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The organ shortage and the increasing demand for organs are universal, worldwide challenges. Health literacy is a powerful tool that can help to increase awareness about organ donation and transplantation on a large scale and to encourage and sustain support for organ donation. The unique perspectives, experiences, and expectations of medical students, renal patients, and hospital administrative staff across the UK, Netherlands, and Spain on the topic of health literacy (HL) campaigns regarding deceased organ donation (DOD) were recorded in a cross-cultural, qualitative study. Focus group discussions enabled participants to express their views on existing HL campaigns and to propose novel pathways for future campaigns.

BackgroundAs systems become more complex, shared leadership (SL) has been suggested to have a dominant role in improving cross-functional working tailored to organisational needs. Little, however, is known about the benefits of SL in healthcare management, especially for UK’s recently formed integrated care system (ICS). The aim of this study was to understand current attitudes, barriers and needs of clinical and non-clinical managers sharing leadership responsibilities in the ICS.MethodTwenty clinical and non-clinical leaders in 15 organisations were interviewed to understand current cross-functional leadership collaborations, and the potential SL may have on the recently established ICS in the National Health Service (NHS). The data were transcribed and analysed thematically.ResultsFindings showed perceptions and experiences of clinical and non-clinical healthcare management in relation to: (1) motivation to execute a leadership position, including the need to step up and a sense of duty; (2) attitudes towards interdisciplinary working, which is reflected in conflicts due to different values and expertise; (3) SL skills and behaviours, including the need for mutual understanding and cooperative attitudes by means of effective communication and collaboration; and (4) barriers to achieve SL in the ICS, such as bureaucracy, and a lack of time and support.ConclusionsSL may help improve current leadership cultures within the NHS; however, for SL to have a tangible impact, it needs to be delivered as part of leadership development for doctors in postgraduate training, and development programmes for aspiring, emerging and established leaders, with clear lines of communication.

This article was published in International Journal of Stress Management on 24 August 2017 (online), available at http://dx.doi.org/10.1037/str0000079

Background and importance User interface design features, such as screen layout, density of information, position of messages and use of colour, may affect the usability of electronic prescribing (EP) systems, with usability problems previously associated with medication errors. Aim and objectives To explore users’ perspectives of the on-screen design features of a commercially available EP system and how these are perceived to affect patient safety. Material and methods The study was conducted at a large London teaching hospital during 2018–2019. Participants were recruited via adverts on the intranet; all prescribers with experience using the EP system were eligible to participate. We used a mixed qualitative approach. First, prescribers were asked to conduct a prescribing task for a simulated patient using a think aloud approach. Second, we conducted a semi-structured interview with each participant to explore their views in more detail, with a focus on patient safety. Interview questions were developed based on the literature and then piloted. Think aloud and interview transcripts were analysed inductively using a thematic approach. Ethics approval was obtained. Results Ten participants took part (three registrars, three foundation year 1 doctors, two foundation year 2 doctors and two pharmacist prescribers). Key themes from the think aloud and interview transcripts included: (1) EP design features and process flow; (2) benefits of EP systems; and (3) suggestions for improvement. For instance, design features such as screen features and layout were discussed with regards to impact on workflow, as well as ‘information overload’. Suggestions for improvement were made in relation to embedding trust guidelines and making changes to system design (eg, colour, fonts, customisation) to increase information visibility and enhance overall attention. Lastly, a need was expressed for better support for interacting with patients while using the system, as well as making drug–drug interaction alerts more targeted to support medication safety while also avoiding alert fatigue. Conclusion and relevance We identified specific interface design factors that may improve the usability and/or safety of EP systems, which can be used to inform future experimental research in this area. Limitations include the small sample size; further work should include similar studies on other EP systems. References and/or acknowledgements Conflict of interest Corporate sponsored research or other substantive relationships: I supervise a PhD student who is partly funded by a supplier of a commercial electronic prescribing system.

Background and importance User interface design can have a significant impact on interactions with online systems. Eye tracking is generally accepted as a useful method to study performance in areas such as interpretation of medical imaging. However, there is little evidence of its use to study user interactions with electronic prescribing (EP) systems, an area in which failure to see and act on key information is particularly critical. Aim and objectives To explore the feasibility of using eye tracking to study EP users’ visual attention and behaviour, with a focus on safe prescribing. Material and methods The study took place at a London teaching hospital from 2018 to 2019. Participants were recruited via the organisation’s intranet. Any prescriber with experience of the EP system was eligible to participate. We used Tobii Pro X3-120 integrated screen monitor trackers in a simulation setting. Participants were asked to complete a prescribing task for a test patient, which included prescribing penicillin for a patient with a penicillin allergy. Data collected included videos of the screen showing the participant’s scan paths. We segmented the data according to when the user switched screens, and calculated percentage of time spent looking in each of the four quadrants of the screen for each. The study was approved as a service evaluation. Results Ten prescribers participated. Overall, the highest percentages of fixation points were at the top left and right corners of the screen, where information is provided on allergies and patient information, respectively. However, each prescriber initially prescribed a penicillin and was stopped only by a pop-up alert. The highest number of fixation points was observed during review of the prescription and final signature, followed by review of the allergy alert and the search for drug names and dosages. Conclusion and relevance Eye tracking is a feasible method for studying EP interactions. The findings will be used to plan a larger evaluation, with the aims of understanding how screen design can help or hinder patient safety, and how type and positioning of decision support information influences the likelihood of it being acted on. Limitations include small sample size; further work should also explore how gaze patterns may differ between novices and experts. References and/or acknowledgements Conflict of interest Corporate sponsored research or other substantive relationships: I supervise a PhD student who is part funded by a supplier of a commercial electronic prescribing system.

Background Small group research in healthcare is important because it deals with interaction and decision-making processes that can help to identify and improve safer patient treatment and care. However, the number of studies is limited due to time- and resource-intensive data processing. The aim of this study was to examine the feasibility of using signal processing and machine learning techniques to understand teamwork and behaviour related to healthcare management and patient safety, and to contribute to literature and research of teamwork in healthcare. Methods Clinical and non-clinical healthcare professionals organised into 28 teams took part in a video- and audio-recorded role-play exercise that represented a fictional healthcare system, and included the opportunity to discuss and improve healthcare management and patient safety. Group interactions were analysed using the recurrence quantification analysis (RQA; Knight et al., 2016), a signal processing method that examines stability, determinism, and complexity of group interactions. Data were benchmarked against self-reported quality of team participation and social support. Transcripts of group conversations were explored using the topic modelling approach (Blei et al., 2003), a machine learning method that helps to identify emerging themes within large corpora of qualitative data. Results Groups exhibited stable group interactions that were positively correlated with perceived social support, and negatively correlated with predictive behaviour. Data processing of the qualitative data revealed conversations focused on: (1) the management of patient incidents; (2) the responsibilities among team members; (3) the importance of a good internal team environment; and (4) the hospital culture. Conclusions This study has shed new light on small group research using signal processing and machine learning methods. Future studies are encouraged to use these methods in the healthcare context, and to conduct further research on how the nature of group interaction and communication processes contribute to the quality of team and task decision-making. Electronic supplementary material The online version of this article (10.1186/s12874-019-0756-2) contains supplementary material, which is available to authorized users.

Purpose Research in psychology or management science has shown that shared leadership (SL) enhances information sharing, fosters participation and empowers team members within the decision-making processes, ultimately improving the quality of performance outcomes. Little has been done and, thus, less is known of the value and use of SL in acute healthcare teams. The purpose of this study is to (1) explore, identify and critically assess patterns and behaviour of SL in acute healthcare teams; and (2) evaluate to what extent SL may benefit and accomplish safer care in acute patient treatment and healthcare delivery. Design/methodology/approach The authors conducted a review that followed the PRISMA-P reporting guidelines. A variety of sources were searched in April 2018 for studies containing primary research that focused on SL in acute healthcare teams. The outcome of interest was a well-specified assessment of SL, and an evaluation of the extent SL may enhance team performance, lead to safer patient care and healthcare delivery in acute healthcare teams. Findings After the study selection process, 11 out of 1,383 studies were included in the review. Studies used a qualitative, quantitative or mixed-methods approach. Emerging themes based on behavioural observations that contributed to SL were: shared mental model; social support and situational awareness; and psychological safety. High-performing teams showed more SL behaviour, teams with less seniority displayed more traditional leadership styles and SL was associated with increased team satisfaction. Research limitations/implications Evidence to date suggests that SL may be of benefit to improve performance outcomes in acute healthcare team settings. However, the discrepancy of SL assessments within existing studies and their small sample sizes highlights the need for a large, good quality randomized controlled trial to validate this indication. Originality/value Although studies have acknowledged the relevance of SL in healthcare service and delivery, a systematic, evidence-based and robust evaluation of behavioural patterns and the benefits of SL in this field is still missing.

Simulation has been applied as a tool for learning and training in sports, psychology and medicine for some time, but its current use and potential for training musicians is less well understood. The aim of this study was to explore musicians’ perceptions and experiences of using simulated performance environments. Nine conservatory students performed in two simulations, each with interactive virtual elements and vivid environmental cues: a recital with a virtual audience and an audition with virtual judges. Qualitative data were collected through a focus group interview and written reflective commentaries. Thematic analysis highlighted the musicians’ experiences in terms of (1) their anticipation of using the simulations, (2) the process of performing in the simulations, (3) the usefulness of simulation as a tool for developing performance skills and (4) ways of improving simulation training. The results show that while simulation was new to the musicians and individual levels of immersion differed, the musicians saw benefits in the approach for developing, experimenting with and enhancing their performance skills. Specifically, the musicians emphasised the importance of framing the simulation experience with plausible procedures leading to and following on from the performance, and they recognised the potential for combining simulation with complementary training techniques.

Simulation has been applied as a successful training, however, an investigation of its effect with implications for musical performance training is still lacking. The aim of this study was to explore the impact of positive and negative simulated feedback on musicians’ performance confidence (PC), perceived performance quality (PQ), state anxiety (SA) and heart rate variability (HRV). Twelve musicians performed the same piece three times: twice in front of three interactive virtual ‘judges’ with positive and negative facial and behavioural feedback and a ‘no judges but identical environment’ control. PC and SA were reported before and after each performance, while musicians’ perceived PQ was addressed after. The HRV was monitored throughout. Using Generalised Estimating Equations to examine relationships between physiological and psychological responses and condition, the results showed a significant influence of condition, with the positive feedback resulting in the highest physiological arousal and PQ ratings. Musicians who experienced an increase in SA before the performance showed a lower HRV during the performance. The SA and PC significantly predicted the PQ, with lower levels of SA and greater degrees of PC leading to a higher perceived PQ. Results are discussed in the light of simulation training.

Auditioning is at the very center of educational and professional life in music and is associated with significant psychophysical demands. Knowledge of how these demands affect cardiovascular responses to psychosocial pressure is essential for developing strategies to both manage stress and understand optimal performance states. To this end, we recorded the electrocardiograms (ECGs) of 16 musicians (11 violinists and 5 flutists) before and during performances in both low- and high-stress conditions: with no audience and in front of an audition panel, respectively. The analysis consisted of the detection of R-peaks in the ECGs to extract heart rate variability (HRV) from the notoriously noisy real-world ECGs. Our data analysis approach spanned both standard (temporal and spectral) and advanced (structural complexity) techniques. The complexity science approaches—namely, multiscale sample entropy and multiscale fuzzy entropy—indicated a statistically significant decrease in structural complexity in HRV from the low- to the high-stress condition and an increase in structural complexity from the pre-performance to performance period, thus confirming the complexity loss theory and a loss in degrees of freedom due to stress. Results from the spectral analyses also suggest that the stress responses in the female participants were more parasympathetically driven than those of the male participants. In conclusion, our findings suggest that interventions to manage stress are best targeted at the sensitive pre-performance period, before an audition begins. *** For a video summary of this article please see http://researchonline.rcm.ac.uk/id/eprint/1809/ ***

Music is increasingly recognised as important in facilitating healthy ageing, yet little is known of what musicians themselves learn when they teach older adults. This article reports the practices of the Rhythm for Life project at the Royal College of Music in the UK, in which conservatoire students taught 10-week programmes of group instrumental music lessons to adult beginners aged between 46 and 90 years. In order to interrogate what four student-teachers learned from their engagement with the project, qualitative data were collected through open-ended questionnaires, diaries and video-stimulated recall interviews. Findings demonstrated that the student-teachers reformulated the ways in which they thought about and taught older adult learners, and developed skills and knowledge relevant to a wide range of educational contexts. The article concludes that models similar to Rhythm for Life, where conservatoires facilitate opportunities for students to teach older adults, may be an effective means of establishing meaningful learning experiences for music students and older adults alike.

Cooperative tasks require coordinated joint actions among the participants, to the extent that a failure in an individual's action may have catastrophic consequences on the task of the group as a whole. One such activity is choir singing, where highly synchronised performance of the individual singers is a prerequisite to successful performance. The aim of this work is to provide a quantitative measure of the level of cooperation, established through the degrees of synchronisation between singers' physiological responses. To this end, we employ two new measures, the intrinsic phase synchrony and intrinsic coherence, which quantify synchronisation in respiration and heart rate variability (HRV) of: (i) five members of a choir and the conductor during a rehearsal and a real performance, and (ii) five members of the audience attending the performance. Both the proposed techniques successfully reveal degrees of synchronisation of singers' physiological signals which can be used as physically meaningful measures of the level of cooperation.

Performing music in public is widely recognized as a potentially stress-inducing activity. However, despite the interest in music performance as an acute psychosocial stressor, there has been relatively little research on the effects of public performance on the endocrine system. This study examined the impact of singing in a low-stress performance situation and a high-stress live concert on levels of glucocorticoids (cortisol and cortisone) in 15 professional singers. The results showed a significant decrease in both cortisol and cortisone across the low-stress condition, suggesting that singing in itself is a stress-reducing (and possibly health-promoting) activity, but significant increases across the high-stress condition. This is the first study to demonstrate that singing affects cortisol as well as cortisone responses and that these responses are modulated by the conditions of performance. *** For a video summary of this article please see http://researchonline.rcm.ac.uk/id/eprint/1808/ ***

Musicians typically rehearse far away from their audiences and in practice rooms that differ significantly from the concert venues in which they aspire to perform. Due to the high costs and inaccessibility of such venues, much current international music training lacks repeated exposure to realistic performance situations, with students learning all too late (or not at all) how to manage performance stress and the demands of their audiences. Virtual environments have been shown to be an effective training tool in the fields of medicine and sport, offering practitioners access to real-life performance scenarios but with lower risk of negative evaluation and outcomes. The aim of this research was to design and test the efficacy of simulated performance environments in which conditions of “real” performance could be recreated. Advanced violin students (n = 11) were recruited to perform in two simulations: a solo recital with a small virtual audience and an audition situation with three “expert” virtual judges. Each simulation contained back-stage and on-stage areas, life-sized interactive virtual observers, and pre- and post-performance protocols designed to match those found at leading international performance venues. Participants completed a questionnaire on their experiences of using the simulations. Results show that both simulated environments offered realistic experience of performance contexts and were rated particularly useful for developing performance skills. For a subset of 7 violinists, state anxiety and electrocardiographic data were collected during the simulated audition and an actual audition with real judges. Results display comparable levels of reported state anxiety and patterns of heart rate variability in both situations, suggesting that responses to the simulated audition closely approximate those of a real audition. The findings are discussed in relation to their implications, both generalizable and individual-specific, for performance training.