about the prevalence and causes of conflict across paediatric specialties.

OBJECTIVE

To report the frequency and characteristics of conflict in a paediatric hospital.

DESIGN AND SETTING

An explanatory sequential mixed-method approach was adopted. A bespoke questionnaire recorded frequency, severity, cause and staff involved in conflict prospectively. Data were recorded for the same two 12-week periods in 2013 and 2014, in one UK children's teaching hospital. Data were analysed using descriptive statistics and correlation, the findings of which informed the construction of a semistructured interview schedule. Qualitative interviews were conducted with six key informant healthcare professionals to aid data interpretation; interviews were analysed thematically.

RESULTS

136 individual episodes of conflict were reported. The three most common causes were 'communication breakdown', 'disagreements about treatment' and 'unrealistic expectations'. Over 448 h of healthcare professional time was taken up by these conflicts; most often staff nurses, consultants, doctors in training and matrons. The mean severity rating was 4.9 out of 10. Qualitative interviews revealed consensus regarding whether conflicts were ranked as low, medium or high severity, and explanations regarding why neurology recorded the highest number of conflicts in the observed period.

CONCLUSIONS

Conflict is prevalent across paediatric specialties, and particularly in neurology, general paediatrics and neonatology. Considerable staff time is taken in managing conflict, indicating a need to focus resources on supporting staff to resolve conflict, notably managing communication breakdown.

Conflict escalation in paediatric services: findings from a qualitative study

OBJECTIVE

To explore clinician and family experiences of conflict in paediatric services, in order to map the trajectory of conflict escalation.

DESIGN

Qualitative interview study, employing extreme-case sampling. Interviews were analysed using an iterative thematic approach to identify common themes regarding the experience and escalation of conflict.

PARTICIPANTS

Thirty-eight health professionals and eight parents. All participants had direct experience of conflict, including physical assault and court proceedings, at the interface of acute and palliative care.

SETTING

Two teaching hospitals, one district general hospital and two paediatric hospices in England, in 2011.

RESULTS

Conflicts escalate in a predictable manner. Clearly identifiable behaviours by both clinicians and parents are defined as mild, moderate and severe. Mild describes features like the insensitive use of language and a history of unresolved conflict. Moderate involves a deterioration of trust, and a breakdown of communication and relationships. Severe marks disintegration of working relationships, characterised by behavioural changes including aggression, and a shift in focus from the child's best interests to the conflict itself. Though conflicts may remain at one level, those which escalated tended to move sequentially from one level to the next.

CONCLUSIONS

Understanding how conflicts escalate provides clinicians with a practical, evidence-based framework to identify the warning signs of conflict in paediatrics.