Strengthening open disclosure in maternity services in the English NHS: the DISCERN realist evaluation study.

Background: There is a policy drive in NHS maternity services to improve open disclosure with harmed families and limited information on how better practice can be achieved. Objectives: To identify critical factors for improving open disclosure from the perspectives of families, doctors, midwives and services and to produce actionable evidence for service improvement. Design: A three-phased, qualitative study using realist methodology. Phase 1: two literature reviews: scoping review of post-2013 NHS policy and realist synthesis of initial programme theories for improvement; an interview study with national stakeholders in NHS maternity safety and families. Phase 2: in-depth ethnographic case studies within three NHS maternity services in England. Phase 3: interpretive forums with study participants. A patient and public involvement strategy underpinned all study phases. Setting: National recruitment (study phases 1 and 3); three English maternity services (study phase 2). Participants: We completed n = 142 interviews, including 27 with families; 93 hours of ethnographic observations, including 52 service and family meetings over 9 months; and interpretive forums with approximately 69 people, including 11 families. Results: The policy review identified a shift from viewing injured families as passive recipients to active contributors of post-incident learning, but a lack of actionable guidance for improving family involvement. The realist synthesis found weak evidence of the effectiveness of open disclosure interventions in the international maternity literature, but some improvements with organisation-wide interventions. Recent evidence was predominantly from the United Kingdom. The research identified and explored five key mechanisms for open disclosure: meaningful acknowledgement of harm; involvement of those affected in reviews/investigations; support for families' own sense-making; psychological safely of skilled clinicians (doctors and midwives); and knowing that improvements to care have happened. The need for each family to make sense of the incident in their own terms is noted. The selective initiatives of some clinicians to be more open with some families is identified. The challenges of an adversarial medicolegal landscape and limited support for meeting incentivised targets is evidenced. Limitations: Research was conducted after the pandemic, with exceptional pressure on services. Case-study ethnography was of three higher performing services: generalisation from case-study findings is limited. No observations of Health Safety Investigation Branch investigations were possible without researcher access. Family recruitment did not reflect population diversity with limited representation of non-white families, families with disabilities and other socially marginalised groups and disadvantaged groups. Conclusions: We identify the need for service-wide systems to ensure that injured families are positioned at the centre of post-incident events, ensure appropriate training and post-incident care of clinicians, and foster ongoing engagement with families beyond the individual efforts made by some clinicians for some families. The need for legislative revisions to promote openness with families across NHS organisations, and wider changes in organisational family engagement practices, is indicated. Examination of how far the study's findings apply to different English maternity services, and a wider rethinking of how family diversity can be encouraged in maternity services research. Study registration: This study is registered as PROSPERO CRD42020164061. The study has been assessed following RAMESES realist guidelines. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research Programme (NIHR award ref: 17/99/85) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 22. See the NIHR Funding and Awards website for further award information.

This study describes the experiences of families and healthcare professionals involved in incidents in NHS maternity care. The incidents caused harm-like injury or death to the baby or woman. We wanted to know whether services involved families in investigations and reviews and how this was done, what worked well, what did not work well and why. To do this, we first looked at what had already been written about 'open disclosure' or OD. Open disclosure is when the NHS admits to families that the care they provided has directly caused harm. After open disclosure occurs, families should be involved in making sure that the NHS learns so it can deliver better care for families in the future. In our reading, we found that families want a meaningful apology, to be involved in reviews or investigations, to know what happened to their loved one, to be cared for by knowledgeable doctors and midwives who are supported in providing open disclosure and to know things have changed because of what happened. Recommendations for involving families in open disclosure have improved, but there is still work to be done to make sure families are involved. Next, we talked to over 100 healthcare professionals involved in government policy for open disclosure in maternity services and 27 families who experienced harm. We spent 9 months observing the work of clinicians at three maternity services to watch open disclosure. We shared early findings with families, doctors, midwives and managers, and included their views. We found that services need to provide dedicated time, education and emotional support for staff who provide open disclosure. Services need to ensure that families have ongoing support and better communication about incidents. Finally, families must be involved in the review process if they want to be with their experiences reflected in reports and kept informed of ongoing improvements.

Marriage and family therapy: examining the impact of licensure on an evolving profession.

Regulatory responsibilities for the profession of marriage and family therapy have shifted from the American Association of Marriage and Family Therapy (AAMFT) to state regulatory boards. The impact of these changes has not been adequately addressed. The purpose of this article is to highlight many of these changes and explore their implications. The educational, experience, and supervision requirements of states regulating the profession of marriage and family therapy in 2007 are examined using descriptive data from 47 regulatory entities and then compared with the current (2012) regulatory standards from 51 regulatory entities. In turn, these are compared with AAMFT prelicensure clinical membership requirements. Results indicate a marked difference between AAMFT prelicensure and state licensure requirements in both 2007 and 2012, but that state requirements continue to evolve. Additionally, the changing roles of the AAMFT and the Association of Marital and Family Therapy Regulatory Boards (AMFTRB) within the profession are explored.

Effects of group therapy on female adolescent survivors of sexual abuse: a pilot study.

Treatment interventions for female sexual abuse survivors was explored through a pilot study examining the relationship between group treatment and adolescent self-image. Self-image was defined as body image, self-reliance, self-control, and impulse-control. An experimental pre-post design was utilized. Participants were 13 female adolescent high school drop-outs with a history of sexual abuse who participated in the National Guard Youth Challenge Program at Camp Shelby in Mississippi. Participants completed the Offer Self- Image Questionnaire for Adolescents. The hypothesis that group therapy was an effective intervention for sexual abuse survivors was not supported; however, this is likely due to the small sample size. Because this was a pilot study, mean trends were observed to see directional changes that may assist future researchers. Observation of mean trends revealed that participants who received group therapy increased in levels of impulse control while the group that did not receive group therapy remained the same. Mean trends also revealed that the experimental group had a decrease in self-reliance whereas the control group maintained their levels of self-reliance.