• Noninvasive continuous intradialytic blood pressure monitoring: the key to improving haemodynamic stability

      Stewart, Paul; Stewart, Jill; University of Derby (Ovid Technologies (Wolters Kluwer Health), 2021-08-27)
      Intradialytic hypotension (IDH) occurs in 20% of haemodialysis treatments, leading to end-organ ischaemia, increased morbidity and mortality; and contributing to poor quality of life for patients. Treatment of IDH is reactive since brachial blood pressure (BP) is recorded only intermittently during haemodialysis, making early detection and prediction of hypotension impossible. Noninvasive continuous BP monitoring would allow earlier detection of IDH and thus support the development of methods for its prediction and consequently prevention. Noninvasive continuous BP monitoring is not yet part of routine practice in renal dialysis units, with a small number of devices (e.g. finger cuffs) having occasionally been used in research settings. In use, patients frequently report pain or discomfort at measurement sites. Additionally, these devices can be unreliable in patients with reduced blood flow to the digits, often manifest in dialysis patients. All existing methods are sensitive to patient movement. A new method for continuously estimating BP has been developed by monitoring arterial pressure near the arteriovenous fistula which can be achieved without any extraneous monitoring equipment attached to the patient. Additionally, artificial intelligence-based methods for real-time prediction of IDH are currently emerging.Key monitoring technologies and computational methods are emerging to support the development of real-time IDH prediction.
    • Perineal Trauma & Suturing

      Chapman, Vicky; Independent Researcher (Wiley Blackwell, 2018-01-18)
    • 'Mixed white and Black Caribbean' millennials in Britain: An exploration of identity

      Clarke, Yasmine; University of Derby (Wiley, 2021-07-26)
      This study presents a qualitative exploration of individuals identifying as ‘mixed white and Black Caribbean’ (MWBC) in Britain. The focus of this research aimed to answer the question, 'how do mixed white and Black Caribbean millennials in Britain experience their identity?' Six participants, aged 22–31 years, were interviewed about their family, relationships and personal values. The results were analysed using interpretative phenomenological analysis and highlighted three main themes: ‘Public Perception’, ‘Caribbean Heritage’ and ‘Conversations’. Each theme was analysed from an integrative psychotherapeutic viewpoint, before concluding with suggestions for counsellors and psychotherapists working with this client group in clinical practice.
    • An Analysis of Frequency of Continuous Blood Pressure Variation and Haemodynamic Responses during Haemodialysis.

      Latha Gullapudi, Venkata R; White, Kelly; Stewart, Jill; Stewart, Paul; Eldehni, Mohammed T; Taal, Maarten W; Selby, Nicholas M; University of Derby; University of Nottingham (Karger, 2021-07-22)
      Higher beat-to-beat blood pressure (BP) variation during haemodialysis (HD) has been shown to be associated with elevated cardiac damage markers and white matter ischaemic changes in the brain suggesting relevance to end-organ perfusion. We aimed to characterize individual patterns of BP variation and associated haemodynamic responses to HD. Fifty participants underwent continuous non-invasive haemodynamic monitoring during HD and BP variation were assessed using extrema point (EP) frequency analysis. Participants were divided into those with a greater proportion of low frequency (LF, n = 21) and high frequency (HF, n = 22) of BP variation. Clinical and haemodynamic data were compared between groups. Median EP frequencies for mean arterial pressure (MAP) of mid-week HD sessions were 0.54 Hz (interquartile range 0.18) and correlated with dialysis vintage (r = 0.32, p = 0.039), NT pro-BNP levels (r = 0.32, p = 0.038), and average real variability (ARV) of systolic BP (r = 0.33, p = 0.029), ARV of diastolic BP (r = 0.46, p = 0.002), and ARV of MAP (r = 0.57, p < 0.001). In the LF group, MAP positively correlated with cardiac power index (CPI) in each hour of dialysis, but not with total peripheral resistance index (TPRI). In contrast, in the HF group, MAP correlated with TPRI in each hour of dialysis but only with CPI in the first hour. EP frequency analysis of continuous BP monitoring during dialysis allows assessment of BP variation and categorization of individuals into low- or high-frequency groups, which were characterized by different haemodynamic responses to dialysis. This may assist in improved individualization of dialysis therapy.
    • Delivering informed measures of patient centred care in medical imaging: What is the international perspective?

      Hyde, Emma; Hardy, Maryann; University of Derby (Elsevier BV, 2021-06-25)
      Focus on patient experience and patient centred approaches within healthcare has substantially increased since the Picker Institute (a not for profit organisation) was established in the 1980’s (Picker Institute, 2021). Picker’s founding principles have been adapted from their original form, to keep pace with changes in health and social care, but remain the cornerstone of research and guidance on person-centred approaches. Organisations such as the National Health Service (NHS) in the UK, the Australian Commission on Safety and Quality in Health Care, and the Canadian Patient Safety Institute, have developed their own guiding principles for patient centred care, reflecting the nature of the health care systems in their respective countries. In the UK professional, statutory and regulatory bodies governing health care professionals, such as the Health & Care Professions Council (HCPC) and College of Radiographers, have also incorporated patient centred approaches and care into their Standards of Proficiency for registrants (HCPC, 2013; CoR, 2018). As guidance and regulation linked to patient care and patient experience has become more widespread, interest in research into patient centred care and approaches has developed. Publications sharing the findings of research projects carried out to investigate patient experience during medical imaging examinations and radiation therapy have also increased. In our research we have sought to define informed measures of patient centred care for medical imaging technologists, and to date have reported the findings from our UK based participant’s (Hyde & Hardy, 2020; Hyde & Hardy, 2021a; Hyde & Hardy, 2021b; Hyde & Hardy 2021c). In this commentary we would like to open up debate about the similarities and differences between UK and international views about patient centred care in medical imaging, and invite expressions of interest from potential collaborators.
    • Older people, dementia and neuro-dramatic-play: A personal and theoretical drama therapy perspective

      Holmwood, Clive; University of Derby (Intellect, 2021-05-10)
      This conceptual article will consider Sue Jennings’ neuro-dramatic-play (NDP) as an overall theoretical framework for working with older people with dementia. NDP was developed over a number of years by pioneering UK drama therapist Sue Jennings. It is a culmination of attachment-based play, drama, movement and storytelling, and arts-based approaches that are used within drama therapy and other play and creative-based work with children. The author will consider from a personal and reflective perspective how NDP approaches can be adapted by drama therapists to work with older people with memory loss based on almost 30-years history of being involved in the field of drama therapy as a student and practioner, and his work with older people, at both the beginning of his career and his current reflections many years later.
    • Fears of compassion magnify the harmful effects of threat of COVID-19 on mental health and social safeness across 21 countries

      Matos, Marcela; McEwan, Kirsten; Basran, Jaskaran; Gilbert, Paul; University of Derby (Wiley, 2021-04-20)
      The COVID-19 pandemic is a massive global health crisis with damaging consequences to mental health and social relationships. Exploring factors that may heighten or buffer the risk of mental health problems in this context is thus critical. Whilst compassion may be a protective factor, in contrast fears of compassion increase vulnerability to psychosocial distress and may amplify the impact of the pandemic on mental health. This study explores the magnifying effects of fears of compassion on the impact of perceived threat of COVID-19 on depression, anxiety and stress, and social safeness. Adult participants from the general population (N = 4057) were recruited across 21 countries worldwide, and completed self-report measures of perceived threat of COVID-19, fears of compassion (for self, from others, for others), depression, anxiety, stress and social safeness. Perceived threat of COVID-19 predicted increased depression, anxiety and stress. The three flows of fears of compassion predicted higher levels of depression, anxiety and stress and lower social safeness. All fears of compassion moderated (heightened) the impact of perceived threat of COVID-19 on psychological distress. Only fears of compassion from others moderated the effects of likelihood of contracting COVID-19 on social safeness. These effects were consistent across all countries. Fears of compassion have a universal magnifying effect on the damaging impact of the COVID-19 pandemic on mental health and social safeness. Compassion focused interventions and communications could be implemented to reduce resistances to compassion and promote mental wellbeing during and following the pandemic.
    • Patient centred care in diagnostic radiography (Part 3): Perceptions of student radiographers and radiography academics

      Hyde, Emma; Hardy, M; University of Derby; University of Bradford (Elsevier, 2021-01-27)
      Awareness is growing of the importance of patient centered care (PCC) in diagnostic radiography. PCC is embedded within professional body publications and guidance documents, but there is limited research evidence exploring the perceptions of student radiographers and radiography academics. This paper shares the findings of a research project seeking to define PCC in diagnostic radiography from the perspective of student radiographers and radiography academics. This paper reports Stage 1 and Stage 2 of the project from the perspective of radiography academic and student radiographer participants, and compare these to the perspective of service users, clinical radiographers and radiography managers, reported previously. Stage 1 used an online survey tool to gauge participant agreement with a series of attitudinal statements. Stage 2 used situational vignettes to promote discussion and debate about PCC approaches. Ethical approval was granted by the University of Derby College of Health & Social Care Ethics committee. Response rates to the Stage 1 survey were above the minimum threshold, with 50 responses from student radiographers and 38 responses from radiography academics. Stage 1 participants were asked to participate in Stage 2 on a voluntary basis. As with service users and service deliverers, care communication, event interactions and control over environment were the key influences on PCC. However, students highlighted differences between reported and observed levels of PCC. There is some way to go to embed PCC in diagnostic radiography practice. As impartial observers of radiography practice, student radiographers highlight the difference between service users and service deliverer’s perceptions of PCC. Whilst the focus of clinical radiographers remains on efficiency it is difficult for student radiographers to challenge the accepted norm. Role models are required to promote PCC behaviours and a holistic approach in radiography practice. A package of educational support and audit tools will be made available to support both service deliverers and student radiographers to deliver PCC.
    • Can compassion-focused imagery be used as an attention bias modification treatment?

      Leboeuf, Isabelle; McEwan, Kirsten; Rusinek, Stéphane; Andreotti, Eva; Antoine, Pascal; Université Lille Nord de France; University of Derby (Springer, 2021-01-06)
      Compassion focused-imagery (CFI), one of the psychological interventions of compassion-focused therapy, is receiving increasing attention. It is a therapeutic tool that targets the process of self-criticism by prompting individuals to imagine themselves as compassionate or to imagine receiving compassion from an ideal compassionate other. This research examines the role of self-criticism in the attentional processing of emotional stimuli, namely, critical and compassionate facial expressions. It is hypothesized that the activation of positive social emotions through CFI plays a role in broadening attention in the processing of emotional stimuli. The McEwan Faces stimulus set, which includes critical, neutral and compassionate faces, was used to create an attentional bias task called the dot probe task. The processing of emotional faces was assessed before and after exposure to either CFI or neutral imagery, controlling for the process of sensory integration (n = 80). A between-subject analysis was used to test the hypothesis. Before the imagery task, participants tended to look away from critical faces, and their level of self-criticism played a role. Both types of imagery significantly reduced the bias away from critical faces when the stimuli were presented for 1200 ms. This effect was reversed in the neutral condition for participants with high levels of self-criticism but not in the CFI condition. Interestingly, self-criticism impacts the attentional treatment of critical faces and the effect of imagery entailing sensory integration on this treatment. CFI seems to preserve this effect for participants with high levels of self-criticism, possibly due to the activation of positive social emotions.
    • A pragmatic controlled trial of forest bathing compared with compassionate mind training in the UK: impacts on self- reported wellbeing and heart rate variability

      McEwan, Kirsten; Giles, David; Clarke, Fiona; Kotera, Yasuhiro; Evans, Gary; Terebenina, Olga; Minou, Lina; Teeling, Claire; Basran, Jaskaran; Wood, Wendy; et al. (MDPI, 2021-01-28)
      Forest Bathing, where individuals use mindfulness to engage with nature, has been re-ported to increase heart rate variability and benefit wellbeing. To date, most Forest Bathing studies have been conducted in Asia. Accordingly, this paper reports the first pragmatic controlled trial of Forest Bathing in the United Kingdom, comparing Forest Bathing with a control comprising an es-tablished wellbeing intervention also known to increase heart rate variability called Compassion-ate Mind Training. Sixty-one university staff and students (50 females, 11 males) were allocated to (i) Forest Bathing, (ii) Compassionate Mind Training or (iii) Forest Bathing combined with Com-passionate Mind Training. Wellbeing and heart rate variability were measured at baseline, post-intervention and three-months follow-up. There were improvements in positive emotions, mood disturbance, rumination, nature connection and compassion and 57% of participants showed an increase in heart rate variability (RMSSD -parasympathetic activity). There were no significant differences between conditions, showing that Forest Bathing had an equivalence with an established wellbeing intervention. The findings will help healthcare providers and policy makers to understand the effects of Forest Bathing and implement it as a feasible social prescription to improve wellbeing. Future research needs to involve clinical populations and to assess the effects of Forest Bathing in a fully powered randomised controlled trial (RCT) .
    • Developing a whole-school mental health and wellbeing intervention through pragmatic formative process evaluation: A case-study of innovative local practice within the School Health Research Network

      Gobat, Nina; Littlecot, Hannah; Williams, Andy; McEwan, Kirsten; Stanton, Helen; Robling, Michael; Rollnick, Stephen; Murphy, Simon; Evans, Rhiannon; University of Oxford; et al. (BMC, 2021-01-18)
      The evidence-base for whole school approaches aimed at improving student mental health and wellbeing remains limited. This may be due to a focus on developing and evaluating de-novo, research led interventions, while neglecting the potential of local, contextually-relevant innovation that has demonstrated acceptability and feasibility. This study reports a novel approach to modelling and refining the theory of a whole-school restorative approach, alongside plans to scale up through a national educational infrastructure in order to support robust scientific evaluation. A pragmatic formative process evaluation was conducted of a routinized whole-school restorative approach aimed at improving student mental health and wellbeing in Wales. The study reports seven phases of the pragmatic formative process evaluation that may be undertaken in the development and evaluation of interventions already in routine practice: 1) identification of innovative local practice; 2) scoping review of evidence-base to identify existing intervention programme theory; outcomes; and contextual characteristics that influence programme theory and implementation; 3) establishment of a Transdisciplinary Action Research (TDAR) group; 4) co-production of an initial intervention logic model with stakeholders; 5) confirmation of logic model with stakeholders; 6) planning for intervention refinement; and 7) planning for feasibility and outcome evaluation. The phases of this model may be iterative and not necessarily sequential. Formative, pragmatic process evaluations support researchers, policy-makers and practitioners in developing a robust scientific evidence-base for acceptable and feasible local innovation that does not have a clear evidence base. The case of a whole-school restorative approach provides a case example of how such an evaluation may be undertaken.
    • Reduction of visual acuity decreases capacity to evaluate radiographic image quality

      Sá dos Reis, C.; Soares, F.; Bartoli, G.; Dastan, K.; Dhlamini, Z.S.; Hussain, A.; Kroode, D.; McEntee, M.F.; Mekis, N.; Thompson, J.D.; et al. (Elsevier BV, 2020-05-16)
      To determine the impact of reduced visual acuity on the evaluation of a test object and appendicular radiographs. Visual acuity was reduced by two different magnitudes using simulation glasses and compared to normal vision (no glasses). During phase one phantom images were produced for the purpose of counting objects by 13 observers and on phase 2 image appraisal of anatomical structures was performed on anonymized radiographic images by 7 observers. The monitors were calibrated (SMPTE RP133 test pattern) and the room lighting was maintained at 7 ± 1 lux. Image display and data on grading were managed using ViewDEX (v.2.0) and the area under the visual grading characteristic (AUCVGC) was calculated using VGC Analyzer (v1.0.2). Inferential statistics were calculated using SPSS. For the evaluation of appendicular radiographs the total interpretation time was longer when visual acuity was reduced with 2 pairs of simulation glasses (15.4 versus 8.9 min). Visual grading analysis showed that observers can lose the ability to detect anatomical and contrast differences when they have a simulated visual acuity reduction, being more challenging to differentiate low contrast details. No simulation glasses, compared to 1 pair gives an AUCVGC of 0.302 (0.280, 0.333), that decreases to 0.197 (0.175, 0.223) when using 2 pairs of glasses. Reduced visual acuity has a significant negative impact on the evaluation of test objects and clinical images. Further work is required to test the impact of reduced visual acuity on visual search, technical evaluation of a wider range of images as well as pathology detection/characterization performance. It seems that visual performance needs to be considered to reduce the risks associated with incomplete or incorrect diagnosis. If employers or professional bodies were to introduce regular eye tests into health screening it may reduce the risk of misinterpretation as a result of poor vision.
    • An iterative run-to-run learning model to derive continuous brachial pressure estimates from arterial and venous lines during dialysis treatment

      Stewart, Jill; Stewart, Paul; Walker, Tom; Viramontes-Hörner, Daniela; Lucas, Bethany; White, Kelly; Taal, Maarten W.; Selby, Nicholas M.; Morris, Mel; University of Derby; et al. (Elsevier BV, 2020-11-28)
      Objective: Non-invasive continuous blood pressure monitoring is not yet part of routine practice in renal dialysis units but could be a valuable tool in the detection and prevention of significant variations in patient blood pressure during treatment. Feasibility studies have delivered an initial validation of a method which utilises pressure sensors in the extra-corporeal dialysis circuit, without any direct contact with the person receiving treatment. Our main objective is to further develop this novel methodology from its current early development status to a continuous-time brachial artery pressure estimator. Methods: During an in vivo patient feasibility study with concurrent measurement validation by Finapres Nova experimental physiological measurement device, real-time continuous dialysis line pressures, and intermittent occluding arm cuff pressure data were collected over the entire period of (typically 4-hour) dialysis treatments. There was found to be an underlying quasi-linear relationship between arterial line and brachial pressure measurements which supported the development of a mathematical function to describe the relationship between arterial dialysis line pressure and brachial artery BP. However, unmodelled non-linearities, dynamics and time-varying parameters present challenges to the development of an accurate BP estimation system. In this paper, we start to address the problem of physiological parameter time variance by novel application of an iterative learning run-to-run modelling methodology originally developed for process control engineering applications to a parameterised BP model. Results: The iterative run-to-run learning methodology was applied to the real-time data measured during an observational study in 9 patients, supporting subsequent development of an adaptive real-time BP estimator. Tracking of patient BP is analysed for all the subjects in our patient study, supported only by intermittent updates from BP cuff measurements. Conclusion: The methodology and associated technology is shown to be capable of tracking patient BP noninvasively via arterial line pressure measurement during complete 4-hour treatment sessions. A robust and tractable method is demonstrated, and future refinements to the approach are defined.
    • Creative critical representation of the choreographer’s creation process

      Collard-Stokes, Gemma; University of Derby (Taylor & Francis, 2020-11-30)
      This review examines Jonathan Burrows: Towards a Minor Dance, a monography by Daniela Perazzo Domm published within the Palgrave Macmillan’s New World Choreographies series. Perazzo Domm’s first monograph introduces British choreographer Jonathan Burrows, whose work is considered an important contribution to contemporary performance practices’ effort to rethink what constitutes choreography. The review focuses of the books main themes of socio-political creativity and collaboration at the intersection(s) of artist, body and composition. The review observes this through the endeavour to question relational aspects between the writer and the choreographer’s creative process.
    • Neuro-dramatic play and a hero's journey: a play-based approach in a UK junior school

      Holmwood, Clive; University of derby (Routledge, 2020-11-30)
      This chapter aims to consider the principles of neuro-dramatic play - NDP (Jennings 2011) as a form of pre-therapy/ structured interventional play. By running nine sessions with a group of 15 children (Years 3 to 6, 7-11 year olds), all of whom had been handpicked by school staff, due to their confidence and self-esteem issues; I will explore the notion of NDP as an effective form of low level play based intervention. By allowing the children to build bridges with each other through the play and going on a fantastical and dramatic hero’s journey, I will consider the appropriateness of NDP as a way of supporting the confidence and self-esteem of a small group of middle school age children in the UK.
    • Routledge international handbook of play, therapeutic play and play therapy

      Jennings, Sue; Holmwood, Clive; University of derby; University of Witwatersrand, South Africa (Routledge, 2020-11-30)
      Routledge International Handbook of Play, Therapeutic Play and Play Therapy is the first book of its kind to provide an overview of key aspects of play and play therapy, considering play on a continuum from generic aspects through to more specific applied and therapeutic techniques and as a stand-alone discipline. Presented in four parts, the book provides a unique overview of, and ascribes equal value to, the fields of play, therapeutic play, play in therapy and play therapy. Chapters by academics, play practitioners, counsellors, arts therapists and play therapists from countries as diverse as Japan, Cameroon, India, the Czech Republic, Israel, USA, Ireland, Turkey, Greece and the UK explore areas of each topic, drawing links and alliances between each.  The book includes complex case studies with children, adolescents and adults in therapy with arts and play therapists, research with children on play, work in schools, outdoor play and play therapy, animal-assisted play therapy, work with street children and play in therapeutic communities around the world. Routledge International Handbook of Play, Therapeutic Play and Play Therapy demonstrates the centrality of play in human development, reminds us of the creative power of play and offers new and innovative applications of research and practical technique. It will be of great interest to academics and students of play, play therapy, child development, education and the therapeutic arts. It will also be a key text for play and creative arts therapists, both in practice and in training, play practitioners, social workers, teachers and anyone working with children.
    • Recreational burlesque and the aging female body: challenging perceptions

      Collard-Stokes, Gemma; University of Derby (Taylor & Francis, 2020-10-28)
      Rejecting the association between aging and asexuality that persists in the UK’s cultural representation of the female aging body, this paper reveals the importance of sensuality and maintaining physical agency to older women. It pays attention to the phenomena of participating in recreational burlesque classes to counter and negotiate potentially negative representations. Through in-depth interviews and researcher-as-participant observation, the paper explores the transformative possibilities mediated through participating in theatrically glamorized performance classes and the processes thereby initiated. The author examines the potential of burlesque to offer improvements to wellbeing and healthier self-perceptions for aging women experiencing marginalization through social invisibility.
    • The magic of the mundane: the vulnerable web of connections between urban nature and wellbeing

      Dobson, Julian; Brindley, Paul; Birch, Jo; Henneberry, John; McEwan, Kirsten; Mears, Meagan; Richardson, Miles; Sheffield Hallam University; University of Sheffield; University of Derby (Elsevier, 2020-10-23)
      Cities are sites of human, ecological and institutional stress. The elements that make up the city – its people, landscapes and processes – are engaged in constant assemblage and disassembly, joining and pulling apart. Reporting the findings of a three-year multi-disciplinary deep case study, this paper examines the role of urban nature in mediating the relationship between stressed humans and stressed places. It applies assemblage theory to show how such relationships can be understood in contexts of multiple pressures. From empirical findings it shows how urban nature contributes to mental wellbeing, but also how institutional stresses linked to austerity policies shape efforts to reconnect humans and nature. Across five strands of research, this article foregrounds the importance of multiple everyday experiences of urban nature and practices of care and maintenance. It calls on researchers, policymakers, planners and practitioners to pay closer attention to the ‘magic of the mundane’ in supporting human wellbeing; in caring for spaces and places; and in providing the services that link people and the natural environment.
    • Patient centred care and considerations

      Hyde, Emma; University of Derby (CRC Press/ Routledge, 2020-07-15)
      This chapter shares the findings of a large scale research project into patient centred care in diagnostic radiography.
    • Delivering patient centred care (Part 2): a qualitative study of the perceptions of service users and deliverers.

      Hyde, Emma; Hardy, Maryann; University of Derby; University of Bradford (Elsevier, 2020-10-07)
      There is growing awareness of the importance of patient centred care (PCC) in health care. Within Radiography in the UK, elements of PCC are embedded within professional body publications and guidance documents, but there is limited research evidence exploring whether perceptions of PCC are equivalent between those delivering (radiographers) and those experiencing (patient) care. This study aimed to address this gap by determining compatibility in perceptions of PCC between those using and those delivering radiography services in order to develop measurable indicators of PCC. This project was funded by the College of Radiographers Industry Partnership Scheme. Ethical approval was granted by the University of Derby College of Health & Social Care Ethics committee. This paper reports Stage 2 of the project, which was a series of focus groups and telephone interviews to enable deeper discussion and exploration of PCC. Situational vignettes were used to promote discussion and debate and encourage suggestions for PCC approaches. Audit tools to assess engagement with PCC were developed at individual and organisational level. Four focus groups and six telephone interviews were carried out in total. Focus groups were held in a variety of locations to promote attendance. Telephone interviews were used to capture participants who could not attend a focus group in person. Disparity between perceptions of service users and those delivering radiography services on what constitutes high quality PCC was evident. Perceived levels of care and the effectiveness of communication appeared to be the key influences on whether PCC was delivered. It is evident from the results of Stage 1 and Stage 2 that we have some way to go before we have parity in how care within diagnostic radiography is perceived, experienced and delivered. Audit tools and an educational toolkit are offered as ways to support increased PCC within diagnostic radiography practice. Several service improvements and audit tools are offered to support the increased delivery of PCC.