by Chris Course, Chair WREN

Summary  
The Welsh Research and Eduction Network (WREN) Spring Study Day took place at the Princess of Wales Hospital, Bridgend on 11th May 2018.  Once again, attendance was well supported by doctors from across the training grades (and an Advanced Neonatal Nurse Practitioner!), as well as Dr Huma Mazhar (from Singleton Hospital), Dr Naomi Simmons (from Glan Clwyd Hospital) and Dr Judith van der Voort (Head of School) joining us for the day to learn more about how the network is getting on and our current activities.

Our educational programme was once again diverse, with talks from Dr Phil Connor and Rhian Thomas-Turner about the new Children and Young Adult’s Research Unit at Noah’s Ark Children’s Hospital for Wales and their plans for increasing junior doctor involvement. Dr Ian Morris then gave an excellent strategy for rapid-fire critical appraisal, with an emphasis on the START assessment (slides available on our website, or on request). Dr Gethin Pugh from the Quality Improvement Skills Team at the Wales Deanery also gave us an introductory workshop to Quality Improvement, as well as teaching us the basics of the Plan, Do, Act, Study model and signposting the further QI training opportunities available.

The WREN Blog continues to go from strength to strength and now receives over 500 hits a month on our articles, under the editorial leadership of Dr Rebecca Broomfield and Dr Annabel Greenwood. They are looking for contributors too, so if you have something to share or a topic you’d love to write about, please get in touch.

Four new projects are being undertaken via the network, three of which are starting now. Details of the WREN projects and their project leads are below. Project leads can be contacted on the Current Project Portfolio page. We will be disseminating these projects amongst the units, but if you would like to get involved in any of the projects in WREN’s current portfolio, please contact the project leads (details below). If you have an idea for a project you would like to develop with WREN’s help, please contact either myself or Siwan Lloyd via our website, or using the details at the top of this newsletter.

The next WREN study day is planned for November 2018 (confirmed date to follow), and we hope that you will be able to join us for another stimulating and thought-provoking study day, building on from the success of the last!

Newly Launched Projects
Project Title: ‘The Impact of the Meningococcal B Vaccination on Septic Screens’
Project Leads: Dr Ele Jones (ST5) and Dr Rebecca Towler (ST5)
Description: Pyrexia is a common adverse effect of the Meningocccal B vaccination. NICE guidelines exist for the management of fever <3 months of age and recommends investigations for sepsis for pyrexial infants but does not make comment of post-vaccination infants. This project aims to retrospectively assess how infants are managed in paediatric and neonatal units who are presenting with fever post-Meningococcal B vaccination over a 12-month period.

Project Title: ‘Aiming to improve paediatric trainees confidence with ECG interpretation’
Project Leads: Dr Ankita Jain (ST6)
Description: The Paediatric Cardiology department at UHW gets several referrals a month from various hospitals to provide their opinion on ECGs done on children for various clinical indications. We would like to help improve confidence in paediatric ECG interpretation, and have developed a structured online educational module.  Using a pre- and post-quiz on ECG interpretation it is hoped to show how skills can be improved.  The link for the quiz is https://goo.gl/forms/2Qj8NBZHBdOYL33d2

Project Title: ‘Can a resus drug App help improve accuracy and reduce stress in time-critical scenarios?’
Project Lead: Dr  Jordan Evans (ST5)
Description: Accurate calculation of WETFLAG resus drugs is critical, but can be affected by stress and the time-critical nature of emergency scenarios. This project aims to assess whether a smartphone app can help to improve prescribing accuracy and reduce doctor stress levels in resus situations.  A pilot study has shown an App to be effective, and this project aims to assess larger numbers of doctors and nurses using the technology in simulated scenarios.

Ongoing Projects
Project Title: ‘Head injuries on the postnatal wards’
Project Lead: Siwan Lloyd, ST3
Description: A pilot study at UHW has demonstrated that infants being accidentally dropped on the postnatal ward is not an uncommon occurrence, however their management and level of investigation following injury was very variable. Following on from this, an all Wales study is underway to determine the incidence, risk factors and management used, with the aim of producing a best practice guideline for these infants and their parents.

Project Title: ‘Re-audit of the Management of Respiratory Distress Syndrome in Preterm Infants’
Project Lead: Chris Course, ST4
Description: Following the initial audit in 2014/2015 by WREN, a Wales Neonatal Network guideline was introduced for the Management of RDS in Preterm Infants in June 2016. The re-audit has commenced March 2018 and is running for six months to assess how the new national guideline has affected patient care.

Project Title: ‘Management of feverish illness in infants <3 months old’
Project Lead: Blanche Lumb, ST1
Description: Do we consistently meet the NICE standards set in the investigation of sepsis in <3 month old infants? This project aims to assess that the appropriate investigations occur in a timely manner, and that appropriate empirical treatment is commenced across paediatric assessment units in Wales. Where we chose to deviate from the guidance, are we documenting this appropriately?​

Upcoming Projects (Planned Start September 2018)
Project Title: ‘Evaluating the impact of the introduction of the SEREN program on Type 1 Diabetes Management in Children’
Project Lead: Matthew Ryan, ST6
Description: SEREN is a structured education package for children newly diagnosed with T1DM. This project will assess SEREN’s impact by using Quality of Life questionnaires, serial HbA1c measurements and number of DKA admissions for children diagnosed with T1DM in the years pre and post introduction.

Dr Annabel Greenwood

As Trainee Representative for Paediatric and Neonatal Organ Donation for Cardiff and the Vale Health Board, I was very much looking forward to this opportunity to spread the word and raise awareness about organ donation.

The concept of organ donation in paediatric practice is relatively new but currently very topical, and a recent article in the March edition of Archives of Disease in Childhood highlighted the fact that despite recent attempts to promote organ donation, donation rates remain fairly static, particularly in the neonatal intensive care setting.

The knowledge and experience of paediatric organ donation amongst healthcare professionals is limited, and it was therefore of no surprise that when we enquired at the beginning of the simulation day whether participants had ever been involved in a case of organ donation, only two had previous experience, one of which was in adult medicine. 

The paediatric simulation day was the first of its kind in Wales, and it was fantastic to see such a wide variety of the multidisciplinary team in attendance, all enthusiastic to learn more about organ donation and the processes involved.

The day began with a case presentation from Gail Melvin, one of the brilliant ‘SNODs’ (Specialist Nurse in Organ Donation).  She recalled one of her experiences of neonatal organ donation and it provided a great insight into the referral process from the consideration of organ donation, right through to harvesting in theatre. 

This set the scene perfectly for the simulation scenario, as the aim was to work through a case from presentation to the emergency department, to withdrawal of life-sustaining treatment, prior to organ donation.  The scenario was broken down into sections, with a debriefing session after each section to optimise the opportunity for discussion.  Actors played the role of the child’s parents, allowing candidates to practice the often difficult and sensitive encounters with families regarding the withdrawal of life-sustaining treatment.

The afternoon session consisted of workshop sessions, covering brainstem death testing and communication skills stations relevant to organ donation.  There was also a brief session outlining a quality improvement project I am currently undertaking aiming to raise awareness of paediatric and neonatal organ donation at a trainee level.

The day was brought to a close with a parents’ account of their personal experiences of organ donation.  This really hit home the huge impact organ donation can have not only on those receiving a donation, but also on the families of the donor.  It was incredible to hear the strength the family were able to take in the face of extreme adversity and despair, in the knowledge that their child was able to help save the life of others through the donation of their organs.

The organ donation team received excellent feedback regarding the simulation day, and following its success, we hope to build upon our education programme, extending similar opportunities to healthcare professionals across Wales.  A date for the diary is an upcoming organ donation deanery study day in August…final details to be confirmed!

If you have any queries about paediatric organ donation or would like to get involved, please feel free to contact me.

For more information on organ donation please visit: 
​https://www.organdonation.nhs.uk/ 

Dr Rebecca Broomfield

Leadership course run in MIT Boston USA

As Clinical Leadership Fellows we were privileged to have the opportunity to attend a Leadership Course at Massachusetts Institute of Technology. 5 of us hopped on a plane at the end of March and flew over to Boston in order to attend ​

We flew in the day before the course and in true tourist fashion made the most of the first day getting over jet lag before the course began. None of us had been to Boston before and despite venturing out to an Irish bar with live music on our arrival we were all up bright and early on the Monday morning. (Thanks jet lag!) We grabbed our lonely planet guides and re-embraced our travelling student identities to explore a fantastic city. 

We spent the day following the Freedom Trail - Boston has a very limited history but what it does have it exploits amazingly! The trail lead us through the start of the American Independence and British invasion. We stopped off in the harbour at lunch time and  took a (freezing cold!) boat trip too see all the islands. We continued our trail and then extended it to include a viewing of the bronze duck statues in the main park. We watched the sunset in the tallest building in Boston with cocktails that were stronger than they tasted! 

The course was facilitated by Dr Tara Swart (@TaraSwart) She holds a BSc in Biomedical Science and PhD in Neuropharmacology from Kings college London. She read Medicine at Oxford University gaining a BM BcH qualification. She is an executive coach and is passionate about disseminating simple, pragmatic neuroscience-based messages that change the way people work. 

This course was not aimed at medics, and I do feel that we would have benefited from a slightly more rigorous focus on the scientific evidence for some of the science taught on the course, however, this was not it's aim and in fact may have alienated some of the audience who were present. Having looked into the evidence presented since the course, there is a significant scientific knowledge base behind the methods taught. 

There has never been a room where, as a medic, Imposter Syndrome has a more appropriate setting. The course was full of chief executives and people who have multi-million pound contracts in their back pockets and more staff working underneath them imagined possible! However, the problems encountered and the neuroscience to increase behaviors and lead change were relevant to both the medical and the commercial setting. The insight which mixing with leaders from completely different worlds to our own has allowed us to gain was worth attending the course alone. 

Right from the word go this course was structured differently to the majority. We sat on circular tables with 4-5 other delegates but at the back of the room were juggling balls, skipping ropes and standing desks. There were refreshments available through the whole day (although, caffeine was removed at 14:00 - it reduces your sleep quality after this time) and at the start we were actively encouraged to access refreshment as needed and walk around the classroom freely. While the skipping only occurred in the breaks some people did take advantage of the juggling balls and juggled at points throughout the teaching. While we learnt on the course that social safety is the area of culture in the workplace and wellbeing which has the biggest impact on the brain the next biggest area is physical activity. By standing up and engaging in a physical activity such as skipping or juggling we were actively engaging our brains and increasing our neuroplasticity, which is the brain's ability to reorganize itself by forming new neural connections throughout life.

Brains tend to hold onto old pathways, in order to create new pathways you need to rest, fuel, hydrate and oxygenate your brain. by exercising you increase the release of brain derived neurotrophic factors (BDNF) which helps with the formation of new pathways.

Neuroplasticity is an important concern when thinking about the neuroscience of leadership. We do not unlearn habits or behaviour, this is not possible but we are able to overwrite these pathways. Translated for use in leadership this could be as simple as giving people an alternative option rather than simply managing an undesirable or ineffective behaviour by saying "don't do that". Making new neural connections for behaviour is tough, but it is the first time which requires the most effort. As you repeat the same pattern of behaviour you strengthen this pathway and therefore make it more automatic.

There are 2 areas of the brain involved with learning new behaviours; the cortex - which is learning by instruction and the limbic system which is learning by experience. Knowledge/organisation of reality happens in the pre-frontal cortex but feeling and managing anxiety is under the control of the limbic system. A brain stem reflex is often change preventing within behaviour modification. Logic is not enough in order to modify behaviour and promote change you need to connect the 2 systems.

The top 7 emotional drivers within the workplace are:

• Feeling valued
• A feeling of being treated fairly
• A feeling of being ‘in the know’ and listened to
• A sense of involvement (belonging)
• A sense of personal growth and development
• Belief in the employer’s honesty and purpose
• Feeling safe (job security)​

Communication is one key area where neuroscience can give us the edge over others. ​​Using your limbic system to promote bonding and enhance the emotions above can give you an edge in leadership. Trust is the number 1 emotion but trust uses more resources than mistrust, and is therefore more difficult to employ.

Can you use neuroscience to create a better bond and increase trust? Yes, and it's as simple as eye contact. When you next communicate face to face with somebody try actively looking with your right eye into their left eye. This will activate their right limbic system which has been shown to create a strong bond. A bond enables colleges to feel more valued and creates a better working culture and environment. I've been trying this out since I returned and I feel that it has enabled me to shortcut some relationship building and create a quicker more valuable relationship. As far as I know, nobody has thought I've been looking at them strangely or even been aware that I am trying out this technique so even if it initially feels awkward for you it's worth a try! Face to face communication is always better, so make the effort to do this when possible. 

The role of stress ....

The right ventral lateral pre frontal cortex is active in stress and has a role in regulating emotions. This area responds to pain - notably physical pain causes the release of natural painkillers whereas psychological pain does not, it also contains cortisol receptors. Cortisol is a fight or flight response hormone. It has a natural morning spike and then maintains low levels throughout the day accept in crisis or when there is a threat to survival. Having too much cortisol can lead to physical manifestations from yourself or the team which you are leading. These include poor sleep, irritability and craving chocolate/caffeine. The physical symptoms can detract from your brain power and demand attention, too much cortisol can also decrease your immunity and increase your abdominal fat thus impacting your physical health. Emotion biases all decisions and stress/fear biases decisions to the emotional system through the cortisol pathways. Interestingly some studies have shown that cortisol levels can be transmitted to others in a similar way to pheromones. Therefore a leader who has high levels of cortisone has the potential to expose others to them as well as themselves. 

Stress is just one of the recognised threats to your brain power in work, others include uncertainty and uncontrollability. As a leader you do have the power to influence these for your team. Can you adapt your leadership in order to make your team feel more in control of the tasks which they are performing? You can definitely reduce uncertainty.

We did a good exercise on the course which focused on re-framing our responses. As a leader when a suggestion is made by a member of your team the automatic response is to say "No". In order to say yes it requires more mental energy as a leader but improving your ability to this can increase the level of control which your team feel they have and promote the positive emotional drivers outlined above. We were tasked in pairs of making a suggestion to overcome a problem to our partner. Initially they had to respond with "No" Then we had to re-ask the question and they had to a respond with "Yes, but .." thus entertaining the idea but outlining the potential barriers stopping this from happening. As the questioner we than had to once again make the same suggestion but our partner needed to respond with "Yes, and..." Using "Yes, and .." reduces the social isolation of your team and increases the attachment and bonding created. Oxytocin, which is released when creating a good bond, shapes the neutral circuitry of trust adaption. Reward and attachment emotions regulate emotion and improve decision making. Thus by utilising this type of leadership within your team you can promote good decision making and reduce stress. There is lots to gain 

During the course all food was provided and the menu was created to promote healthy eating and ensure that the nutrients provided promoted brain agility. It was followed up with an evening reception - I'm not sure where the wine fits into a healthy lifestyle but it was definitely welcome after all the information provided during the course. 

Our thanks also have to go to Mr William Fleming, a fellow course participant who took us out to sample the local seafood in the evening, but also allowed us to pick his corporate brain with ideas that could benefit our leadership styles and leadership within the NHS. (I think/hope he learnt a little bit from us too!)

During day 1 we were taught that people are 15% more productive on the days that they do 30 minutes of aerobic exercise in the morning. While i'm not sure this counts as aerobic exercise, we took this on board and as a group of Clinical Fellows all attended the precourse early morning yoga session. The picture above is the view from the glass walled classroom we were practicing in, this rivals the morning session of beach yoga I took part in while travelling for the most breathtaking yoga view. It was a calming start to the day, followed by a breakfast of foods, as yesterday specifically selected to enhance wellbeing and increase brain agility.

We were more focused on day 2 on our own strengths and weaknesses and what we can do to improve our leadership while increasing our own resilience and mental toughness. If we can maintain our mental toughness and resilience as leaders then we promote a culture within our organisation that it is important to do the same.

Prior to the course we completed a Neurozone questionnaire. This is a detailed questionnaire which enables you to focus on small changes you can make to maximise your own potential and therefore improve your leadership. Two of my areas for focus are improving my sleep and increasing the diversity of my exercise. Both of these require a small change but have the potential to have a big impact on my reserves. 

Culture
Culture and patterns of behaviour and beliefs frequently impact perception, cognition and actions. You have a responsibility as a leader to use your skills to create a culture where your team members thrive. Your actions as a leader speak louder than the word which you use. 

Further reading: “Neuroscience for Leadership: Harnessing the Brain Gain Advantage” Tara Swart, Kitty Chisholm & Paul Brown

We had a day to play with before flying home, part of my year is focusing on simulation and medical education. Therefore I took advantage of being in Boston to visit the 'Centre for Medical Simulation' which has a worldwide reputation. There was a course going on that day and so I got to see their sim suite in action and speak to their faculty. It was very interesting to note that they are also focusing on the educational value of simulation and how we can evidence this. Their facilities are excellent and it was exciting to be able to spend a short time there.

The afternoon was spent at the Boston Tea Party museum learning about leaders who promoted a change by making a stand - very relevant to the topics which we had been covering, and yet another leadership perspective.

Boston was fantastic, I would recommend it as a city break. The course was an amazing opportunity to understand some of the rational behind current leadership techniques and put a neuroscience basis to their implementation. I have a lot of areas to work on to maximise my own leadership potential and am looking forward to trialling these out over the coming years.

Dr Rebecca Broomfield

Please read this blog with Nickelback "What are you waiting for?" playing in the background. It encapsulates the mood i'm aiming for! https://youtu.be/w-Ng5muAAcg

Nestled somewhere near the middle of Wales, with very limited phone signal and Wi-Fi that intermittently functions is Elan Valley. Its a stunning location to explore for people who love outdoor adventures and the location for a fantastic 3 day team building residential which was facilitated by Academi Wales as a part of the Pg Cert qualification I am enrolled in during my year as a Clinical Leadership Fellow. It is an amazing place to focus on team-working and your role within that team. 

A team role as defined by Dr Meredith Belbin is "A tendency to behave, contribute and interrelate with others in a particular way"  He has grouped these roles into 9 clusters of behaviour. When you take the Belbin self reported questionnaire you get a break down of your personal team preferences. The outline of the roles is described in the picture below. You don't need a person for each role to create a good team but you should try to consider all perspectives. It may be also useful to look at a team which isn't functioning to its best, does everybody within that team have the same preference and therefore the same perspective on a problem. Having the same preference can be a source of conflict as well as preventing the team achieving its goal. 

My primary preference was the 'Shaper' role with my secondary preference being 'Resource Investigator' As a group of Leadership fellows we had surprisingly diverse results, reinforcing that no type is better or worse in a leadership role. 

The report was slightly different from the other personality or preference reports we have completed this year. Instead of looking at areas to develop we were encouraged to focus on developing our strengths rather improving on our weaknesses.

Each role has it's own strengths and weaknesses, knowing the preference of your team member allows you to distribute workload to their strengths, thus improving the efficiency of your team. For example, I had a low score for the 'Completer Finisher' role therefore, as a leader, I need to identify a person on my team who has strengths in this role in order to ensure my team actually completes their tasks!

Once we had learnt the theory and our own preferences we were split into teams in order to put this into practice. The teams were selected in order to ensure that the majority of the roles were covered in within team. 

The details of what exactly happened in Elan Valley will forever stay amongst the team who attended. (Trust is an important part of creating a functioning efficient team environment!) But we participated in a variety of tasks that allowed us to explore our own role and communicating and motivating the other team members. 

The morning focused on goal based tasks. Each task started had a time limit and started with a printed instruction. Each task had rules which could not be broken and a goal which needed to be achieved. An example of one of the tasks we undertook was a maze task. A maze was laid out out of sight from the team and we were put into a large square laid out on the ground unable to see the maze. Our team was only allowed to communicate within the box, only 1 team member was able to leave the box at any one time and all members had to successfully navigate their way across the maze to complete the task. There was of course a time limit on this. Our first team member returned to tell us the structure of the maze, we had to work out, remember and communicate a pattern of boxes which we could step on to get across to the other side of the maze. This task acutely demonstrated to me the importance of others perspectives and the importance of communication. People like to be communicated with differently depending on their thought processes. (Just in case you were wondering we managed to get all of our team members across within the time limit and only received one penalty!)  

The afternoon was structured slightly differently. The whole cohort was brought back together and we were to function as subsections of an overarching team. The team goal was to earn 'money'. The money would then be spend on unlocking clues which would give us the location of a prize which we were aiming to achieve. We could earn money by completing a variety of tasks. Tasks were diverse and each has a value attached to it. We split into our sub-groups and decided which tasks we wanted to complete in order to earn money and then spend the afternoon working through these tasks. Again, of course there was a time limit set on this. All the subgroups had to come back together to decide how this money was spent. 

​Some of the afternoon tasks were more adventurous and required taking team work to a whole other level. My personal favorite task was the "leap of faith". This involved climbing up a tiny rope ladder onto a small triangle platform which was positioned high into the trees and then jumping off. You were harnessed and your team members were in control of the ropes. In order to work your way up the ladder you needed to trust your team members not to let you fall with the ropes, you needed a team member to anchor your ladder to stop it flapping about in the wind and enable you to climb straight and you needed encouragement from the team when halfway up you suddenly realised that it was a long way down! Despite ripping a pair of jeans I managed to get to the top and jump. It was a good exercise in overcoming barriers and how important support and trust were within a team. (Just for completeness we earned enough money and managed to get a well earned box of chocolates!) 

I learnt a surprising amount about myself and team roles from participating in the residential course. However, the most important of these was 

The role of communication in good team-working cannot be underestimated. It is vitally important especially when you've realised that people don't all think like you or have the same perspective as you do. Obviously this covers the face-to-face communication when outlining a task but also the importance when managing a large busy team in communicating the overarching vision of the team which you want all members to progress towards. It is very difficult to motivate and drive forward a team when you do not all have a shared vision as to what you want to achieve. I would suggest reflecting on how you manage a team and the actions you use to motivate other members. How many conflicts or mistakes have been due to poor communication?

Other than communication the importance of looking at things from others perspectives was emphasised to me throughout these personally challenging activities. When faced with a problem, taking on a different viewpoint or consulting a member of your team who you know has a different role preference to you can fundamentally change how you choose to tackle it. As a part of this it is also important to remember the importance of your role within your team, you may have a perspective which nobody else has considered. 

Listening is a vital part of communication. 

However, it's importance can often get overlooked when concerned about getting your opinion heard and shouting loud enough to have your say in a team activity. How many times do you have a conversation where you are already planning your answer? the next point your want to make? or even thinking about what you are having for dinner that evening.

(Unsurprisingly) communication works best when you actually listen to the people in your team. When you honestly reflect on this can you say that you always do this? Most people don't. Next time you are communicating with a college try giving them all of your attention, focusing in on what they say and responding to this rather than your previously planned out structure of how you want the conversation to go. Since trying this out after the residential I have noticed a significant improvement in my communications and my ability to influence change. 

Things I am currently working on developing are: 

• Active listening
• Getting a wide variety of perspectives - deliberately seeking out feedback from those who I know will have a different opinion to my own. 
• Preparation - making sure I know the background and what I want to achieve when going into an important meeting or conversation. 

At the end of this blog I would suggest looking at the Belbin team role definitions and reflecting on where you fit? Who do you need on your team to compliment your perspective? What can you work on to get better outcomes for your patients?  

https://academiwales.gov.wales/
​​https://www.elanvalleylodge.co.uk/
http://www.belbin.com/

Dr Rebecca Broomfield

It would be worth having a discussion within your workplace about debriefing. Do you debrief as a whole team? Is TALK a tool which could enhance the way your team work together? When getting started and initial discussion should take place in order to identify and agree potential situations which will prompt its use, focusing on positive events as well as negative. Once established then TALK can easily be adapted to different situations so don't let this initial discussion limit you!

I attended a workshop in order to facilitate using the TALK debriefing tool. I personally think that this tool is useful and needs to become embedded in the culture as much as the 'ABCD' algorithm for assessing a patient. It is initially a bit clunky to use, because it is unfamiliar but once practiced would easily facilitate difficult discussions. It could be argued that we already debrief and therefore why do we need a tool?

There are several advantages which I can see:

• Progresses the conversation from just talking into key learning points and actions which can then be achieved. 
• Removes hierarchy allowing all members of the team to initiate discussion.
• Promotes a culture for debriefing after positive events as well as negative. 
• Focus on solutions rather than problems, therefore promoting a positive working environment. 
• Can be used to focus in on specific quick fire problems or best practice rather than discussion of the whole case. 

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