Management and leadership Flashcards
Resistance to Change Lewin’s Forcefield Analysis
It is important to support the desired change to make sure it continues and is not lost; this is especially useful if we apply this to understanding how people move through change and why they resist change.
There will always be driving forces that make change attractive to people, and restraining forces that work to keep things as they are.
Successful change is achieved by either strengthening the driving forces or weakening the restraining forces.
The forcefield analysis integrates with Lewin’s three stage theory of change as you work towards unfreezing the existing equilibrium, moving towards the desired change, and then freezing the change at the new level so that a new equilibrum exists that resists further change [2].
Maslow
In order to successfully facilitate transformation Maslow’s hierarchy is a popular way of considering your colleagues’ needs. This is based on the premise that when employees feel valued and looked after they will usually give their best in return. The hierarchy can provide leaders with the tools to build on team satisfaction. Maslow’s Hierarchy of Needs was developed by psychologist Abraham Maslow as early as 1943: his theory contends that as humans strive to meet our most basic needs, we also seek to satisfy a higher set of needs [4].
Maslow presents this set of needs as a hierarchy (Fig 1). The blue boxes to the right of the hierarchy show some of the unfreezing techniques that can be used in overcoming resistance to change, and motivating and focusing a group to accomplish change.
Advantages
Managers should consider the needs and aspirations of individual staff.
Disadvantages
The broad assumptions in 2 above have been disproved by exceptions e.g. hungry, ill artist working in combination.
Whilst this research provides a basic framework, life is complex.
Transition
Resistance to Change
Transition
During the transition, people are ‘unfrozen’ and moving towards a new way of being. That said, this stage is often the hardest as people are unsure or even fearful.
Imagine bungee jumping or parachuting. You may have convinced yourself that there is a great benefit for you to make the jump, but now you find yourself on the edge looking down. Scary stuff! But when you do it you may learn a lot about yourself.
This is not an easy time as people are learning about the changes and need to be given time to understand and work with them. Support is really important here and can be in the form of training, coaching, and expecting mistakes as part of the process.
Using role models and allowing people to develop their own solutions also help to make the changes. It’s also really useful to keep communicating a clear picture of the desired change and the benefits to people so they don’t lose sight of where they are heading.
Refreezing: establishing stability
Kurt Lewin refers to this stage as freezing although a lot of people refer to it as ‘refreezing’. As the name suggests this stage is about establishing stability once the changes have been made.
The changes are accepted and become the new norm. People form new relationships and become comfortable with their routines.
This can take time.
In today’s world of transformation the next new transformation could happen in weeks or less. There is just no time to settle into comfortable routines. This rigidity of freezing does not fit with modern thinking about change being a continuous, sometimes chaotic, process in which great flexibility is demanded.
So popular thought has moved away from the concept of freezing. Instead, we should think about this final stage as being more flexible, something like a milkshake or soft serve ice cream, in the current favourite flavour, rather than a rigid frozen block. This way ‘unfreezing’ for the next change might be easier.
Support the desired change to make sure it continues and is not lost.
Accomplishing Change Kotter’s 8 Step Model
Let us just take some time to recap:
• We have looked at Kurt Lewin’s theory of forcefield analysis integrated with his three stage theory of change applied to transformation in healthcare settings
• We have also explored the application of Maslow’s Hierachy of Needs in engaging and motivating colleagues in transforming care
We can now piece the jigsaw together within John Kotter’s 8 step model (Fig 1) to motivate and focus a group to make transformation [1].
Create a sense of urgency
Think about how you would create a sense of urgency.
Step 2
Creating a guiding coalition
No one person, no matter how competent, is capable of single- handedly:
• Developing the right vision
• Communicating it to vast numbers of people
• Eliminating all of the key obstacles
• Generating short-term wins
• Leading and managing dozens of change projects
• Anchoring new approaches deep in an organisation’s culture
Putting together the right coalition of people to lead a change initiative is critical to its success. That coalition must have the right composition, a significant level of trust, and a shared objective [1]
Getting the vision right
In order to focus the group requires a clear vision [1].
Think back to earlier in the session. Can you remember the fundamental reasons for having a clear vision?
Communicating the vision
Gaining an understanding and commitment to a new direction is never an easy task, especially in complex organisations. Under-communication and inconsistency are rampant. Both create stalled transformations [1].
Identify the most effective modes to communicate the vision.
Empower broad-based action
• Remove obstacles
• Enable constructive feedback
• Provide lots of support from leaders
• Reward and recognise progress and achievements [1]
Generating short-term wins
How?
1. Set aims that are easy to achieve - in bite-size chunks
2. Work on manageable numbers of initiatives
3. Finish current stages before starting new ones
4. Remember, SMART objectives are:
o Specific
o Measurable
o Achievable
o Realistic
o Timely
Short-term wins tend to undermine the credibility of cynics and self-serving resistors. Clear improvements in performance make it difficult for people to block the needed transformation. Likewise, these wins will gather critical support from those higher than the folks leading the transformation i.e. Directors, Trust Board. Finally, short-term wins have a way of building momentum that turns neutral people into supporters, and reluctant supporters into active helpers [1].
Don’t let up
Foster and encourage determination and persistence - ongoing change - encourage ongoing progress reporting - highlight achieved and future milestones.
Resistance is always waiting in the wings to re-assert itself. Even if you are successful in the early stages, you may just drive resistors underground where they wait for an opportunity to emerge when you least expect it. They may celebrate with you and then suggest taking a break to savour the victory.
The consequences of letting up can be very dangerous. Whenever you let up before the job is done, critical momentum can be lost and regression may soon follow. The new behaviours and practices must be driven into the culture to ensure long-term success. Once regression begins, rebuilding momentum is a daunting task [1].
Step 8
Make it stick
Reinforce the value of successful change via recruitment, promotion, new change leaders. Weave change into organisational culture.
New practices must grow deep roots in order to remain firmly planted in the culture. Culture is composed of norms of behaviour and shared values. These social forces are incredibly strong. Every individual that joins an organisation is indoctrinated into its culture, generally without even realising it. Its inertia is maintained by the collective group of employees over years and years.
Changes – whether consistent or inconsistent with the old culture – are difficult to ingrain.
Tradition is a powerful force. We keep change in place by creating a new, supportive and sufficiently strong organisational culture. A Guiding Coalition alone cannot root change in place no matter how strong they are. It takes the majority of the organisation truly embracing the new culture for there to be any chance of success in the long-term [1].
a) Motivation is the state of mind which pushes all human beings to perform to their highest potential, with good spirits and a positive attitude
Maslow’s Theory of Hierarchical Needs
Abraham Maslow postulated that a person will be motivated when all his needs are fulfilled. People do not work for security or money, but they work to contribute and to use their skills. He demonstrated this by creating a pyramid to show how people are motivated and mentioned that ONE CANNOT ASCEND TO THE NEXT LEVEL UNLESS LOWER-LEVEL NEEDS ARE FULFILLED. The lowest level needs in the pyramid are basic needs and unless these lower-level needs are satisfied people do not look at working toward satisfying the upper-level needs.
Below is the hierarchy of needs:
• Physiological needs: are basic needs for survival such as air, sleep, food, water, clothing, sex, and shelter.
• Safety needs: Protection from threats, deprivation, and other dangers (e.g., health, secure employment, and property)
• Social (belongingness and love) needs: The need for association, affiliation, friendship, and so on.
• Self-esteem needs: The need for respect and recognition.
• Self-actualization needs: The opportunity for personal development, learning, and fun/creative/challenging work. Self-actualization is the highest-level need to which a human being can aspire.
Hertzberg’s two-factor Theory
Hertzberg classified the needs into two broad categories; namely hygiene factors and motivating factors:
The two-factor theory (also known as Herzberg’s motivation-hygiene theory) argues that job satisfaction and dissatisfaction exist on two different continua, each with its own set of factors. This runs contrary to the traditional view of job satisfaction, which suggests that job satisfaction and dissatisfaction are interdependent.
Herzberg and his collaborators investigated fourteen factors relating to job satisfaction in their original study, classifying them as either hygienic or motivation factors. Motivation factors increase job satisfaction while the presence of hygiene factors prevent job dissatisfaction.
Herzberg’s two-factor principles
Hygiene Factors (Dis-satisfiers)
• Working condition
• Coworker relations
• Policies & rules
• Supervisor quality Improving the hygiene factors decreases job dissatisfaction
Improving motivator factors increases job satisfaction Motivating factors (Satisfiers)
Achievements
• Recognition
• Responsibility
• Work itself
• Personal growth/advancements
Advantages
Herzberg's work led to a practical way to improve motivation, which had, up to that point, been dominated by Taylorism (salary, wages). In particular ' job enrichment' programmes mushroomed. The aim of these was to design work and work structures to contain the optimum number of motivators. This approach counters the years of Taylorism, which sought to break down work into its simplest components and to remove responsibility from individuals for planning and control.
Disadvantages
There remain doubts about Herzberg's factors applicability to non-professional groups, despite the fact that some of his later studies involved the clerical and manual groups. The numbers in these categories though were small, and researchers still argue about the applicability of the manual and clerical group. Social scientists argue about the validity of his definition of 'job satisfaction'.
McGregor (Theory X and Theory Y)
Managers were perceived by McGregor, whose theories are still often quoted, to make two noticeably different sets of broad assumptions about their employees.
Motivation
b) It is important to support the desired change to make sure it continues and is not lost; this is especially useful if we apply this to understanding how people move through change and why they resist change. There will always be driving forces that make change attractive to people, and restraining forces that work to keep things as they are. Successful change is achieved by either strengthening the driving forces or weakening the restraining forces. The force field analysis integrates with Lewin’s three stage theory of change as you work towards unfreezing the existing equilibrium, moving towards the desired change, and then freezing the change at the new level so that a new equilibrium exists that resists further change.
In order to successfully facilitate transformation Hertzberg’s two-factor Theory is a good way of considering your colleagues’ needs. This is based on the premise that when employees feel valued or recognised and responsible will usually give their best in return. Making sure the hygiene conditions are maintained i.e. good working conditions and motivation factors are in play i.e. team feel valued by playing active part in the change process, feel responsible or in charge of process will keep them motivated. Involving the team early on in the change process and actively involving the them in the change process will keep the team motivated. Staff should feel the change is needed and actively seek to change.
Question: What is performance management?
Answer: Performance management (PM) is a way of ensuring that the goals of an organisation, a department, or an employee are consistently being met in an effective and efficient manner. Performance management can even include the processes to build a product or service, as well as many other areas.
Most performance management frameworks centre around the organisation’s goals and aim to measure the inputs, processes and outputs that relate to these. This process is illustrated in Fig 1.
1. Establish key goals
In this framework goals must be specific, measurable, action orientated, realistic and time orientated (SMART).
They may be paitent driven and linked to clinical guidelines and protocols, reporting systems and/or complaint management system
2. Establish metrics
It is important to define what has to be measured to ensure the goals are achieved.
Consider, what factors (drivers) influence the outcomes you want. Select those that have the greatest impact to measure. These are ‘driver’ metrics. You may need to develop your own metrics as well as use those available.
Then look to process metrics around efficiency (process input, staff, equipment, etc), effectiveness (process output, doing what you say you will do) and productivity (expected output vs actual output.)
3. Understanding performance
To understand the gap between current and desired performance you need to design your data collection and reporting systems.
Start by:
• Agreeing a method for establishing current performance
• List the resources needed
• Agree data formats
• Identify benchmarking data
• Set the reporting calendar
• Establish roles and responsibilities
• Detail training requirement
• Validate the process with stakeholders
4. Initiate performance
With the data you have collected decide on a set of achieveable actions that are possible. Assign responsibilities and owners.
5. Review
Without reviewing the effectiveness of your actions you won’t know if you have met your original goals
Consider the following example:
Sainburys wanted to look at how to reduce the number of lorries on the road without impacting on the quality of their products. They looked at what their biggest bulk items were. They chose to focus on toilet rolls. After measuring the diameter of the toilet roll, they worked out that by reducing it by 11 mm they would be able to fit more rolls on the lorry. This meant 500 fewer lorries on the road each year.
1. Establish key goals: How to reduce the costs of delivery of one of the biggest bulk items, toilet rolls, and maintain quality for the customer
2. Metrics: A ruler
3. Understand performance: A reduction in the diameter of the toilet roll by 11 mm will increase the quantity in each delivery significantly
4. Initiate performance: A reduction in the diameter of the toilet roll by 11 mm
5. Review: It led to 500 less lorries a year on the roads
You may want to ask and analyse several questions about your service at the same time. To avoid confusion consider using a balanced scorecard approach [3].
The balanced scorecard framework allows organisations to clarify their vision and strategy and translate this into a set of clear goals and action points. It provides feedback around both the internal business processes and external outcomes in order to continuously improve strategic performance and growth.
Strategy -analysis
You can use the McKinsey 7-S Model in a wide variety of situations where it’s useful to examine how the various parts of your organization work together.
For example, it can help you to improve the performance of your organization, or to determine the best way to implement a proposed strategy.
The framework can be used to examine the likely effects of future changes in the organization, or to align departments and processes during a merger or acquisition. You can also apply the McKinsey 7-S model to elements of a team or a project.
The model categorizes the seven elements as either “hard” or “soft”:
The three “hard” elements include:
Strategy. Structures (such as organization charts and reporting lines). Systems (such as formal processes and IT systems.)
These elements are relatively easy to identify, and management can influence them directly.
The four “soft” elements, on the other hand, can be harder to describe and are less tangible, and more influenced by your company culture. But they’re just as important as the hard elements if the organization is going to be successful.
Let’s look at each of the elements individually:
Strategy: this is your organization's plan for building and maintaining a competitive advantage over its competitors. Structure: this is how your company is organized (how departments and teams are structured, including who reports to whom). Systems: the daily activities and procedures that staff use to get the job done. Shared Values: these are the core values of the organization and reflect its general work ethic. They were called "superordinate goals" when the model was first developed. Style: the style of leadership adopted. Staff: the employees and their general capabilities. Skills: the actual skills and competencies of the organization's employees.
The placement of Shared Values in the center of the model emphasizes that they are central to the development of all the other critical elements.
The model states that the seven elements need to balance and reinforce each other for an organization to perform well.
Checklist Questions for the McKinsey 7-S Framework
The following questions are a starting point for exploring your situation in terms of the 7-S framework. Use them to analyze your current situation (Point A) first, and then repeat the exercise for your proposed situation (Point B).
Strategy:
What is our strategy? How do we intend to achieve our objectives? How do we deal with competitive pressure? How are changes in customer demands dealt with? How is strategy adjusted for environmental issues?
Structure:
How is the company/team divided? What is the hierarchy? How do the various departments coordinate activities? How do the team members organize and align themselves? Is decision-making centralized or decentralized? Is this as it should be, given what we're doing? Where are the lines of communication? Explicit or implicit?
Systems:
What are the main systems that run the organization? Consider financial and HR systems, as well as communications and document storage. Where are the controls and how are they monitored and evaluated? What internal rules and processes does the team use to keep on track?
Shared Values:
What are your organization's core values? What is its corporate/team culture like? How strong are the values? What are the fundamental values that the company/team was built on?
Style:
How participative is the management/leadership style? How effective is that leadership? Do employees/team members tend to be competitive or cooperative? Are there real teams functioning within the organization or are they just nominal groups?
Staff:
What positions or specializations are represented within the team? What positions need to be filled? Are there gaps in required competencies?
Skills:
What are the strongest skills represented within the company/team? Are there any skills gaps? What is the company/team known for doing well? Do the current employees/team members have the ability to do the job? How are skills monitored and assessed? If something within your organization or team isn't working, chances are there is inconsistency between one or more of these seven elements.
Once you reveal these inconsistencies, you can work to align these elements to make sure they are all contributing to your organization’s shared goals and values.
The process of analyzing where you are right now, in terms of these elements, is worthwhile in itself. But for it to be truly effective, you’ll also need to determine the desired future state for each factor. This will help you make changes and improve performance so that all seven factors are aligned across your organization.
Culture
Effective leadership
Strategic thinkingCollaborationEmotional intelligenceCritical thinkingCommunicationMotivationFeedbackTough conversationsCoachingMaking values visible and viral
Strategic planning
• Mission
Goal setting
• Underlying corporate/departmental objectives
• S/W [Internal] McKinsey 7 S’s
• O/T [External] PESTELI
1. Where are we now?
• Evidence/best practice, e.g. literature, comparator approaches
• Programme objectives
2. Where do we want to be?
• Resource allocation, budget
• Implementation / action plan
3. How do we get there?
• Evaluation, measurement, audit etc
4. How will we know if/when we get there?
Stakeholder mapping and influencing
A stakeholder is a personal or a group that has
an interest or concern in the outcome of projects.
The term is most often associated
with business where stakeholders
are individuals who have a stake in
the profitability of an organization.
For public health projects,
stakeholders interests may stem from professional,
political, personal, or even economic reasons.
I’m going to introduce you to
a useful technique called stakeholder analysis
Stakeholder analysis is a three-step process.
The first step is to identify
a comprehensive list of stakeholders.
The second is to assess the degree of power and interest.
The final step is to estimate
how supportive they will be of the project.
You are a public health specialist working in the local health improvement team. You have read about the implementation of smoke free policies in hospitals across the country. You have developed a successful business case to support your local hospital to become smoke free and will lead on the implementation of the project. The policy involves completely banning smoking across the hospital grounds. Smoking cessation support and nicotine replacement therapy will be offered to smokers (both staff and in-patients) free of charge.
For the following list of stakeholders, predict their degree of power and interest, and estimate how supportive they are likely to be of this project
Stakeholder Power Interest Support
Hospital staff (HS) L / M / H L / M / H S / N / R
Patients (P) L / M / H L / M / H S / N / R
Hospital directors (HD) L / M / H L / M / H S / N / R
Smoking cessation service provider (SC) L / M / H L / M / H S / N / R
Public health improvement team (PH) L / M / H L / M / H S / N / R
Local media (M) L / M / H L / M / H S / N / R
Budget holder for health services (BH) L / M / H L / M / H S / N / R
Local politician (LP) L / M / H L / M / H S / N / R
Systems thinking and systems leadership
1what is it and what does it mean for the senior manager?
a system is any kind of entity that is made up of parts that interact together these parts and their interconnections create a hole which in turn produces some kind of result using a systems perspective is important0:30because it helps us to better understand what helps or hinders the success of health interventions
Suzanne Suzanne is a senior manager0:40in a large Regional Health Organization0:42the high rate of obesity is an issue in0:44her community and she’s been mandated to0:47address this problem her first instinct0:49is to develop a program to get more0:51people active but what is realistic to0:54expect from this approach systems0:56thinkers believed that viewing a program0:58like this apart in isolation of the1:01larger system within which it operates1:03the whole tends to ignore other aspects1:07that might influence its potential for1:08impact why research tells us that1:11obesity is the result of a combination1:13of many physiological psychological1:16social environmental and economic1:18factors that all interact with one1:21another for example at the individual1:24level there are issues such as human1:26physiology exercise habits food choices1:29and one’s occupation but beyond the1:32individual there are other factors at1:34play such as the local built environment1:37quick and easy access to junk food and1:39larger food industry practices such as1:43trends in portion sizes sugar and fat1:46content the interaction of all these1:49influences make obesity the product of1:51what we call a complex system if Suzanne1:54were to use a systems approach she would1:57realize that relying on simple linear1:59cause-and-effect solutions for one2:01program would ignore those interactions2:03and likely fail while Suzanne’s staff at2:06the program level have a tendency to2:08think only within the bound2:10of their program senior managers and2:12planners like Suzanne are in a unique2:15position to do what systems thinkers2:16call zooming out zooming out considers2:20how other aspects outside of a programs2:22traditional boundaries both within the2:24organization and Beyond might influence2:27the success of the program by zooming2:29out and looking at the influence of2:31other interventions policies structures2:33patterns and norms in the broader system2:36Suzanne is better able to strategically2:38consider other values and perspectives2:41and the interrelationships among each2:43that may impact obesity rates in her2:45community in doing so she can identify2:48more powerful leverage points outside of2:51the program that have the potential to2:53facilitate and support changes in2:54obesity leverage points are places2:57within the system that can be tweaked in2:59a way that supports greater impact for3:01example are there actions Suzanne and3:04her team might take that could increase3:06the community’s access to opportunities3:08for physical activity while some3:10leverage points are within Suzanne’s3:12capacity to change others will be beyond3:15her control however it will still be3:18useful to be aware of these as she plans3:20for the program adopting a systems view3:22won’t change the boundaries of this3:24program but it will expand the3:26boundaries of the evaluation by3:28recognizing the importance of the3:30different perspectives and values of3:32those outside the program and the3:33interrelationships throughout the system3:35Suzanne can ensure that the evaluation3:38is framed in a way that captures the key3:40boundaries diverse perspectives and3:42interrelationships that serve as3:44important leverage points in the system3:46course Suzanne’s budget won’t permit an3:49evaluation of the entire system but she3:52can ensure that any evaluation she3:54Commission’s will provide her with more3:56strategic direction on how to3:58effectively address obesity within her4:00community for example in addition to4:03recommendations for improving the4:05program the results of the evaluation4:06might indicate opportunities for new4:09partnerships or external policy change4:11if her community has poor walking and4:13cycling infrastructure where might she4:16and her team advocate or who could they4:18collaborate with to make changes by4:20asking these questions Suzanne is4:23finding that4:23using a systems approach helps her focus4:26on the broader issue of obesity in her4:28community instead of a single program in4:30her organization she gains a better4:32understanding of what external factors4:35are influencing the program’s success4:36and can set more reasonable expectations4:39of what it can accomplish she’s also4:41learning what needs to change both4:44within and outside of the program to4:46better maximize her organization’s4:47effectiveness many now believe that a4:50systems approach holds the most promise4:52for addressing complex health problems4:55like obesity which is not only good for4:57Suzanne but good for everyone
Collaborating in public health: the example of climate change
Climate change: a challenge for public health
Climate change is having a profound public health impact. In this final lesson, we want to use climate change as an example of how public health interests can align with wider policy issues.
The impacts of climate change on public health can be thought of as either direct or indirect. The direct impacts of climate change include issues such as heat stress and extreme weather events. The indirect impacts include the changing epidemiology of infectious diseases, increasing number of refugees due to starvation and famine, and deaths from conflict and war. It’s more often these indirect impacts that, while deferred, may have greater and more wide-ranging implications for public health practice.
The United Nations’ View
Review the following report from United Nations Framework Convention on Climate Change which explores how climate change is impacting the public’s health across the globe. As you’re reading, pay particular attention to how climate change is exacerbating health inequalities.
UNFCCC report
The WHO’s View
For a brief overview of the key public health impacts climate change, have a look at the ten climate change facts from WHO.
WHO Review of Health and Climate Change
Commentary
From these reports, you should be beginning to see how wide-ranging and inter-connected all these issues are. This is precisely the sort of thinking and exploration of topics that are expected of the public health practitioner.
https://www.fph.org.uk/policy-advocacy/special-interest-groups/special-interest-groups-list/sustainable-development-special-interest-group/resources-on-sustainable-development-and-climate-change/
Stages in group/team development (growth-cycle)
Bruce Tuckman’s 1965
‘Forming, Storming, Norming, Performing’ team-development model
Dr Bruce Tuckman published his Forming, Storming, Norming, Performing model in 1965 (Tuckman. 1965). He added a fifth stage, ‘Adjourning’ (this is also known as ‘De-forming’ or ‘Mourning’), around 1975 (Tuckman, 1975). The Forming, Storming, Norming, Performing theory is an elegant and helpful explanation of team development and behaviour. Similarities can be seen with other models, such as Tannenbaum and Schmidt Continuum and especially with Hersey and Blanchard’s Situational Leadership® model, developed about the same time.
Forming
members get to know each other
establish rules and tasks
understand group/team roles
acquire information/resources
identify and rely on the leader or develop a decision making hierarchy
Storming
check understanding of tasks across the group
tackle the challenges the group/team have been set
strengths and weaknesses of individuals start to emerge
internal conflicts likely to surface
members may resist task emotionally
Norming
process of normalisation settles in
conflicts settled
begin working to known strengths, overcoming weaknesses
co-operation amongst team/group members develops
views are exchanged
norms (new standards) are developed
Performing
'team/group working 'achieved
flexible roles developed centred around task achievement
solutions found/ implemented
team/group begin to 'perform' against agreed objectives, outputs, performance levels
Typically it is at the ‘Norming’ stage that the group/team starts to become effective, once the ‘norms’ have been developed, individuals understand their roles and there is general consensus about how the tasks are to be achieved, how the required outputs attained. Norms are influenced by organisational factors such as policies, management style of superiors, rules and procedures on the one hand and, on the other hand by individual employees influence on others in the group/team.
A 5th Stage:
Tuckman’s fifth stage, ‘Adjourning’, is the break-up of the group, hopefully when the task is completed successfully, its purpose fulfilled; everyone can move on to new things, feeling good about what’s been achieved. From an organisational perspective, recognition of and sensitivity to people’s vulnerabilities in Tuckman’s fifth stage is helpful, particularly if members of the group have been closely bonded and feel a sense of insecurity or threat from this change.
High-performing teams celebrate success, seek to understand why they have been successful as well as considering what they could have done better; all groups/teams though ought to consider how they have performed, using techniques such as ‘after-action reviews’ or ‘lessons-learned’
Why do some teams not succeed?
It needs to be understood however that many groups/teams do not progress neatly, or harmoniously, through the above-defined phases. Many falter at the forming and storming phases, perhaps members are insufficiently motivated, irreparable conflicts emerge. Leadership is important and sometimes failure occurs because of the lack of a natural or suitable leader who is either appointed or emerges. There are many ways in which group/team development can be restricted and that is why normally it is better to have a group/team leader, be they acting with (i.e. ‘appointed’) or without (i.e. self-selected by team or group) formal authority.
Performing Teams
Much has been written over recent decades about teams, about how and why they are formed, how and why they operate - and about how well - or otherwise - they perform. Here is a seminal example of how teamwork and collaboration can lead to improved performance:
Prevention and screening
Having completed this session you will be able to:
• State the principles of screening for disease
• Describe the features of a good screening test
• Describe the Wilson-Jungner criteria
• Recognise the risks and benefits of screening
• Describe the major screening programmes currently in operation in the UK
• Describe the tensions between the science and politics of screening
In all disease, the goal is prevention. Click on each title below for further information.
Primary prevention is the prevention of disease occurrence, for example, by screening for familial hypercholesterolaemia to prevent early cardiovascular disease.
Secondary prevention Secondary prevention involves controlling disease in its early form with the aim of achieving a better outcome for the patient. For example, through detecting cystic fibrosis in neonates, or through detecting cancer in its early forms.
Tertiary prevention Tertiary prevention involves prevention of complications once the disease is present, for example, prevention of blindness in diabetics by retinal screening.
This session aims to explore the role of screening in primary, secondary and tertiary prevention of disease in the UK.
Question:
What is screening?
Answer: Screening is the investigation of a population with the aim of detecting a particular feature. Features are chosen on the basis of their ability to predict disease. For example, a positive faecal occult blood test may be a marker for bowel cancer.
The idea of screening is attractive because a positive result from a screening test makes it possible to diagnose and treat a potentially serious condition at an early stage.
Screening involves the testing of people who either do not have, or have not recognised, the signs or symptoms of the disease being screened for. A screening programme should comprise a complete system, which includes a register of eligible participants, and procedures for issuing invitations, for ensuring follow up steps happen, and for providing adequate information and support to participants.
All the tests apart from prostate specific antigen (PSA) testing are routinely used as screening tests in screening programmes currently running in the UK.
A. False. PSA testing forms part of the prostate cancer risk management programme but is not a good screening test because a high proportion of those testing positive do not have prostate cancer. There is no prostate cancer screening programme currently in operation in the UK.
B. True. 2-view mammography is breast cancer screening.
C. True. Liquid-based cytology smear is cervical cancer screening.
D. True. The Ortolani test checks for developmental dysplasia of the hip and is part of the newborn and infant physical examination screening programme.
E. True. HIV testing is done during routine antenatal care as part of the infectious diseases in pregnancy screening programme.
F. True. Ultrasound scanning has a screening role in two national screening programmes: the abdominal aortic aneurysm screening programme and the fetal anomaly programme.
G. True. Immunoreactive trypsin is used as a screening test for cystic fibrosis in the newborn bloodspot screening programme.
The Ideal Screening Test
Normal Ranges
Screening tests are rarely 100% accurate. Normal ranges are based on population distribution curves, which means that 5% of ‘normal’ individuals will have abnormal test results. Similarly some with disease will have normal test results.
D+ D-
Test + TP a FP b All those tested positive
Test - FN c TN All those tested negative
All those you have disease All those who do not have disease
An ideal screening test should have:
High sensitivity i.e. pick up all those who have the disease. TP/TP+FN
High specificity i.e. exclude those who do not have the disease. TN/TN+FP
High positive predictive value i.e. detect only those who have a disease. TP/TP+FP
High negative predictive value i.e. exclude only those who do not have the disease. TN/TN+FN
A disease has a screening population prevalence of 2%.
The screening test used has 95% sensitivity and 95% specificity.
In a population of 2000, 40 patients will have the disease and 2 will receive a false negative result. Of the 1960 patients who do not have the disease, how many patients will receive false positive results?
D+ D-
T+ TP 38 FP 98
T- FN 2 TN 95% of 1960 = 1862
40 1960 2000
95*1960/100 = 1862
When considering any intervention in medicine, it is important that you weigh the benefits against the risks for any individual.
There are a number of negative effects of screening:
• False positive results
• False negative results
• Interval cases
• Unchanged outcome
• Risk of over-treatment
• Hazards of the screening test
• Diversion of resources
False positive results
As screening tests are not 100% accurate, they will sometimes suggest that an individual has disease when, in fact, that person does not.
For example:
Overall, 4% of women screened in the UK Breast Cancer Screening Programme are recalled for further investigation following initial mammography.
Of the women recalled, nearly 1 in 5 ( 1/5 *100 =20%) receive a diagnosis of breast cancer. The other 4 have had false positive results.
For each breast cancer death prevented, about three over diagnosed cases will be identified and treated. More than 10% of these women will experience important psychological distress, including anxiety and uncertainty, for years because of false positive findings. The breast cancer specific psychological distress may last for up to three years, and may even reduce the likelihood that women will return for their next round of mammography screening.
False negative results
Individuals screening negative for a disease make the logical assumption that they do not have that disease.
However, screening tests are not 100% accurate. A few will have the disease and still receive a negative screen.
For example:
The sensitivity of faecal occult blood screening for bowel cancer is somewhere between 55% and 92%. Taking the 92% figure, for every 100 people who have bowel cancer and are screened, 92 are detected with this test, but 8 are missed.
The individuals who have bowel cancer but receive a negative test, receive false reassurance that they do not have bowel cancer. They may ignore symptoms and signs that would otherwise have prompted them to seek medical help and this in turn may delay diagnosis and result in poorer outcome.
Interval cases
For some conditions, screening is a one-off event and does not need repeating. The neonatal bloodspot screening programme for congenital diseases is an example of a once-only screen.
When a condition may be acquired, screening is repeated at intervals. Therefore, an individual may receive a true negative result when first screened, but on subsequent screening may receive a true positive result, as the disease has developed in the intervening period. This is why cancer screening programmes are repeated at intervals.
However, fast developing conditions may arise and reach a stage where early treatment is not possible within the time interval between screening tests. These are known as interval events.
A true negative screening result may give false reassurance and reduce the likelihood of an individual reporting symptoms or signs that may lead to diagnosis of an interval event resulting in later diagnosis.
Unchanged outcome
Screening is only beneficial when early detection results in a better outcome. When an outcome is unchanged, detection at an earlier stage may result in increased anxiety and a longer period of ‘illness’ and unpleasant but ineffective treatment.
For example:
A pilot study of screening newborn boys for Duchenne muscular dystrophy was undertaken in the 1990s in Wales and screening has continued there. There are currently no plans to extend the programme elsewhere in the UK because there is no treatable early stage of the disease. Screening just increases the length of time that the family is aware of the child’s diagnosis, which may increase length of morbidity.
The counter argument to this is that, given advance warning of Duchenne’s muscular dystrophy, parents can make appropriate plans to cope with an increasingly disabled child and, as antenatal diagnosis is possible, early diagnosis may also prevent the birth of further affected children before the diagnosis is known in the first child.
Risk of over-treatment
The aim of screening is to detect disease at an early stage. However, screening may also detect changes that would never have led to serious disease and would have resolved spontaneously.
For example:
In the past, all sexually active women were offered cervical smear testing. However it was found that, although cervical cancer was very rare in women under the age of 25, abnormalities on smear testing were common.
Many of these abnormalities resolved spontaneously with time but abnormal smear results caused a great deal of unnecessary anxiety in younger women. Furthermore, some younger women underwent unnecessary treatment, including procedures that potentially could lead to cervical damage and problems in pregnancy later in life.
For this reason, in 2003 the lower age limit for cervical screening was changed to 25.
Hazards of the screening test
Physical hazards
Screening tests themselves may cause harm. Breast cancer screening uses x-rays. Although the radiation dose each women is subjected to is low, and the risks are very small, radiation itself may cause cancer.
Those screening positive for bowel cancer on faecal occult blood testing, are referred for further screening with a colonoscopy. The risk of bowel perforation with colonoscopy is about 1 in 1000.
Hazards to others
Some neonatal bloodspot tests have implications, not only for the child tested, but also for other family members too. A positive screen for sickle cell disease or cystic fibrosis results in cascade testing and possible identification of other family members carrying the gene. This may have implications for those individuals. In some cases it may also raise questions about paternity of the affected child.
Diversion of resources
In any country there are only limited resources for healthcare. Screening huge numbers of people and following up those with abnormal results is expensive. There is always a choice between spending money on screening and spending money on other services to benefit patients.
Furthermore, identifying more people with disease at earlier stages can put additional pressure on existing services and result in poorer services for people with other conditions.
Example
5 out of 5 correct.
If a new cancer appears 2 years after screening, it is unlikely that it was missed at screening. It has probably arisen since screening and thus is an interval cancer.
Neonatal bloodspot screening for cystic fibrosis (CF) tests for immunoreactive trypsin. Those testing positive are further tested for the 4 most common gene mutations causing CF. Children with CF having rarer genes may be missed, resulting in a false negative test.
Screening for diabetes and high cholesterol is widely available in the UK. A positive test can cause great anxiety, which can have long-lasting effects. Repeat testing may be normal.
Screening tests are not without complications. A further screen with colonoscopy is offered to all those people who have abnormal faecal occult blood tests and 1 in 150 people who have a colonoscopy have a gastrointestinal bleed.
Early detection does not always result in a better outcome. A woman found on screening to have breast cancer who subsequently dies from it in a relatively short period of time has not gained any benefit from screening. Her knowledge of having the disease has been extended, as has her time undergoing unsuccessful treatment.
How do we decide which conditions to screen for?
The World Health Organization recommends that screening should only be introduced to the target population if the Wilson-Jungner criteria are met.
The Wilson-Jungner criteria
1. The condition being screened for is an important health problem - this may be because it is common (e.g. cardiovascular disease), or because the consequences for the individual are severe if not detected (e.g. phenylketonuria)
2. The natural history of the condition is well understood
3. There is a detectable early stage
4. Treatment at early stage is of more benefit than at later stage
5. There is a suitable test to detect early stage disease
6. The test is acceptable to the target population
7. Intervals for repeating the test have been determined
8. Adequate health service provision has been made for the extra clinical workload resulting from screening
9. Risks, both physical and psychological, are less than the benefits of screening
10. The costs of screening are worthwhile in relation to the benefits gained
There is no ideal screening test. For any screening test, always explain:
• The purpose of screening
• The likelihood of positive or negative findings and the possibility of false positive or negative results
• The uncertainties and risks attached to the screening process
• Significant medical, social or financial implications of screening for the particular condition or predisposition
• Follow up plans, including availability of counselling and support services
In the UK, screening programmes are overseen by the NHS National Screening Committee. They review the evidence for implementation of screening programmes and present their recommendations to the government for consideration. They also monitor ongoing screening programmes for cost, effectiveness and harms.
In all cases, screening is targeted at a particular sector of the population to increase its effectiveness.
Current screening and risk management programmes in the UK fall into three categories:
Antenatal
• NHS Foetal Anomaly Screening Programme
• NHS Infectious Diseases in Pregnancy Screening Programme
• NHS Sickle Cell and Thalassaemia Screening Programme
Newborn
• NHS Newborn and Infant Physical Examination Screening Programme
• NHS Newborn Blood Spot Screening Programme
• NHS Newborn Hearing Screening Programme
Adult
• NHS Abdominal Aortic Aneurysm Screening Programme
• National Screening Programme for Diabetic Retinopathy
• NHS Breast Cancer Screening Programme
• NHS Cervical Cancer Screening Programme
• NHS Bowel Cancer Screening Programme
• NHS Chlamydia Screening Programme
• NHS Prostate Cancer Risk Management Programme
• NHS Health Check for Vascular Risk
Always ensure that the person being screened (or responsible parent) has been given adequate information about the screening test being offered to make an informed choice about whether to have the test or not.
Make sure that consent has been given before performing the test.
Most women undergo some form of screening before or during pregnancy, which aims to identify, prevent and treat actual or potential problems, such as:
• Routine blood and urine tests
• NHS Fetal Anomaly Screening Programme
• NHS Infectious Diseases in Pregnancy Screening Programme
• NHS Sickle Cell & Thalassaemia Screening Programme
• Other genetic conditions
Routine blood and urine tests
Although not included in any formal screening programme, many of the blood and urine tests routinely performed in pregnancy as part of usual antenatal care are screening tests. These include:
• Haemoglobin estimation - screening for anaemia in pregnancy
• Blood group and antibody screen - enables detection of babies at risk from rhesus disease and prophylactic measures to prevent sensitization of the mother
• Urine testing - urinary tract infection is associated with premature labour and around 10% of pregnant women have asymptomatic urine infections. Proteinuria may be associated with pre-eclampsia
You should ensure that women are given information about the reasons for, significance of and results of routine tests, and record in the notes that permission has been given to do them.
NHS Fetal Anomaly Screening Programme
All pregnant women should be offered:
• A screening test for Down syndrome that meets agreed national standards
• An ultrasound scan between 18 weeks and 20 weeks 6 days to check for physical abnormalities in their unborn baby and placenta praevia. This is in addition to the routine dating ultrasound scan performed between 11 weeks and 13 weeks and 6 days
• Information to help them decide if they want screening or not
NHS Infectious Diseases in Pregnancy Screening Programme
Women are offered screening with a single blood sample for four infectious diseases in pregnancy:
• Hepatitis B - to identify women who carry the virus so that babies at risk of infection can receive a course of vaccine following birth
• HIV - Identification and treatment of pregnant women with HIV can significantly reduce the risk of the virus affecting the baby and can also benefit the mother’s health
• Rubella - to identify women who are not protected so that they can be offered the measles, mumps and rubella (MMR) vaccination following the baby’s birth. This will protect future pregnancies from the virus
• Syphilis - treatment with antibiotics can benefit the unborn baby if infection has been transmitted
NHS Sickle Cell and Thalassaemia Screening Programme
In England, screening for sickle cell and thalassaemia is offered to all women early in pregnancy. The level of screening depends on where they live.
• High prevalence areas - all women are offered screening for sickle cell, thalassaemia and other haemoglobin variants
• Low prevalence areas - all women are offered screening for thalassaemia using standard red blood cell indices. In addition, the Family Origins Questionnaire is used to assess the risk of either the woman or her partner being a carrier for sickle cell and other haemoglobin variants. Those in identified high risk groups are offered laboratory testing
Partners of women identified as being a carrier (having a trait) or who have the disorder should be offered screening. If both parents are identified as being carriers, the unborn baby is at risk of developing the condition and the mother should be referred promptly for specialist counselling and further investigations.
Other genetic conditions
Some mothers with a previous child born with a genetic disorder or strong family history of a genetic disease may be offered specialist antenatal genetic screening. Refer for genetic advice pre-natally or, if already pregnant, as soon as possible after pregnancy is confirmed.
No screening test is perfect. There will always be some false negatives. Therefore, screening does not detect 100% of pregnancies with a Down syndrome foetus or guarantee a physically normal baby.
The combined test for Down syndrome is positive when the risk of a Down syndrome child is greater than 1 in 150. Therefore, a large proportion of these women will have a false positive test and the child will not have Down syndrome.
If a low-lying placenta is found at the time of the routine anomaly scan, another scan is offered at 32 weeks.
Women who are rhesus negative should be tested for antibodies at 28 weeks. The woman should also be given routine anti-D prophylaxis at 28 weeks and 34 weeks.
Elective caesarean section, avoidance of breastfeeding, antiviral treatment in pregnancy, and antivirals for the neonate can reduce transmission of HIV from mother-to-child to less than 2%.
If a woman is found antenatally not to be rubella immune, vaccination should be deferred until after she has had her baby. Pregnancy should be avoided for 1 month after vaccination.
In England, blood testing for sickle cell disease depends on the area that the women lives in. In high risk areas, blood testing is automatically offered. In low-risk areas, only those found to be at risk on the basis of the Family Origins Questionnaire are offered blood screening.
The aim of screening neonates is to discover physical developmental or behaviour problems as early as possible so that appropriate management can commence, thus preventing secondary complications. The following screening programmes are available:
NHS Newborn and Infant Physical Examination Screening Programme
The NHS Newborn and Infant Physical Examination Programme (NIPE) is part of the National Child Health Promotion Programme. It offers parents a head-to-toe physical examination for their baby to check for problems or abnormalities. The examination is carried out within 72 hours of birth and then again at 6-8 weeks of age.
As well as a general physical examination and an opportunity to discuss any problems, particular attention is paid to examination of the baby’s eyes, heart, hips and testes (boys only).
NHS Newborn Blood Spot Screening Programme
The aim of bloodspot screening is to identify babies at high risk of having conditions for which early diagnosis and treatment improves outcome. Parents are entitled to decline screening for all or any one of the conditions being screened for.
Neonatal bloodspot screening involves taking a blood sample obtained by pricking a baby’s heel. The blood is placed on special filter paper and sent for analysis. The test is usually carried out by the midwife when the baby is 5-8 days old and the result is available by 6 weeks.
Further information on conditions presently tested for under the ‘Newborn Blood Spot Screening Programme’ will be discussed later in the session.
NHS Newborn Hearing Screening Programme
One to two babies in every 1,000 are born with a hearing loss in one or both ears. The early identification of hearing loss is important for a child’s development.
Parents are offered a hearing screening test for their child within 2 weeks of birth. Two types of screen are used:
• Oto-acoustic emission (OAE): Involves placing a small soft-tipped ear-piece in the outer part of the baby’s ear and playing quiet clicking sounds. In a hearing ear, the cochlea produces sounds in response to the clicks that can be recorded and analysed by the computerized screening system.
• Automated auditory brainstem response (AABR): Involves placing small sensors on the baby’s head and neck and then presenting quiet clicking sounds through tiny, soft head-phones (muffs). A computer analyses the responses to sounds at and around the brain stem.
Below is the list of conditions presently tested for under the Newborn Blood Spot Screening Programme. Click on each condition for further information.
• Phenylketonuria (PKU) The neonatal blood spot test detects high levels of blood phenylalanine in newborn babies. Treatment is with lifelong dietary restriction of phenylalanine. With treatment, growth and development are normal.
• Cystic fibrosis (CF) Screening detects immunoreactive trypsin (IRT) which is increased in children with CF. If IRT is raised, the blood is deoxyribonucleic acid (DNA) tested for the most common gene alterations. Screening also detects healthy carriers. If a child tests positive, parents and siblings should receive genetic counselling and genetic testing for the condition
• Congenital hypothyroidism (CHT) Untreated, children with abnormally low levels of thyroid hormone fail to grow properly and have varying degrees of learning disability. The neonatal bloodspot test detects low levels of blood thyroxine. Treatment is with thyroxine replacement and results in normal growth and development.
• Sickle cell diseaseAbnormal haemoglobin is screened for using either high performance liquid chromatography (HPLC), or iso-electric focusing (IEF). The test detects sickle cell disease and trait, as well as some other haemoglobinopathies. If a child tests positive, parents and siblings should receive counselling about the meaning of the results and be offered genetic testing themselves.
• Medium chain Acyl CoA dehydrogenase deficiency (MCADD) Testing is positive when levels of C8 carnitine are elevated. Rarely other metabolic disorders may be detected. If a child tests positive, the child, parents and siblings should be offered genetic counselling and testing. Treatment with diet, supplements and prompt medical help if the child is unwell improves outcome.
• Homocystinuria, tyrosinaemia and other conditionsThe test for homocystinuria and tyrosinaemia is currently available only in Northern Ireland. This neonatal bloodspot test detects high levels of blood homocystine and tyrosine. Special diets started as early as possible in life result in better outcomes. In May 2014, the UK National Screening Committee announced their recommendation for homocystinuria screening to be offered to all UK newborns, together with new tests for three other genetic conditions: Maple Syrup Urine Disease (MSUD), Glutaric Aciduria type 1 (GA1) and Isovaleric Aciduria (IVA).
Example :
Whilst attending for a routine antenatal check, Charlotte, who is 36 weeks pregnant with her first child, tells you that she has never heard of any of the diseases that the neonatal bloodspot test screens for and is undecided whether to allow her baby to have the test.
Benefits of Newborn Bloodspot Screening
While these 9 conditions are very rare, for any baby that has any of these conditions, the benefits of screening are enormous. Detecting these conditions early means your baby can be started on treatment as soon as possible, to improve their health and help prevent severe disability or death occurring from the condition.
Limitations of Newborn Bloodspot Screening
The main limitations of newborn bloodspot screening are:
• Newborn bloodspot screening will not detect all conditions screened for.
• Newborn bloodspot screening does not make a diagnosis – it suggests that a baby may be at high risk of having one or more of the conditions screened for. This is known as ‘screen positive’
• Newborn bloodspot screening may identify a baby that is screen positive but after further diagnostic tests it turns out that the baby does not have the condition – this is known as a ‘false positive’
• Newborn bloodspot screening may not identify a baby that is later diagnosed as having one of the conditions screened for. This is extremely rare and is known as a ‘false negative’. It means that even though the screening result showed your baby was at low risk of having the disease and doesn’t need further testing, they may still be diagnosed with one of the conditions screened for.
• If, at any time, a parent or legal guardian has concerns about their baby or symptoms appear that they are worried about they should always contact their doctor.
There are a number of different non-cancer screening programmes for adults in the UK. Click on each of the headings for more information.
NHS Abdominal Aortic Aneurysm Screening Programme Abdominal aortic aneurysm screening is the newest screening programme now operating throughout the UK. All men will be offered screening with a single ultrasound scan at the age of 65. Men with aortic diameter of:
• less than 3 cm (960 in every 1000 men) are discharged from the programme
• 3-4.4 cm are offered annual ultrasound surveillance and lifestyle advice
• 4.5-5.4 cm are offered 3-monthly surveillance and lifestyle advice
• 5.5 cm or greater (5 in every 1000 men) are offered referral to a consultant vascular surgeon and lifestyle advice
It is estimated that screening will reduce the number of premature deaths from ruptured abdominal aortic aneurysm by up to 50%.
National Screening Programme for Diabetic Retinopathy Retinopathy screening is offered annually to all diabetic patients over the age of 12.
Systematic screening of diabetic patients for retinopathy involves digital photography of the retina followed by a two-stage or three-stage image grading process to identify the changes of sight-threatening diabetic retinopathy in the retina.
Patients with sight-threatening changes are referred or ophthalmology review and treatment, as needed.
NHS Chlamydia Screening Programme The objective of Chlamydia screening is the control of Chlamydia through the early detection and treatment of asymptomatic infection, thus preventing the development of squelae - such as infertility and ectopic pregnancy - and reducing onward disease transmission.
Screening is offered opportunistically to any sexually active young person under the age of 25. To maximise uptake, a wide variety of community-based venues are used to deliver the screening service.
For women, a self-taken vaginal swab or first void urine sample is used. For men, a first void urine sample is used. Samples are analysed using a Nucleic Acid Amplification Test (NAAT). A minimum of five weeks is recommended between tests.
Those screening positive are treated with either oral doxycycline 100 mg twice daily for 7 days, or oral azithromycin 1 g as a single, one-off dose. Partner notification is important.
NHS Health Check (for Vascular Risk) Screening of patients who have diabetes or have a history of cardiovascular disease for cardiovascular risk factors is well-established. The aim is to control cardiovascular risk for secondary prevention purposes.
Its purpose is primary prevention of heart disease, stroke, diabetes and kidney disease.
Everyone between the ages of 40 and 74, who has not already been diagnosed with one of these conditions, will be invited once every five years to have a check to assess their risk of heart disease, stroke, kidney disease and diabetes and will be given support and advice to help them reduce or manage that risk.
Example
Primary prevention is prevention of disease before it has occurred. Checks for healthy people to determine vascular risk are aimed at prevening them ever getting cardiovascular disease. Screening antenatally for HIV is aimed at preventing transmission of HIV from the mother to the baby, and screening antenatally for blood group is aimed at identifying rhesus negative women to prevent them developing antibodies and their babies developing rhesus disease.
Secondary prevention involves controlling disease in early form with the aim of achieving better outcome for the patient. For example through detecting early breast cancer, congenital hypothyroidism in neonates or abdominal aortic aneurysms before they burst.
Tertiary prevention involves prevention of complications once the disease is present, for example prevention of blindness in diabetics by retinal screening
In the UK there has been a national screening programme for breast cancer since 1988. The aim of the programme is to detect breast cancer at an early stage in order to increase survival chances.
Woman
The sensitivity of breast cancer screening tests in women aged over 50 is approximately 85%. Most of the cancers detected by screening have good prognosis.
The screening test
2-view mammographic screening is currently offered to women aged 50-70 years every 3 years. This is soon to be extended to women aged 47-73 years. Older women may also request screening every 3 years.
High risk women under the age of 50
Women with family history of breast cancer may be at increased risk of breast cancer themselves and may benefit from earlier screening and/or genetic screening.
The timing and type of investigation depends on the individual woman’s risk. Annual MRI surveillance can also be offered to women aged 30-39 with a personal history of breast cancer who remain at high risk, or in older women if mammography has shown a dense breast pattern. See NICE Guideline CG 164 for further details. [1]
This programme aims to detect colorectal cancer at an early stage to increase survival chances. If 60% of those aged between 60 and 69 are screened, 1200 deaths will be prevented each year.
Bowel screening
Faecal occult blood (FOB) testing kits are sent every 2 years to all patients between 60 and 69 years of age. Patients over 70 years old may also request testing kits.
The test kit has three flaps, each with two windows. Two samples are taken from a bowel motion and spread onto the two windows under the first flap using the cardboard sticks provided. The flap is then sealed and the process repeated for the subsequent two bowel motions. Once all six windows have been used, the kit is returned. Kits must be returned within two weeks of the first sample being taken.
Possible outcomes
FOB result Action
Normal No positive spots Screening offered again in 2 years if under 70 years of age.
Unclear
4% tested 1-4 positive spots Test repeated. If the second test is abnormal, colonoscopy is offered.
If the second test is normal, a third test is requested. If the third test is normal repeat screening in 2 years is offered if under 70 years. If the third test is abnormal, colonoscopy is offered.
Abnormal 5-6 positive spots Colonoscopy is offered
Technical failure Laboratory error Repeat testing is offered
Spoilt kit Patient error Repeat testing is offered
Follow up
Uptake of colonoscopy following abnormal FOB testing is about 80%. Sensitivity of colonoscopy to detect significant abnormalities is about 90%.
For 50%, no abnormalities are found on colonoscopy. 10% are found to have bowel cancer.
40% have a polyp found at colonoscopy. Polyps are usually removed during the procedure.
• If 1-2 adenomas under 1 cm diameter - the patient is returned to the routine FOB screening programme
• If 3-4 adenomas under 1 cm diameter or one or more adenoma >1 cm diameter - the patient is offered 3 yearly colonoscopy until 2 negative examinations are recorded
• If 5 or more adenomas, or 3 or more adenomas with one >1 cm diameter, colonoscopy is repeated after 12 months then 3 yearly until 2 negative examinations are recorded
Rarely other conditions (e.g. ulcerative colitis) may be found at colonoscopy.
High risk individuals
Family history
Patients with 2 first degree relatives with a history of colorectal cancer or one first degree relative with a history of colorectal cancer under the age of 45 should be referred for colonoscopy at age 35-40 (or at presentation, if later) and again at 55 years.
Refer for specialist follow up and genetic counselling if more than two first degree relatives have had colorectal cancer or there is a history of a genetic condition predisposing to bowel cancer.
Ulcerative colitis
Patients with ulcerative colitis have increased risk of colorectal cancer. All patients should be offered routine colonic surveillance as part of their specialist follow up programme.
Previous colorectal cancer
After successful treatment of colorectal cancer, younger patients are routinely followed up with colonoscopy every 5 years until the age of 70.
Cervical
Screening prevents 1000-4000 deaths per year in the UK from squamous cell cancer of the cervix
The screening test
You should give all women information about the risk of cervical cancer, the screening test, the possible results of screening and their implications.
When taking a cervical screening test, avoid menstruation if possible (note on the request form if unavoidable). The ideal time for taking a test is mid-cycle.
Health professionals responsible for performing cervical screening should receive adequate training. Skills should be updated every 3 years. Poor technique misses up to 20% of abnormalities.
The test is taken by rotating a special cervical brush clockwise through 5 complete rotations over the transformation zone of the cervix. The brush is then either rinsed into a vial of preservative fluid or the head of the brush is broken off into the vial. The cells in the vial are analysed using a technique known as liquid-based cytology.
The screening programme
A cervical screening test is routinely offered to all women aged 25-64 years who are sexually active. There is no upper age limit for the first test.
Frequency of screening depends on age:
• 25-49 years - 3 yearly screening interval
• 50-64 years - 5 yearly screening interval
• 65 years and older - Only screen those who have not been screened since the age of 50 years or who have had recent abnormal tests
Depending on the result and the woman’s past history, a recommendation is made by the screening service for:
• Rescreening after the normal screening interval
• Rescreening sooner than the normal screening interval
• Referral to the colposcopy service for further evaluation
Results may be relayed via the woman’s GP practice or notified directly by the cytology laboratory to the woman.
The Prostate Cancer Risk Management Programme
Prostate cancer screening using the prostate specific antigen (PSA) test has been the subject of extensive research in recent years, but its benefit remains unproven. While the latest results (2012) from a large European trial showed a relative reduction in prostate cancer-specific mortality of 20% in screened populations, there was no reduction seen in overall mortality, and this was associated with a high level of over treatment. To save one life, 37 additional additional cases of prostate cancer need to be treated [2]
The UK National Screening Committee has recommended that a prostate cancer screening programme should not be introduced in England at this time. Instead a risk management programme is in operation.
You should provide men requesting PSA testing with information explaining the pros and cons of screening. If the man is over 50 years old and still wants to be tested, this can be arranged through the NHS.
Which of the following Wilson-Jungner criteria would a screening programme for prostate cancer meet?
Select one or more options from the list below.
Possible answers:
A.
Important health problem
B.
Natural history is well understood
C.
There is a suitable screening test
D.
There is a detectable early stage
E.
Treatment at early stage is beneficial
F.
Risks and costs of screening are worthwhile
10000 men die every year in the UK as a result of prostate cancer and 1 in 8 men will have prostate cancer in their lifetime. In certain groups, such as African Caribbean populations, this increases to 1 in 4. Prostate cancer is an important disease.
The natural history of prostate cancer is not understood. There is no means to detect which ‘early’ cancers become more widespread.
The PSA test, although quick and easy, is not very specific. Two in every three men with a raised PSA on screening do not have prostate cancer. This can cause anxiety and over-investigation for well men.
Although recent evidence shows that screening does reduce death rates from prostate cancer, and early prostate cancer can be detected with PSA testing, incidental post-mortem evidence of prostate cancer is high (75% of men over the age of 75 years). Very few of these cases become clinically evident, so many more men would be found with prostate cancer by screening than would die or have symptoms from it. The potential for overtreatment is high. In addition, for many men with early prostate cancer, treatment does not seem to alter prognosis.
Peak incidence of morbidity and mortality of prostate cancer is in old age (75-79 years). At this age the risks of treatment are higher, and the potential years of life saved by screening are small. On current evidence, the risks and costs of screening for this age group are not worthwhile.
The Politics of Screening
Screening policy is a high profile health issue in the UK. The general public views screening as a fail-safe mechanism to prevent disease. Governments use introduction of new screening programmes as a political tool to gain popularity and votes. It intuitively seems right to prevent disease through screening.
High profile cases involving celebrities who were either not screened and developed disease or were screened and ‘saved’ as a result, fuels media coverage of the topic.
In reality, it is very difficult to decide whether a potential screening programme is worthwhile or not. Ideally, for all screening programmes the Wilson-Jungner criteria should be met before a screening programme is initiated. However, there is often insufficient information to make this decision, and the only way to get these answers may be to pilot the screening programme.
Session Key Points
• Screening is the investigation of an asymptomatic population with the aim of detecting a particular feature indicative of current or future disease
• Before instituting a screening programme the Wilson-Jungner criteria should be met
• Screening aims to prevent consequences of disease through detection of those with disease, or those at risk of disease, at a stage where preventive treatment can be instituted
• A good screening test has high sensitivity, and specificity, and high positive and negative predictive value
• Negative effects of screening include false reassurance that a person does not have disease, increased morbidity when treatment makes no difference, and cost and resource implications that result from screening
• In the UK, screening programmes are overseen by the NHS National Screening Committee
Evaluation comes in a variety of forms, but all of these types of evaluation seek to answer some common questions. These might include for interventions that you’re
planning to implement, will it work?
For interventions you’re already rolling out, is it working?
For interventions that you might have piloted but are looking to scale up, did it work?
Evaluation describes a toolbox of approaches that if employed correctly enable us to improve health and public health services, whether it’s a new service or an existing one. More specifically and in the definition used by the United Nations Development Program, evaluation is a rigorous and structured assessment of a completed or ongoing activity, intervention, program, or policy that will determine the extent to which it’s achieving its objectives and contributing to decision-making. In this way, evaluation shares characteristics with what might more loosely be called informal assessment. But evaluation is systematic and intended to inform implementation or improve service effectiveness. Conversely, informal assessment is more often opportunistic, both in what it examines and whether or not the information is used. Evaluation can be applied to any intervention whether an individual project or a broader program.
evaluation is much more: number 1, contextual. We’re only really interested in whether or not it worked in this setting whether it works elsewhere is beyond our scope. Number 2, collaborative. We want to know what worked well, and what didn’t work well. Whether this is objective or subjective is actually less important as we really value stakeholder engagement both to collect information and deliver improvement in the future. So what do we need to know to answer the question, did it work? Well, we have to understand what the aim of the intervention was, and what the objectives were. If these weren’t clear at the beginning of the intervention, then it makes evaluation more difficult.
Outcome evaluation: it can only be attempted following the intervention or after it’s run sufficiently long for a change an outcome to be feasible.
e.g. The aim of our breast cancer screening program is to reduce breast cancer mortality among women. Conceptually, it’s easy to propose an indicator to measure breast cancer mortality. But let’s make sure that we propose an indicator that fulfills the three CDC criteria.
But let’s make sure that we propose an indicator that
fulfills the three CDC criteria.
Our indicator is, deaths from breast cancer per 100,000 women age 16 years and above per year. Do you remember the CDC criteria for a valid indicator from the previous video?
A good indicator is specific, observable, and measurable.
So let’s apply those criteria to our indicator. Well, it’s measurable. We’re using a rate. Adult deaths per year multiplied by 100,000. It’s observable. Mortality is routinely and robustly collected in most high-income settings where screening programs are implemented and it’s specific, all women aged 16 years and above.
Once we’ve collected the information and calculated the statistic, we need to contextualize this indicator. We could do this either by comparing our statistic with mortality over time,
that is before and after the implementation of the screening program. Alternatively, we could compare the mortality rate for our population with a comparative population perhaps in another country. If our mortality decrease is always lower, then we can much assume that the program is working. That would be our key outcome evaluation finding.
To reduce breast cancer mortality among women undergoing screening.
So let’s propose the indicator. The proportion of women who are alive at five years following breast cancer screening. Now for those CDC criteria. Let’s test that now.
Our indicator is measurable because we’ve stipulated we’re going to use a proportion versus accountable rate.
Our indicator is observable. As provided, we can follow the women up. Whether or not they’re alive should be comparatively easy to determine.
Our indicator is specific, women at five-years following their breast cancer screening.
For now, we’re not going to include those women who didn’t undergo screening.
So you calculate the corresponding statistic. In this case, the proportion of women alive
after five years following screening. Now we need to contextualize this.
We can compare our statistic for women who did not attend screening with those women who did attend screening. Of course, any findings are subject to selection bias but I hope you can
see that by comparing these statistics, we can evaluate how effective this screening is.
So, let’s recap on the difference between these two examples.
The first evaluated whether our program worked at the population level.
The second evaluated whether our program worked for those who were screened.
What I want you to take away from this, is that evaluation answers only the question that you set.
Therefore, the learning is that you must be very clear in setting the question
The Donabedian approach to evaluation
It’s the Donabedian framework. Let’s imagine I’ve been asked by my client to evaluate their new smoking cessation service, that’s substituting regular tobacco based cigarettes with a new type of e-cigarette.
It’ll take four years to implement and they require findings for their funder at the end of each year. The client has been charged by the funder to undertake an evaluation, that comprehensively evaluates the program, informing them of whether to cancel, continue or scale up the intervention.
But first a question, what type of evaluation strategy do you recommend or employ?
• The client is aware there’ll be routinely collecting the following information:
• The number of patients assessed,
• the number of patients booked,
• the number of appointments attended,
• the number of patients receiving the e-cigarette device, and carbon monoxide tests at six weeks and six months, post initiation with the e-cigarette.
• They’ll also be undertaking a Patient Experience Questionnaire.
• This is a relatively common situation. The client will be good at collecting information related to that management and performance monitoring.
• However, they’re missing some important potential indicators.
Step for the Donabedian model.
First published in 2003 but actually developed during the nineteen sixties.
Donabedian describes three types of indicator: structure, process, and outcome.
More recently, an intermediate creeping has been added, output
What I love about this model is its simplicity. While it was conceived to measure healthcare specifically, it’s another take on the idea of measuring system quality
Here are the indicators proposed by the client. The first four indicators are processes, the fifth, carbon monoxide testing, could be an outcome or possibly an output but more on that later.
While the number of people undergoing carbon monoxide testing is a process, the results of these tests are a proxy of smoking cessation.
Well, the Donabedian model adds to our situation. That it highlights, we don’t have any structure indicators and we need more thought and potential indicators that evaluate outcomes.
So what are structures? Well, they’re buildings, equipment, staff and training that go into providing the service.
Adding these to the evaluation particularly as the service is ramping up, will allow us to monitor and understand program progression in the absence of processes to measure,
that is, before the patients arrive.
Let’s turn to outputs and outcomes.
The difference between these can be a little confusing at first, outcomes are what we’re eventually trying to change. In our situation, an outcome could be lung cancer incidence. In a similar way, an output may be the number or proportion of attendees who stopped using traditional cigarettes after six weeks or six months
If I’m using the pure Donabedian model, then there’s no difference between outputs and outcomes.
But hopefully you can see that outputs are typically an intermediate step between process and the change that you’re hoping for.
So let’s look at what a simple Donabedian model based evaluation might look like for this service using a formative or process evaluation approach.
I’m going to break out outputs and outcomes separately in this example.
First of all, we take the structures - thinking about the buildings,
IT and stuff that we have to put in place in order for the service to operate – slide above
While we monitor these resources over the life course of the project, they’re particularly important to the earlier stages, in the absence of processes and outcomes, they allow us to keep track of progress.
Next, we turn to processes.
We want to identify the key process indicators that will approximate to how well the service is operating.
In this case, we’ve picked how many patients have been enrolled, how many clinic appointments have been booked, and how many have been attended.
These Indicators considered together, may enable us to identify problems with the process system.
For example, is it that we fail to recruit patients or is it that they’re not turning up? – slide above
Outputs are next, they’re essentially the results of the intervention. We’ve included patient satisfaction, remember the domains of quality.
But we’ve also included a number of increasingly important outcome measures that will
allow us to examine where potential problems are arising. Perhaps lots of patients are smoke-free at
six weeks but they’re relapsing at six months.
Perhaps we could add further appointments at the six-week mark to sustain the response.
While we should be pragmatic in our evaluation, we shouldn’t shy away from advocating for
longer-term follow-up to assess real outcomes.
In this case, we’ve proposed a follow-up at five years looking at smoking status, which will be easy to measure, if we can track down participants.
Then the rather more challenging lung cancer incidence measure. As we have a huge number of people coming through the service and an incredibly effective intervention, then I think it’s comparatively unlikely we’ll see the incidence change over such a short period of time.
You can download a more detailed copy of the indicator matrix later.
So in summary, using the Donabedian model in this context has allowed us to categorize the indicators already available, and spurred us into thinking about what we are potentially missing,
in this case, structures and outcomes.
Perhaps more importantly though, a connection is now emerging between what we put in, structures, what we do, processes, what we hope to get out, outputs, and what the impact actually is, the outcome. This is a control logic model. We do x and we get y, but I’ll tell you more about this later.
Introduction
This guidance aims to help public health practitioners when conducting evaluations. This section provides an overview of what evaluation is, when it should be undertaken, and different types of evaluation. These are described in more detail on other pages. There is also a glossary defining the important terms and a guide to other resources.
Definition of evaluation
Evaluations tell us what works and what does not. An evaluation should be a rigorous and structured assessment of a completed or ongoing activity, intervention, programme or policy that will determine the extent to which it is achieving its objectives and contributing to decision-making (Menon, Karl and Wignaraja, 2009). For example, an evaluation might aim to determine if an intervention reached its intended audience, was implemented as planned, had desired impacts, improved outcomes and/or to establish for whom, how and why it had its effects.
Evaluation involves collection of information or data and facilitates judgements about the success and value of an intervention. Evaluations can be used to inform changes to improve an intervention, and aid decision-making about future courses of action. Evaluation can also help to ensure public accountability and that best use is made of limited resources.
Public health evaluations can vary in size and scope. For example, a study might evaluate the effects of government policies on health inequalities throughout England, or evaluate whether the provision of well-fitting slippers reduces falls in a home for older people. In this way, evaluations can improve services locally and provide evidence for national policy-making and, thereby, improve public health practice.
When should an evaluation be conducted?
It is particularly important to conduct an evaluation when one or more of the following criteria are met:
• there has been a significant investment of time, money and/or resources
• there is a possibility of risk or harm
• the intervention represents a novel or innovative approach
• the intervention is the subject of high political scrutiny or priority
• there is a gap in services or knowledge about how to address a problem or provide effective services for a particular population
In contrast, evaluations should not be conducted:
• if constant changes or modifications have been made to the intervention (because the evaluation could be premature and inconclusive)
• if the intervention is too early in development (unless the evaluation is designed as a formative evaluation with the aim of improving an intervention)
• if there is a lack of clarity or consensus on objectives because this makes it difficult for the evaluator to establish what is being evaluated
• for purely promotional purposes, that is, evaluations should not begin with the aim of identifying ‘success stories’
Further guidance on when to evaluation can be found in the evaluability section.
Stages of evaluation
There are 4 stages to evaluation.
1. Defining your evaluation questions. What do you want to discover; for example, what outcomes will you assess for whom, and over what time frame?
2. Data collection.
3. Analysing the data collected in stage 2 to answer the questions defined in stage 1.
4. Clarifying the implications of the findings and producing recommendations.
Further details can be found in the section on planning an evaluation.
Types of evaluation
We will consider 3 categories of evaluation.
Outcome evaluation
Public health interventions are intended to improve outcomes. Outcome evaluations are assessments of the results of an intervention and measure the changes brought about by the intervention (WK Kellogg Foundation, 2004). They therefore collect and analyse data on specific outcomes that are thought to be influenced by the intervention. The findings from an outcome evaluation can then tell us how effective the intervention is at changing those outcomes.
Several different study designs are used in outcome evaluations, including single-group pre-post comparisons, quasi-experimental studies with matched control groups, and randomised controlled trials. Each of these designs provides a different level of evidence about the effectiveness of an intervention: they vary in the extent to which they are able to attribute any observed change to the intervention (as opposed to other initiatives taking place at the same time) and demonstrate cause and effect (see causality for more information).
The section on outcome evaluation provides additional information and lists resources providing more detail.
Process evaluation
Process evaluations are assessments of whether a policy is being implemented as intended and what, in practice, is felt to be working more or less well, and why (HM Treasury, 2011). They do not primarily focus on outcomes but on how an intervention or service works. Process evaluations are often conducted alongside outcome evaluations (see above), and are usually used to evaluate complex interventions which have several components and are addressing multiple aims. They typically collect data on different aspects of the intervention, using mixed methods. The methods section provides further description and examples of evaluation methods.
In public health, process evaluations often assess how interventions are delivered within particular settings. They also investigate behavioural and other changes in the staff delivering and people receiving the intervention. Such changes in processes may explain observed changes in health outcomes, and the influence of contextual factors on how an intervention operates and brings about change.
Process evaluations are useful for understanding why interventions work in one service or area but not in another. They can also highlight for whom an intervention works best, enabling optimal targeting of particular interventions or services, or providing insight into aspects of the intervention that might need changing for other groups.
A key component of a process evaluation is construction of a logic model that explains how the intervention is thought to generate outcomes. Further details on what logic models are and how to create them is provided in the section on logic models.
Process evaluations are critical to improving the effectiveness of interventions, services and policies as they identify how interventions work, including strengths and weaknesses in delivery that influence effectiveness. More information and resources can be found in the process evaluation section.
Economic evaluation
Economic evaluations are assessments of the value gained from and the costs of resources used to implement a policy, programme or intervention (HM Treasury, 2011). An economic evaluation can clarify the costs and benefits of an intervention compared to an alternative course of action. This information can support decision-makers in allocating future resources, setting priorities and shaping health policy.
Economic evaluations depend on assessment and valuation of resources (for example, staff time) to estimate the costs involved in and stemming from an intervention. The outcomes or benefits of an intervention, often expressed in terms of quality-adjusted life years, also need to be carefully assessed. However, in public health, where there are long time lags between interventions and outcomes. it can be challenging to capture benefits fully.
The section on economic evaluation provides further description, examples and lists relevant resources.
Unfortunately, it’s pretty common for evaluation not to have been built in from the start,
which means you’ll commonly be coming to the project towards the end or even after it’s concluded.
Thinking about evaluation can be incredibly helpful when designing an intervention.
For example, thinking about your key performance indicators can focus the design on delivering outcomes.
When you know you’re going to be measured, you’re probably more likely to think about the future.
So why don’t smart people build evaluation into their projects from day one?
Well, almost anyone working in health systems or public health will have come across
evaluation at some point in their career, so it’s definitely not about awareness.
People in all fields of policy and practice are often scared of evaluation.
• They believe it requires expert knowledge,
• they don’t have time or resource,
• or they fear that their team will be disadvantaged if that project is found not to work.
In public health, some of these anxieties are even more pronounced.
We’re often seeking to implement complex, multi-faceted interventions, which are difficult to measure, or where effect is difficult to attribute.
It’s often very difficult to demonstrate something that hasn’t happened as is the case and effective prevention, and our impact is often many years into the future.
It’s true that evaluation is resource intensive, it can threaten future work, and sometimes,
it’s very difficult for us to demonstrate a fact, but none of these are good enough reasons
to avoid evaluation.
I hope you’ll agree with me that it’s unethical for us to continue to pour scarce resource into interventions that actually don’t work.
So we’ve talked about quality and how we can measure it in health care.
We’ve also taken a minor diversion to examine some of the reasons that evaluation is
conveniently missed in health intervention development and implementation.
Neo-Human Relations Theory
This group were social psychologists who developed more complex theories:
Maslow
McGregor (Theory X and Theory Y)
Herzberg
Likert
Argyris
McGregor (Theory X and Theory Y)
McGregor characterised how managers perceive the motivation of employees:
Theory X assumes that people dislike work and must be coerced, controlled, and directed toward organizational goals. Furthermore, most people prefer to be treated this way, so they can avoid responsibility.
Theory Y—the integration of goals—emphasizes the average person’s intrinsic interest in his work, his desire to be self-directing and to seek responsibility, and his capacity to be creative in solving business problems.
More nuanced view that the application of one or other approach depends on the nature of the work to be done and the individual.
Theory X (essentially ‘scientific’ mgt)
Lazy
Avoid responsibility
Therefore need control/coercion
Theory Y
Like working
Accept/seek responsibility
Need space to develop imagination/ingenuity
Advantages
Identifies two main types of individual for managers to consider how to motivate.
Disadvantages
Only presents two extremes of managerial behaviour.
- Team roles
Meredith Belbin5 was driven by the increasing importance of team-working in organisations at the time, Belbin set out to identify what made a good team, based on research in the UK and Australia. He identified from his research eight team roles necessary for effective team working:Implementer (the company worker)
Co-ordinator (chairman)
Evaluator – monitor
Finisher – completer
Innovator (plant)
Resource investigator
Shaper
Team worker
Mnemonic: ICE FIRST
Belbin found that in successful teams all eight roles (see detail below) could be seen in operation, and concluded that when selecting people for a team, filling the eight roles was as important as choosing technical skills or experiences. However, the team may consist of less than 8 people as most people fulfil more than one role.
Belbin’s ideas continue to be used by thousands of organisations world-wide because they make sense and are known to work. The concept works best when used openly within a team or across an organisation. Individual preferences are only useful if they’re known to others, so teams can assess who can best fulfil each role. You can use role identification as a form of team-building: it reinforces the fact that everyone is bringing something to the team, so you all need each other if you are to be successful.
The abbreviations after each title are the common shorthand used when describing and charting the roles.
Extrovert Roles
Outward looking people whose main orientation is to the world outside the group, and beyond the task(s) in hand.
Plant
PL
The Innovator. Unorthodox, knowledgeable and imaginative, turning out loads of radical ideas. The creative engine-room that needs careful handling to be
effective. Individualistic, disregarding practical details or protocol - can become an unguided missile.
Resource
Investigator
RI
The extrovert, enthusiastic communicator, with good connections outside the team. Enjoys exploring new ideas, responds well to challenges, and creates this attitude
amongst others. Noisy and energetic, quickly loses interest, and can be lazy unless under pressure.
Chairman
CH
Calm, self-confident and decisive when necessary. The social leader of the group, ensuring individuals contribute fully, and guiding the team to success. Unlikely to
bring great intellect or creativity.
Shaper
SH
Energetic, highly-strung, with a drive to get things done. They challenge inertia, ineffectiveness and complacency in the team, but can be abrasive, impatient and easily
provoked. Good leaders of start-up or rapid-response teams.
Introvert Roles
Inward-looking people principally concerned with relations and tasks within the group.
Monitor
Evaluator
ME
Unemotional, hardhard-headed and prudent. Good at assessing proposals, monitoring progress and preventing mistakes. Dispassionate, clever and discrete.
Unlikely to motivate others, takes time to consider, may appear cold and uncommitted. Rarely wrong.
Team
Worker
TW
Socially-oriented and sensitive to others. Provides an informal network of communication and support that spreads beyond the formal activities of the team. Often
the unofficial or deputy leader, preventing feuding and fragmentation. Concern for team spirit may divert from getting the job done.
Company
Worker
CW
The Organiser who turns plans into tasks. Conservative, hard-working, full of common sense, conscientious and methodical. Orthodox thinks who keeps the team
focussed on the tasks in hand. Lacks flexibility, and unresponsive to new ideas.
Completer
Finisher
CF
Makes sure the team delivers. An orderly, anxious perfectionist who worries about everything. Maintains a permanent sense of urgency that can sometimes help and
sometimes hinder the team. Good at follow-up and meeting deadlines.
Different roles will of course be important at different times, and high-performing teams will normally be aware as to which role(s) should dominate at any particular time. Belbin roles can of course be linked to personality types (e.g. Myers Briggs Type Indicators), where common words such as ‘Extrovert’ and ‘Analyst’ will be found - but remember that Belbin roles are
- Consensus Techniques
The two most used consensus techniques are the Delphi Method and Nominal Group Techniques:
Delphi Surveys
A Delphi survey is a structured group interaction process that is directed in “rounds” of opinion collection and feedback (Turoff and Hiltz, 1996). Opinion collection is achieved by conducting a series of surveys using questionnaires. The result of each survey will be presented to the group and the questionnaire used in the next round is built upon the result of the previous round11. It is most useful as a way of collecting and distilling the opinions of experts.
Identify potential participants - ensure they are representative
Round 1: invite participants to suggest relevant issues/ factors that should be considered. Produce questionnaire of closed questions plus opportunity for respondents to suggest additional ones.
Round 2: participants score their level of agreement/ disagreement with each statement. Aggregate results and include on next questionnaire.
Round 3 participants review their original scores in the light of the group scores.
Advantages:
large numbers of participants
geographically dispersed
low cost
anonymity possible
Disadvantages:
no face to face discussion of different views
little quantitative data acquired
validity of answers uncertain
predefined questionnaire
Nominal (expert) Group Techniques
The Nominal Group technique allows quick decision making with groups of different sizes, by allowing everyone to state their opinions which are then rated by the group as a whole. It is most useful if seen as an alternative to surveys, evaluation forms or focus groups. The steps are as follows:
Assemble group and state the subject under consideration
Allow every member to write their opinion or idea down independently in a set time
Each member in turn states their idea, which is written down by the facilitator, who may be an expert, the Delbecq technique (Delbecq, 1975), or a non-expert (Glaser technique) without further discussion
After a set time discuss the ideas, with the facilitator potentially helping participants to find common ground and develop hybrid ideas
Ideas can only be removed from the list by unanimous agreement or changed by consent of the member proposing the idea
Score and rank ideas to identify solution
Advantages:
ratings are anonymous
allows thinking time in silence
discussion uncovers ambiguity and increases validity of answers
discussion allows some statements to be redefined if necessary
panellists enjoy it
Disadvantages:
representativeness of panellists
definitions of agreement/ disagreement
potential influence of outlier with a small sized panel
moderate cost
dependant on panellists attending
- Consensus
An agreement - or at least no one disagrees so strongly that they feel unable to accept the consensus view!
Uses in management
to determine the level of support for a policy and the extent of opposition
to identify areas of disagreement which would be fruitful areas for further research
to provide a basis for quality assurance, in the absence of clear scientific evidence.
Applications in health services management
individual clinical care
organisational priority
prioritising services
strategic planning
research needs
a) Consensus development
Objectives:
to explore uncertainty/ differences of opinion to reduce disagreement to define areas of agreement/ disagreement
Features:
incorporate wide range of people’s views
ensure representative views
ensure all participants have an equal opportunity to express their views, provide opportunity for participants to explain their views and reconsider them
Need for structured methods because committees may not reflect consensus:
some individuals dominate discussion
hierarchical organisation will inhibit junior people from disagreeing with seniors
people often find difficulty in being seen to change their opinion in public
fear of appearing naïve or ignorant
b) Consensus development conferences
Consensus development conferences were started in US in 1977 and were a mixture of three activities:
a. Judicial process
b. Scientific meeting
c. Town meeting
Consultants in Communicable Disease have used this approach, for example around an outbreak of a new disease such as SARS. Other examples include:
breast cancer screening
indications for tonsillectomy
availability of insect sting kits for non-physicians
caesarean section
regional strategy for ENT services
A topic must meet the following selection criteria:
It should have public health importance; it should affect or broadly apply to a significant number of people.
Controversy or unresolved issues should surround biomedical/scientific aspects of the topic that would be clarified by the consensus approach, or there should be a gap between current knowledge and practice that a CDC might help to narrow.
It must have an adequately defined and available base of scientific information from which to answer the conference questions and to resolve the controversies insofar as possible.
It should be amenable to clarification on technical grounds, and the outcome should not depend mainly on the subjective judgments of panellists.
Five principles:
independent panel
meeting held in public, decisions made in private
previously posed questions
consensus statement produced
dissemination of statement
Three groups involved:
planners
speakers
panellists
Advantages
involve key researchers with opposing views, rather than supposedly objective written reviews of evidence
opportunity for panellists to question experts
opportunity for public to participate
process open to public scrutiny
Disadvantages
high cost
representativeness of panel
ability of non-expert panel to understand the issues
Cautions
Consensus development is not a substitute for scientific research, but a method of assessing current opinions. The consensus view is just as likely to reflect collective ignorance as wisdom. A consensus technique cannot generate additional knowledge.
Group effectiveness
Handy (1993) provides two dimensions for group effectiveness:
a. Ability to achieve organisational goals (formal goals)
b. Ability to satisfy individual members social and psychological needs (informal goals)
Ideally maximal group effectiveness is achieved when the needs and expectations of the organisation are one and the same as those of the individuals:
a. The givens
the group
the task
the environment
b. Intervening factors
leadership style
motivation
processes
c. The outcomes
productivity
member satisfaction
Elements to encourage good team working
The list below suggests the main elements to encourage good team working but it is not exclusive. There may be other elements that affect particular teams that are not on this list:
clear team goals and objectives
clear accountability and authority
diversity of skills and personalities
clear individual roles for members
shared tasks
regular internal formal and informal communication
full participation by members
reflexivity
diversity
the confronting of conflict
monitoring team objectives
feedback to individuals
feedback on team performance
outside recognition of a team
two way external communication
team rewards
encouragement of self-development/ training
support
Handy’s physical factors affecting group effectiveness7
Handy suggested that the following characteristics can affect effectiveness:
proximity increases group interaction
interaction increases cooperative feelings
physical barriers can prevent group formation
location of group meeting gives out signals
shared facilities encourage group identity
An overview of group effectiveness can be looked at under two groups of factors:
Immediate constraints - these set the scenario for the group, the closer they match the expectations of the members, the more effective the group
Group size
Small groups tend to be more cohesive and encourage full participation as opposed to large groups, although there are advantages and disadvantages in both. Larger groups have a greater diversity of the talent, skills, knowledge etc., whereas the larger the group, the less chance of any individual member participating.
A good size group consists of 5 - 7 people.
Membership
A group with knowledgeable members does better in progressing a task than an inexperienced group. A group with a wide range of talents represented in membership does better than one with a narrow range.
Nature of task
In a production line, technology often disperses employees and makes group cohesiveness difficult. Decision making, creative thinking often require a variety of membership/ leadership styles and talents. If task is urgent (e.g. outbreak team) then groups tend to be forced to be task-orientated.
Environmental
Close geographical proximity, preferably in the same building, helps the cohesiveness and effectiveness of a group. Bureaucratic organisations prefer formally set up groups. Matrix organisations prefer project led groups and are often more participative in style and therefore suit organisations where large numbers of professionals are employed.
Group motivation and interaction
These factors tend to be more modifiable than those set out under contract of members and leadership. Note all factors in (1) may have been set up by a supervisor, who is by definition external to the group.
Success or otherwise primarily depends on individual motivation and people’s perception of the importance of the task and their role within it. Adequate and timely feedback is important, together with the individual’s satisfaction with the membership of the group.
Group interaction
This depends on leadership, group motivation, and appropriate rules and procedures. Leadership depends on the optimum mix of attention to task and attention to people, taking the total situation into account.
Group motivation arises not just from individual motivation, but also the ability of leadership to develop a team spirit and obtain a high level of commitment from team members. This high level of interaction encourages the openness of the team to discuss and to become more compatible with pursuit of task.
Appropriate rules and procedures are necessary to control decision making and conflict. These can be simple, but may need to be more complex if the task is part of a multi-faceted complex goal or organisation.
- Inter-group (between groups) behaviour
Whether formal or informal groups exist, it is important to have knowledge of behaviour within and between groups in organisations.
Behaviour within a group is determined by key factors:
Individual motivation
Group leadership
Nature of task
(e.g. problem solving v. production)
Environment
(physical, social)
Group norms
(standard of behaviour)
Group cohesiveness
(loyalty to group)
Size of Group
Breaking an organisation down into smaller units (work groups) in order to cope adequately with the diversity of tasks that face it, creates opportunities to develop task interests and special know-how, but, at the same time it also creates rivalries and competing interests which can be damaging to the organisation’s mission statement.
The first systematic study of inter-group interaction was carried out by Sherif et al (1961). While it was removed from the arena of large organisations, two groups were studied in a boy’s recreational camp; it was an example of a planned observation study.
The two groups were encouraged to develop separate identities. The following observations were made between the groups:
a. Each group began to view the other group as an enemy
b. Hostility increased as communication between them decreased; this encouraged negative stereotyping of each other to arise
c. The effects of winning or losing an inter-group competition:
Winning:
maintains or increases group cohesiveness but reduces motivation
moves group's attention away from task towards individual needs
Losing:
tends to lead to disintegration of group by 'scapegoating'
task becomes all important
this focus allows the group to critically appraise themselves and realistically assess what changes are required to make the group effective
d. Inter group competition therefore has advantages and disadvantages
Advantages:
group develops a level of cohesiveness
group focuses on task
Disadvantages:
group develops competing or even conflicting goals
inter-group communication/co-operation breaks down
Impact of competition within each competing group
members loyal to group
concern for task accomplishment is greater than member's psychological needs
more autocratic leadership
each group becomes more highly structured and organised
member loyalty demanded by group
Impact between competing groups
other group seen as the 'enemy'
distortion of perception
hold negative stereotypes of other groups
if groups are forced into interaction, reinforcement of above
Sherif8, as well as other researchers, has followed up the resolution of inter-group conflict and recommendations for organisations:
a. Encourage and reward groups on their contribution to the organisational goals (‘the common good’) rather than just to individual group goals
b. Stimulate high level of interaction and communication between groups and provide rewards for inter-group collaboration
c. Encourage movement of staff across group boundaries in order to increase mutual understanding of problems
d. Avoid putting groups in head on conflict by competing for resources or status
- Communication in groups
Factors affecting communication in groups
Communication in groups is complex and without careful organisation can have a negative impact on the outputs from the group.
Supporting factors
There is better communication in groups that:
are meaningful to their members
spend time initially and periodically on their communication processes
give good member satisfaction and participation
are flexible
Inhibiting factors in group communication
how much we speak
to whom we speak
whether we speak defensively or openly
how much we hear
Level of communication depends on:
individual's personal needs and goals versus groups needs and goals
personal identity, image and role within the group. Who am I?
power influence and control. Who has it?
acceptance by other group members, intimacy
- Group norms
Guide behaviours facilitate interaction by specifying the kinds of reactions expected or acceptable in particular situations. Group norms exist when:
conformity and cohesiveness increase to the point where individuals (non-deliberately) suppress criticism as a result of internalisation of the group norms (Janis,1989)
when members work closely together sharing the same set of values, and when faced with a crisis that puts everyone under stress
- Group think
What is group think?
The term was devised in the 1970s by the American psychologist Irving Janis, who analysed group decision making in the Bay of Pigs fiasco. He defined group think as a form of decision making characterised by uncritical acceptance of a prevailing point of view. It is a form of collective delusion, where bizarre policies are rationalised collectively and contradictory evidence is discredited. Members of the group suffer an illusion of both invulnerability and morality, and construct negative stereotypes of outsiders. In the health service this may happen where a health authority is under great outside pressure because of e.g. a huge overspend.
Eight Main Symptoms of Group Think:
a. Illusion of Invulnerability: Members ignore obvious danger, take extreme risk, and are overly optimistic.
b. Collective Rationalisation: Members discredit and explain away warning contrary to group thinking.
c. Illusion of Morality: Members believe their decisions are morally correct, ignoring the ethical consequences of their decisions.
d. Excessive Stereotyping: The group constructs negative stereotypes of rivals outside the group.
e. Pressure for Conformity: Members pressure any in the group who express arguments against the group’s stereotypes, illusions, or commitments, viewing such opposition as disloyalty.
f. Self-Censorship: Members withhold their dissenting views and counter-arguments.
g. Illusion of Unanimity: Members perceive falsely that everyone agrees with the group’s decision; silence is seen as consent.
h. Mindguards: Some members appoint themselves to the role of protecting the group from adverse information that might threaten group complacency.
Avoiding Group Think
a. The group should be made aware of the causes and consequences of group think.
b. The leader should be neutral when assigning a decision-making task to a group,
initially withholding all preferences and expectations. This practice will be especially
effective if the leaders consistently encourages an atmosphere of open inquiry.
c. The leader should give high priority to airing objections and doubts, and be
accepting of criticism.
d. Groups should always consider unpopular alternatives, assigning the role of devil’s advocate to several strong members of the group.
e. Sometimes it is useful to divide the group into two separate deliberative bodies as feasibilities are evaluated.
f. Spend a sizable amount of time surveying all warning signals from rival group and organisations.
g. After reaching a preliminary consensus on a decision, all residual doubts should be expressed and the matter reconsidered.
h. Outside experts should be included in vital decision making.
i. Tentative decisions should be discussed with trusted colleagues not in the decision-making group.
j. The organisation should routinely follow the administrative practice of establishing several independent decision-making groups to work on the same critical issue or policy.
