Clinical pathways (CPs) are intended to standardise and improve care but do not always produce positive outcomes, possibly because they were not adapted to suit the specific context in which they were enacted. This qualitative study aimed to explore staff perspectives of implementation of a CP for routine screening, assessment, referral and management of anxiety and depression (the ADAPT CP) for patients with cancer, focussing on perceived feasibility of the CP and negotiated adaptations made during the implementation phase.n = 88) and 6 months later, half-way through the implementation period (n = 89). Monthly meetings with lead multi-disciplinary teams at the eight enhanced sites were recorded. Data were thematically analysed.The ADAPT CP was implemented in 12 urban and regional oncology services in Australia. Services were randomised to receive core versus enhanced implementation strategies. Core sites received support until implementation commencement and could access progress reports. Enhanced sites received proactive, ongoing support during the 12-month implementation. Purposively selected staff were interviewed prior to implementation (Six overarching themes were identified: ADAPT is of high value; timing for introducing the CP and screening is difficult; online screening is challenging; a burden too much; no-one to refer patients to; and micro-logistics are key. While early screening was deemed desirable, diverse barriers meant this was complex, with adaptations made to time and screening location. Online screening prompted by email, seen as time-saving and efficient, also proved unsuccessful in some services, with adaptations made to in-clinic or phone screening, or repeated email reminders. Staff negative attitudes to ADAPT, time constraints, and perceived poor fit of ADAPT to work roles and flows, all impacted implementation, with key tasks often devolving to a few key individuals. Nevertheless, services remained committed to the ADAPT CP, and worked hard to create, review and adapt strategies to address challenges to optimise success.This study demonstrates the interactive nature of health service change, with staff actively engaging with, forming views on, and problem-solving adaptations of the ADAPT CP to overcome barriers. Obtaining staff feedback is critical to ensure health service change is sustainable, meaningful and achieves its promise of improving patient outcomes.The study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN12617000411347.The online version contains supplementary material available at 10.1186/s12913-022-07532-2. Clinical pathways (CPs) outline a sequence of standardised, evidence-based clinical management steps with timeframes and expected outcomes, for defined patient groups . They arWithin the literature, there is significant debate regarding if, and to what extent, CPs should be adapted during implementation. Some advocate for strict adherence to the published CP , 14; othOur group developed a CP for screening, assessment, referral, and management of anxiety and depression in adult cancer patients (ADAPT CP) . The eviWe developed implementation strategies  to addreThe ADAPT CP was implemented for 12 months, in a cluster randomised controlled trial (CRCT) evaluating two different implementation strategies (core versus enhanced) in 12 Oncology services in New South Wales (NSW) representing approximately 25% of cancer centres in the state, which were set in 7 of the 15 Local Health Districts of NSW, the most populous state in Australia . The stuWe have earlier described how the CP was tailored during the initial engagement with services prior to implementation . This pan = 12) were purposively selected to provide diversity in urban versus regional settings and size of patient load, and randomised to core or enhanced implementation support arms.Participating sites were public or private oncology services providing cancer care for ≥ or < 100 patients per year (to examine how the ADAPT CP was used in sites with more or less patient throughput). Exclusion criteria included inability to commit to required study processes, and insufficient technology to support use of the ADAPT Portal. Potential sites , a subset of staff at each service, purposively selected to include members and non-members of the lead team and multi-disciplinary representation, were invited to participate in a semi-structured phone interview exploring attitudes to and expectations of the ADAPT CP. We aimed for a sample sufficient to ensure saturation of themes within different staff groups and different services.Non-members of the lead team were included to ensure representation of views of frontline staff enacting the ADAPT CP. Interviews were conducted by three female researchers trained in qualitative methods with no involvement in preparing services to deliver the ADAPT CP. Interviews were conducted again 6 months later (T1) to obtain feedback regarding how the ADAPT CP was working in practice, any CP adaptations made and their rationale. The interview guide was developed based on a recent systematic review and implementation outcomes , 24 and Research staff minuted monthly meetings to capture discussion and decisions made.Interviews were audio recorded, transcribed verbatim and coded in NVivo12 . Data wen = 10), private (n = 1) and public-private partnership (n = 1) services were included.Seven metropolitan and five regional cancer services participated in the ADAPT CRCT  and 89 were interviewed at T1. Due to staff changes, leave or unavailability, different individual staff members were approached at T1; 64 staff were interviewed at both T0 and T1, 24 only at T0 and 25 only at T1. Average interview duration was 22 mins and 24 min at T0 and T1 respectively. Participants had on average 6 years of experience in their role (range 0 to 33). See Table (M = 10.50). Average meeting duration was 35 min. Forty-one meetings (49%) were delivered in-person, 35 (42%) online (web-conference), and eight (10%) via teleconference. There were 366 attendances across all meetings (M = 4.21 per meeting); the majority of attendees  were lead team members  participant ID (P), and assessment point (T) are identified for each interview quote e.g., NURS_S01P05T1. See Table Attitudes towards ADAPT CP were positive throughout implementation. Participants believed the ADAPT CP would ensure all patients who needed psychosocial help would be identified, including those with non-visible distress, facilitate early identification of morbidity to enable timely and appropriate care, and keep patients positively connected to the service.“I think it [ADAPT CP] is needed and useful, I think everyone knows it’s common for cancer patients to have anxiety and depression, we all recognise that treatment is useful.” (MED_S11P05T0).“It’s seen as a … positive way to stay engaged with the team even after discharge.” (PSYCH_ S07P05T0).“I’ve had a couple of patients actually thank me about it, … just reaching out … I think … they’ve found that quite nice.” (NURS_S01P04T1).“The staff have said that, because of ADAPT, we have picked up patients who needed help even though they didn’t appear to need help.” (MED_S01P09T1).“somewhat redundant”  and duplicated existing services, “re-inventing the wheel” (PSYCH_S12P07T1).However, some felt ADAPT was “To be honest, I think we had a pretty good way of doing it before ADAPT … but it’s good to have a bigger version and it’s online so people can do it self-directed” (NURS_S07P04T0).Despite positive attitudes, challenges to implementing ADAPT CP were identified by staff, including timing. Some sites initially chose to introduce ADAPT and the rationale for regular screening at the patient’s first oncologist appointment. However, patients were sometimes hard to identify at this time (due to multiple entry points into the system) and too overwhelmed. Staff were focused on co-ordinating treatment plans and yet to develop a relationship with the patient. If some time elapsed before the patient was screened, some patients forgot or lost motivation.“I think it’s given at the wrong time … they have a thousand things to think about when they’re first seeing the doctors in that situation. So … I think that’s very inappropriate” (NURS_S04P03T1).“Team says if the patient does not know them at this stage and if it is introduced over the phone, it could be difficult to sell.” .tough” for nursing staff on top of existing clinical responsibilities, and time consuming.Screening in clinic immediately prior to or during treatment also presented issues, as anxiety and depression scores could be transiently and contextually high. Staff also found introducing ADAPT during clinics was “… we had a few people that have screened while they’re having treatment, … they can screen quite high because they’re quite anxious just about how it’s going to go, and what’s happening and it’s all new... Whereas if they did it at home or after their treatment, then they might actually have screened differently.” (PSYCH_S02P01T1).“After discussion with the ADAPT team, several services changed to later registration which was perceived to work better:“We were doing the distress thermometer on first presentation and so, there was an awful lot of people that I was contacting. So now … they’re screened more appropriately and at a better time. because everyone’s going to flag high on initial presentation … it’s culled a bit of work out.” (PSYCH_ S05P01T1).One service shifted from introducing ADAPT at the surgical clinic to discharge planning, although even this was not deemed optimal:“ emailed staff regards inclusion of ADAPT in discharge planning. She feels this has had no impact on ADAPT activity, mainly because patients are very pre-occupied with other issues at discharge.” .more feasible” as patients were there much longer (PSYCH_S03P08T1). Another said:One nurse noted that conducting screening in the chemotherapy suite was ““So I’ve spoken to all my colleagues … we feel to introduce them to the ADAPT program is best when the nurse does drug education … and then when they come in to Cycle 1 in the chair … we then say, would you like to register? And if they do, we register there and then.” (NURS_S02P09T1).One site organised a back-up approach by the Nursing Unit Manager if ADAPT was not introduced; other sites simply accepted that some patients would be missed.While initially thought to offer considerable benefit in saving time and providing greater convenience to patients, online screening prompted by email had a low uptake, and even when patient-preferred, low adherence . Staff cited barriers such as older age and lower socio-economic background contributing to patients not having an email address, lacking access to devices at home or lacking the technological literacy to complete email screening independently. Furthermore, without staff present to prompt screening, it was quickly forgotten by patients.“We’d imagined that people would register and then they would screen via emails and electronically, but that hasn’t happened.” (PSYCH_S10P01T1).“We have quite an older population here, so a lot of people don’t have email addresses.” (AH_S06P03T1).“A few people have said, oh, yeah, yeah, I remember that being in my inbox and, um, they just don’t want to address it really.”(NURS_S12P01T1).However, some staff believed that the way ADAPT was communicated to patients was critical in influencing adherence, as opposed to the medium or format of screening.“I think … that we have to push it so that it’s almost not optional … this is what we do; how do you want to receive this? Do you want to do it here, or do you want to do it at home?” (NURS_S02P08T1).One site identified two instances where family members had completed email screening without patients being aware this had taken place , which raised concerns. Another site became concerned that email screening may lead to delays in offering support to patients expressing high distress, violating their duty of care.“[Nursing staff] was questioned … about patients screening highly distressed/suicidal on a Friday night and then this not being acted on until a Monday and conveyed it would not be acceptable to leave them 3 days without contact.” .In the case above, it was ultimately decided that since patients are automatically referred by the online portal to resources and helplines if their distress score is high, and since a direct suicide question is not asked, then online screening by email could continue. One site developed an email reminder system for patients if they did not screen immediately:“Team reconfirmed that email is preferred as finding people in clinic and getting hold of them over the phone can be logistically difficult and time-consuming … Email reminders sent by  to remind patients to screen.” .Other sites reverted to in-clinic screening or telephone follow-ups with patients to prompt screening.not my role,” that they lacked required skills, or just could not fit them into their already stretched workload, and that ADAPT caused friction. A social worker said:Despite initially reporting that the ADAPT CP fulfilled service and personal mission, many staff felt ADAPT tasks were ““Nurses are run off their feet … Nurses cannot and will not prioritise this work”. .“They’re like, that’s not my thing, that’s not my job …” (NURS_S01P06T1).“I also get a sense that there might be some hesitation to actually discuss anxiety and depression … they [nursing staff] are worried that if they open a can of worms, the patient will … almost decompensate, and what do they do?” (PSYCH_S06P13T1).In one site, the view was expressed that ADAPT would never be accepted unless it was made mandatory:“ noted that the only way people will engage with it is if this is mandated …. if [Med Onc] and [Director of Cancer Services] make them do it.” .Conversely, other staff felt that ADAPT had reduced their burden.If anything, it’s probably made things a little bit easier for us, [because] we can pick the patients up earlier …. rather than waiting until things fall down and then, we’re trying to pick them back up.” (NURS_S01P04T1).“Some services put significant thought into role responsibilities to maximise efficiency and efficacy, and make use of existing staff skills, both initially, and over time.“We’ve got the girls out the front. We’ve got it set up that they’ll be able to help them out once … the patient has been educated about the program and the screening …” (ADMIN_S02P05T0).“We were mindful during the planning stage of … who’d have the clinical confidence to go asking questions or running through surveys with patients, so admin were delegated tasks which were specific to their role, and nursing staff and the new [psychosocial staff] were allocated roles which were according to their competencies.” (NURS_S05P06T0).Some sites tried to reduce burden by involving more staff to share the load.“ADAPT is ‘everybody’s business’ such that all people need to be involved rather than this being the responsibility of a single person” ."… there’s five of us. So we each just take one day and then if … an alert comes on in that day then it’s our responsibility to do the triage conversation” (PSYCH_S02P01T1).In some sites, however, back-up staff were unwilling to help out, particularly to pick up patients not seen by the designated screener. In other sites, roles devolved to only a few, often the champion or lead team, to ensure tasks were completed."This theme has been raised consistently throughout the implementation, but attempts to engage medical staff, ward staff, step down facility staff, outpatient staff have failed.” .“So we have a lead team … we were meant to share the workload between us …. But it’s ended up being … just between three of us … and I think that’s what’s been so difficult” (NURS_S10P02T1).“invisible on the ward.”However, restricting ADAPT roles to the lead team could mean that most clinical staff lost awareness of ADAPT, which became “They’re heavily involved in it and they’re managing it quite well. So it’s … almost to the point, non-existent for everyone else on the ward.” (NURS_S07P06T1).Finally, if the person responsible for screening went on leave, or was sick, the system broke down:“Registrations: have been lower than expected over the last 2 months and it became apparent that in the absence of the administrator who had been placing pamphlets and registration slips, this task had not been completed by anyone else which led to a breakdown in the workflow.” .One site decided to make adaptations by devolving some of the work to patients themselves, by prompting patients to screen via email and complete their own registration:“If all patients screen via email and patients fill out mandatory fields themselves, it could be possible to eliminate the registration slip step...” .Some services had no, or insufficient, inhouse psychosocial staff, and were concerned that having identified psychological morbidity, they could not facilitate appropriate and timely support. Some services relied on referral to a local GP, private providers or a psychiatrist.“… at the moment, … we have only got one clinical psychologist … and so, that is quite difficult … for our patients to get into that, so … some people that potentially could, afford to … pay to go to see somebody privately...”(NURS_ S01P04T0).“We don’t have much psychosocial support here at all. We have a social worker.” (NURS_S03P05T0).There was also a perception by staff that external pathways were not always ideal or were difficult for patients to access. However, this was the only option for referral at some services in the absence of inhouse psychosocial staff.Some services saw this as an opportunity and took the initiative to expand referral sources when gaps were identified in planning to implement the ADAPT CP.“Pathways for these patients to go to, apart from the social worker … are starting to be developed which is great” (NURS_S03P04T1).“We’ve got access now to a Telehealth interview with an area psychiatrist who is providing psychology services one afternoon a month … for those higher-level distress patients. It’s better than it has been, because … [previously] we have to contact the GP and ask them to do a mental health plan. Then they get put on a waiting list for, um, to see a psychologist in the community. And that’s still under-resourced and hasn’t changed.”(NURS_S02P08T1).Some services discussed workflow breakdowns due to clinic processes that did not emerge until implementation was underway, for example, unclear procedures or inadequate record-keeping.Many services innovatively developed their own systems for ADAPT CP processes, such as who did what, placing ADAPT registration forms in patient files, providing a script for staff to use when introducing ADAPT, and having an agreed sequence for paperwork so that missing steps could easily be identified and rectified. These adaptations were well received."So we got the flow sheet … and tweaked it and … even during training as other things came up … with the volunteers and their concerns, things have been tweaked again … which has been really good … that has been able to work for us." (NURS_S01P04T0)."So … they’ve come up with a whole practice around that which they’ve highlighted and mapped out and done that very well so far, so, happy with the way they’re working on those." (ADMIN_S01P10T0)."Suggestion by  was the New Patient Form have an ADAPT tick-box included so specialists remember to raise it with patients" .Staff noted that the initial thought that went into developing systems could make or break the success of the CP.“And I do think all those little things add up … just make it easier when you’re in the clinic and you’re trying to think of ten things, and this one just can tell you automatically” (MED_S06P02T1).While many services adapted the ADAPT CP, services varied in the degree to which they formally notified ADAPT research staff of changes leading to the local workflow being updated. Five services notified no changes, four 1 change and three 2 changes. Examples of initial and final detailed service workflows for two services are provided in Additional file This is one of the first studies to document stakeholder experiences of implementing a CP, and the adaptations to the CP made as a result to address feasibility issues. The CP in this case was for screening and management of anxiety and depression in cancer patients (the ADAPT CP) .Despite steps taken to maximise the ADAPT CP implementation success , and a belief expressed by many stakeholders in the value of the CP, barriers to its adoption and implementation feasibility were still encountered.These included finding the right time to initiate screening when patients had formed a trusting relationship with staff, were no longer overwhelmed, yet were sufficiently early in their care to allow identification of distress before it developed into a clinically significant problem. The Australian Clinical Practice Guidelines for managing anxiety and depression in cancer patients  do not sA second issue which emerged was the virtue or otherwise of online screening. Online screening has been promoted as a way to reduce costs and increase feasibility and acceptability for patients who may be too rushed or uncomfortable to complete questionnaires in the clinic , and decAnother key barrier to implementation of the ADAPT CP identified by participants, was the perceived staff burden, on top of existing roles and responsibilities, of required tasks related to ADAPT. The degree to which this activity was felt to be a reasonable and valid part of diverse staff’s roles, core to service and individual mission, impacted the way services responded. As Damschroder et al.  has commprior to implementing a new CP.Management could also choose to strongly endorse participation in new psychosocial CPs and perform audits to ensure compliance. Furthermore, at a service level, adequate resourcing is vital to allow staff to complete required tasks without risking stress and burnout. A recent Australia survey found 38% of respondents reported lack of resources as a major barrier to implementing psychosocial care . DespiteIn the current study, many services made creative adaptations to overcome challenges, demonstrating the key importance of leadership and active engagement by a range of stakeholders (delivery partners) in implementing change, as noted by Yamey et al. . WithoutThis study is not without limitations. While we had good multidisciplinary representation, some staff did not agree to be interviewed, thus their views were not represented. While interviewers were independent of the ADAPT research team who interacted with staff during implementation, social desirability bias may nonetheless have impacted responses, leading to a more positive perspective being presented than was actually felt. Due to more intensive interaction of ADAPT Team with Enhanced arm sites during implementation , there may have been barriers/challenges and adaptations at Core services during the implementation phase to which the ADAPT Staff were not privy and thus not reported here.“Most good ideas … do not spread with such ease. They require the backing and energies of committed individuals and organizations to design and carry out strategies for expansion that are carefully tailored to the realities of their settings.” Chambers and Norton [before they are widely implemented. Furthermore, they argue it is important to recognise that interventions are adapted all the time. It is therefore critical that real world adaptation is not ignored, but rather documented and studied so that we can better understand how and why some interventions are more sustainable than others. In this study, we documented staff perspectives just before and midway through implementation of a clinical pathway to identify and manage anxiety and depression in patients with cancer, and the adaptations made to the CP to overcome feasibility and adoption challenges, adding to the scarce literature on intervention implementation in real-world studies.As noted by Simmons et al.  “Most god Norton  have argAdditional file 1. First and final ADAPT workflows for two contrasting sites. Red indicates where steps have been added to the workflow, blue indicates where adaptations to previous workflow decisions have been made.


Background:Dementia care guidance highlights the importance of supporting people living with dementia to access engaging and meaningful activities to promote their quality of life. There is a growing evidence base for the efficacy of heritage settings and arts-based interventions to provide social prescribing opportunities to help support wellbeing in this population. This study extended previous research and explored the potential processes underlying this effect in multiple small group object handling sessions in a museum setting.   Methods:A mixed-methods design was used comprising a measure of subjective wellbeing and thematic analysis to explore in-the-moment session content across multiple sessions. Four people with dementia participated in three, one-hour group object handling sessions led by two facilitators.Results:Pre-post wellbeing scores showed increases after each session though this was largely not significant. Qualitative findings provided more compelling results, however, and identified four key themes: facilitating, interest in exploring objects, active participation, and group collaboration; interpretations were made around the dynamic interaction of themes and subthemes over the course of three sessions.Conclusions: This is the first study we are aware of that has taken an in-depth look at multiple museum-based group object handling sessions for people living with dementia. Findings offer ways to optimise object handling sessions for people with dementia by providing in-depth information about the processes involved across multiple object handling sessions facilitated by museum/heritage professionals in a museum setting. This has useful implications for community-based activities as part of dementia care planning and public health programming. The study contributes to a deeper understanding and elucidates the processes that enhance wellbeing for this population who participate in such sessions. It also helps to develop further theoretical understanding about why these types of activities are helpful in community-based dementia care. Limitations and implications for future research are discussed. Although there are a range of symptoms, dementia is a syndrome often characterised by progressive decline in cognitive functioning, motivation, affective control and social behaviour . It can In the interest of supporting people to live well with dementia, it is important to explore opportunities for interventions that can increase quality of life and wellbeing in the wider community. Participative arts interventions  have become a growing area of interest due to their potential for positive outcomes for PLWD and carers , includiResearching art gallery and museum-based interventions for this population has suggested positive outcomes related to cognitive functioning . The research adhered to theTo help further situate the sample and act as a screening tool, the brief version of the mini mental state examination  that were part of the museum’s collection. Olfactory experiences in dementia care have been shown to be potentially engaging experiences that can evoke personal responses and reflection. Three sessions were chosen based on the design of a previous arts intervention study bySessions were guided by a protocol , providing an uninterrupted 360-degree recording of group interaction, were used to record the verbal and visual content of sessions. About the size of a tennis ball, this device is unobtrusive and did not appear to distract from the objects or group interaction. An additional audio recording device was also used as a backup. Sessions were led by two Wellcome Collection facilitators who were trained in working with people living with dementia. LD, PC and HZ observed all sessions unobtrusively from the back of the room but did not take part. A handout was provided after each session  and post-intervention (post-session three), session-by-session and baseline to post-intervention repeated measures pairwise t-tests were completed usingNVivo 12. FollowingAudio content from the entirety of the three object handling sessions was transcribed and subsequently coded using software packageQuality assurance.Data were gathered from four white British participants diagnosed with a dementia , all of M = 11.25;p = .037). However, although some pre-to-post changes approached significance, the majority of pre-to-post change scores were not significant. This is likely a Type II error due to the very small sample (N = 4) and with a larger sample size, may have been significant.Mean pre-post CWS scores for each of the five subscales  and composite scores of all subscales were calculated for each object handling session . The greatest subscale change score at session 1 was for the Well subscale, in session 2 the Interested subscale and at session 3 the Happy subsale. For the composite score, average change scores ranged from an increase of 30 points at session 1 to 15 at session 3 (out of a possible score of 500). These change scores are in the same direction as those reported byData were analysed using an inductive thematic approach to identify themes in order to address three research questions: Q1: What is the process of facilitation? Q2: What are the roles of material objects? Q3: What is the process of person-to-person interaction within the group? The final thematic map  and the Facilitating conditions created by the contributions of the facilitators, led to groupmembers actively participating in expressing themselves and interacting in a variety of ways,exploring objects from a range of perspectives. This led to a sense of group cohesion andgroup collaboration (including both participants and facilitators) in the further exploration of objects. Objects appeared to provide a shared focus, acting as a vehicle through which these processes took place.The thematic map displays the themes and subthemes identified within and across the group sessions. Arrows and lines depict the dynamic interactions between themes, with thicker lines representing a stronger relationship.Facilitatingguiding and pacing, validating and sharing.This theme relates to the process of facilitation during the object handing sessions and comprises three subthemes:Guiding and pacing reflects the direct guidance facilitators expressed to encourage exploration and learning. This included direct questions to participants to prompt or further exploration , relating to participants own experiences or knowledge , eliciting opinions or preferences  and instructions or changes in topic, which also appeared to help structure the sessions . This also included information provided by facilitators around objects  or to pace sessions by prompting further group discussion before sharing knowledge about an object .Validating describes the action taken by facilitators to acknowledge what participants have said, responding to and encouraging their contributions . This also included efforts to reach out directly to participants who may have been quieter in the session to support their participation, valuing all members of the group (F1: “Would you like to pass it on to [name] and see what he thinks”).Sharing referred to facilitators self-disclosing within the sessions, such as expressing not knowing , sharing personal information and their opinions around objects (F2: “It’s got a great fragrance.”) and using humour (F2: “So it wouldn’t have gin in it (laughs)?”).facilitating may have contributed to a sense of equal status in the group between facilitators and participants and enabled safe and respecting conditions for participation.Overall,Active participation. This theme relates to the contributions of participants within the object handing sessions and is made up of the subthemes:curiosity, connecting, voicing difference andsharing. Independence and the confidence to actively participate within the sessions may have been enabled by the conditions created by the process of facilitation.Curiosity relates to the participants’ stance in the sessions around the objects and associated group discussion in asking questions  and guessing and hypothesising . The latter formed the most prominent part of the sessions towards exploring and discovering more about objects. This may reflect the sense of safety created in the group that allowed participants to take risks and guess without the fear that may be associated with giving an incorrect response.Connecting describes the ways participants communicated with other participants and facilitators within the sessions. This was often in the form of asking questions, which may have been directed at other participants, facilitators or the wider group (P3: “Which country was that in then? Where was that?”), to clarify what had been said , or responding more generally. This is inclusive of all participants and their own personal patterns of communication. For example, one group member generally communicated using shorter phrases  than other participants, however the frequency of their contributions suggested they were engaged. Another group member more frequently took on the role of changing topic or moving the group on . This may reflect participants’ idiosyncratic personalities and the roles they take up in groups, or possibly the impact of dementia on communication skills.Voicing difference demonstrates participants’ ability to express differing opinions, disagree with and challenge others in the group . This occurred frequently during discussion as hypotheses were generated and appeared to be tolerated by and even drive the group in making further hypotheses.Sharing refers to participants self-disclosing within the session. This may relate to the sharing by facilitators, which may have been enabling for participants to feel able to share. Participants expressed not knowing (P2: “I don’t know what you’d use it for”), shared personal opinions (P1: “I think this is fantastic.”), personal stories and experiences  and humour (P3: “Get that out and hope it doesn’t mess up the rest of the stew”. (All laugh)).properties and features, meaning-making andassociations, refers to how objects were explored through discussion in the OH sessions by both participants and facilitators. The number of these reflects the “multifaceted” (P3) nature of many of the objects. The fact that many of the objects were items participants, and in some cases the facilitators, did not know much about, appeared to allow them to be explored from many different angels. As such, the objects may have acted as a vehicle for a wide range of interaction within the group.This theme, comprising three subthemes:Properties and features of objects refer to discussion about the physical objects themselves. For example, their weight or material , smell , and decorative features (P4: “It’s got a lovely pattern on the bottom”).Meaning-making describes how group members responded to and made sense of objects beyond their physical properties. There was much discussion around the potential identity and function of the objects  but I don’t think that’s what it was for”) and their age (P1: “I mean to me it looks 20th century”). This subtheme also included discussion around whether objects were authentic , their origin (P3: “It’s from China is it?”), and what they may represent .Associations captures the links that were made beyond the objects. This included likening objects to other things  and conversations that led on from the discussion of objects. For example, during a conversation about an iron fish, discussion led to the role of iron in diet  and when exploring a glass furniture leg protector . This also links to personal stories that were shared, for example when using spices in the session .Group collaboration This theme relates to the process of the group coming together as a whole within the object handing sessions and comprises the subthemes:sharing responsibility and process of discovery.Sharing responsibility describes the finding that both facilitators and group members came to share, as reflected within the themes offacilitating andactive participation. This participation of sharing stories, using humour and moving the group on as previously reported, as well as recapping what had been discussed (F1: “I think you said cinnamon.”) appeared to reflect a shared responsibility for group participation. This may have contributed to a sense of equal status in the group and group cohesion.Process of discovery reflects the process through which members built on each other’s ideas. This described the learning of new information , sharing different ideas and problem solving around objects  and the co-curation of a display case in the final session .exploring objects (including both participants and facilitators and in particular around identity and function) and codes relating tofacilitating andactive participation: asking questions (both facilitators and members), participants guessing and hypothesising, participants sharing opinions and preferences and facilitators providing information.Researchers  looked at the final frequency of each code across each of the three sessions as well as the identified themes, to explore whether any clear changes or patterns could be identified across the sessions. Some fluctuation in the frequency of codes was observed with the varying topics of conversation around different objects. However, no clear changes or patterns were found, suggesting the frequency of the codes and the overall themes were relatively stable across each of the three sessions. Across all three sessions, the most frequently recorded codes were those relating toPre-post CWS scores may suggest an overall increase in participants’ self-reported wellbeing after object handling sessions.guiding and pacing,validating andsharing to encourage participation), which may have empowered participants to haveactively participate in expressing themselves . This led togroup collaboration, between participants and facilitators,sharing responsibility for the group discussion and in building on each other’s ideas to come todiscover more about an object together. The objects appeared to provide a shared focus within the group through which these processes took place, demonstrated by the many perspectives from which they were explored . It is possible these processes impacted on participants’ experiences of feeling happy, well, interested, confident and optimistic, as reflected in the CWS.The identified themes generated from the verbal content of sessions suggest that wellbeing may have been increased through the process of facilitation , and also linked to anactive participation . These subthemes interacted to contribute to the theme ofgroup collaboration, illustrating a dynamic interaction of subthemes and themes in forming the in-the-moment processes within the group.active participation.The field notes and observations of the three researchers who were present across all sessions, revealed that these dynamic processes appeared to take place more quickly in sessions 2 and 3; this observation was confirmed after viewing the video data. This may have been linked to the familiarity of the setting and as the group, including the facilitators, became more adept at creating an atmosphere that promotedThat there were no clear changes found in the frequency of codes or in the identified themes across the three sessions may be a limitation of the methodology used, or a reflection of the high level of engagement across the sessions, perhaps due to the different objects used. It is also possible that benefits were limited to in-the-moment changes and were not maintained or built on across sessions due to the range of impairments associated with the types of dementia the participants in this study were living with. Future research could explore this further by focussing on a greater number of sessions to see effects over time.This study offers a tentative understanding of the processes through which group object handling sessions may promote wellbeing in people living with dementia. Although this was a small-scale exploratory study, it nevertheless highlights key components of sessions that can inform future training of facilitators to optimise sessions for this population. This also has important implications for the role of museums in public health , and socExpanding training beyond those who work in museum and heritage settings would raise awareness of dementia in the wider community. This could also enable people working in creative settings to adapt their ways of working to be more accessible for PLWD in line with The Prime Minister’s Challenge on Dementia . For exaThe small sample size can be viewed as both a strength and a limitation of the research. The participants were not representative of the demographic diversity of the population of PLWD across characteristics such as ethnicity, socioeconomic status and type and stage of dementia, thus limiting the applicability of the present study’s findings. Further, due to the sample size, the statistical analysis lacked power and the general lack of significant findings is possibly due to a Type II error. More longitudinal data collected over several months would be helpful to understand the ongoing effect of the sessions on subjective wellbeing. Input from care partners  about their observations would further illuminate if the sessions were impactful in day-to-day life.active participation and its implications for understanding the agency of people with dementia  to help explain the possible processes present in the facilitation of sessions, the roles of material objects, and person-to-person interactions. Facilitators’ guidance created conditions within the group that led to group members to actively participate in expressing themselves (including voicing different opinions), leading to group cohesion and collaboration between participants and facilitators in sharing responsibility for the group and building on each other’s ideas to discover more about objects. Objects were explored from many different perspectives and provided a shared focus within the group through which these processes took place. These findings should be viewed tentatively due to the small sample size; however, they offer important insights concerning how to optimise sessions for this population. Future research using multiple groups and a more diverse sample can extend the present study’s findings but perhaps more importantly, other qualitative methodologies may provide additional information about the narrative and discourse that occurs in museum object handling groups. And finally, as a freely available measure that is non-obtrusive to use and easy to score, the Canterbury Wellbeing Scales, should be considered in community-based programmes for early to middles stages of different dementias.This was the first study to explore the process of facilitated small group object handling sessions involving people living with a dementia, in a museum setting, across multiple sessions. Findings suggest a positive influence of object handling on the subjective wellbeing in people living with dementia, and identified four key themes  describing the nature of their interest and their qualifications, the intended use of the data, plans for obtaining ethical approval at their respective institution, and signing a confidentiality agreement to assure protection of data whilst in their possession. When ethical approval has been provided as evidenced by a signed letter from the ethics panel, transcript data will be transferred via an encrypted and password protected file. Access to transcripts is only permitted by the requesting researcher(s) and cannot be shared with others.Quantitative data. Zenodo: Subjective wellbeing in people living with dementia: exploring processes of multiple object handling sessions in a museum setting underlying quantitative data.http://doi.org/10.5281/zenodo.4715016 - Excerpt from a coded transcript.pdf- Initial & Final codebooks.pdf .Data are available under the terms of the I appreciate Dr. Camic et al. responding so thoroughly to my inquiries. This is a well written study, although small, that contributes significantly to the area of use of museums in promoting quality of life for persons with dementia.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?PartlyReviewer Expertise:Dementia, palliative care, museum studiesI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This is a small mixed method study looking at the effect of object handling for persons living with dementia. It constituted four individuals diagnosed with dementia, participating in three exploratory sessions of one hour each. Sessions were led by a facilitator, audio and video recorded. The Canterburry Wellbing Scales were used pre and post experience.  A thematic map was developed from qualitative analysis of the sessions. Comments: First of all I would like to thank the authors for their contribution on expanding the effects of museum based interventions for persons with dementia. Current literature and the framework in which this study sits were well presented in the paper. My comments are mostly addressing clarifications. I would like to know more details regarding the process itself. How many objects were presented per session? How were they chosen? Page 6 what is the purpose behind “novel, diverse”, etc. Was one object discussed at a time among all participants as it was passed around? I even wonder how close participants were sitting to each other and the facilitator? (Pre Covid I am assuming). I would like to know more about the questions asked. Was there a process or script in which the questions were created? The second session with smell adds a little complexity, why were smells chosen? Was there also a tactile component such as touching the cinnamon sticks? A table with a list of the objects and attributes might be helpful. There is little data, to my knowledge, about how persons with dementia respond to the types of artwork presented in museum programs for dementia/care partners 9abstract, sculpture, everyday objects in new settings etc).  It appears this study could contribute to that literature with more description of participants specific reactions? I would like to see a little more written about the “museum setting”.  A conference room was used within the museum. Is there an aspect of one coming to a museum, a special place, that is specifically helpful to this process? Was it the use of museum objects that were special? I wasn’t sure if there was a connection to current displays that might tie in with which objects were presented? Minor comments: P4 What was the intervention in the Ander study? P4 Paddon, what objects were used? P4 The questions at the end of the paragraph referencing Keady seem confusing. Is the inference meant to be that these questions are less relevant? P5 Stakeholder involvement – not sure this paragraph is needed. With the thematic map I wondering about the overlap/connection with socialization and group collaboration as socialization tends to be a key factors in activities such as yours. Facilitators sharing, sharing responsibility and participants sharing, are these components of socialization? This is touched upon in summary of findings “shared focus” but again is this at least in part socialization? P14 discussion of the olfactory experience. I wonder if this and description of the objects could be earlier in the paper – methods. With the pandemic occurring and impacting in person gatherings and in person events for persons with dementia (even post Covid) I wonder if it would be helpful to postulate how this process may be done via video with participants having the same object in hand to discuss? Thank you for allowing to review this interesting paper.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?PartlyReviewer Expertise:Dementia, palliative care, museum studiesI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Responding to Reviewer 2, Dr. Lee Burnside  Thank you for your helpful and insightful comments and for your close read of our paper. Our responses to each of your comments follow. 1.    I would like to know more details regarding the process itself. How many objects were presented per session? How were they chosen? Page 6 what is the purpose behind “novel, diverse”, etc. Was one object discussed at a time among all participants as it was passed around? I even wonder how close participants were sitting to each other and the facilitator? (Pre Covid I am assuming). I would like to know more about the questions asked. Was there a process or script in which the questions were created? Response: Thank you for these comments and questions. We have added to and revised the following (subsection Object handling sessions): “Facilitators welcomed participants at the beginning of each session passing around one object at a time and encouraged touching and generating discussion through asking a range of sample prompts and questions to encourage participation and exploration before sharing information about each object. Questions were used flexibly, in an open dialogic way, within the sessions based on the interaction of participants. A total of 20 objects were used across the sessions; 14 objects came from the museum’s collections including 4 spices, while others were contributed by PC. Six to nine objects were used in each session. Objects were jointly decided upon by the facilitators and researchers and selected to be novel and diverse in their cultural, historical and sensory qualities in order to maximize variety, interest and opportunities for exploration that did not rely on previous memories or knowledge. The study’s protocol, including sample questions, photos and descriptions of the objects used in each session are available as extended open access files .2.    The second session with smell adds a little complexity, why were smells chosen? Was there also a tactile component such as touching the cinnamon sticks? A table with a list of the objects and attributes might be helpful. esponse: We chose to include smells based on (a) previous research about olfactory responses in dementia care , and (b) the museum had a collection of spices that were frequently refreshed and part of the interactive visitor experience to relevant collections. The museum facilitators and researchers agreed that this would both highlight objects in the collection and provide an olfactory and tactile experience. Spices were contained in small glass bottles and passed around, one at a time, as were the other objects. This generated a good deal of discussion about how these spices might be used .  R In the subsection, Subjective wellbeing  (in the Discussion section), we have added the following: “Olfactory experiences in dementia care  have generally revealed positive responses across different stimuli  and should be considered when planning object handling sessions.”3.    There is little data, to my knowledge, about how persons with dementia respond to the types of artwork presented in museum programs for dementia/care partners . It appears this study could contribute to that literature with more description of participants specific reactions? Response: We definitely agree, there is a paucity of research that looks specifically at how people with dementia respond to different types of art works. The Meet Me at MoMA programme was the first study that we are aware of that looked at figurative and abstract modern art, and although not designed as a comparative study, did find abstract art often produced more engaged and longer discussions.      A cross-sectional observational study, undertaken in The Netherlands, addresses this issue: Hendriks, I., Meiland, F., Slotwinska, K., Kroeze, R., Weinstein, H., Gerritsen, D., & Dröes, R. (2019). How do people with dementia respond to different types of art? An explorative study into interactive museum programs. International Psychogeriatrics, 31(6), 857-868. doi:10.1017/S1041610218001266. An earlier, smaller scale, mixed-methods study in the UK, also looked at art works in two different museums , Camic, P. M., Tischler, V. and Pearman, C. H. (2014). Viewing and making art together: a multi-session art-gallery-based intervention for people with dementia and their carers. Aging & Mental Health, 18, 161–168. doi: 10.1080/ 13607863.2013.818101, and there may be others.      Because the present study used different types of material objects, most of which would not be considered “art”, we are not confident that describing individual responses in more detail than we have already done, would make a meaningful contribution. However, future researchers could access our audio and video files (access instructions are provided at the end of the article) and explore this interesting issue.4.    I would like to see a little more written about the “museum setting”. A conference room was used within the museum. Is there an aspect of one coming to a museum, a special place, that is specifically helpful to this process? Was it the use of museum objects that were special? I wasn’t sure if there was a connection to current displays that might tie in with which objects were presented? Response: In the Methods section (Design and setting subsection) we have made clear this is a “specialist” museum and added the following: “The museum’s focus is to connect science, medicine, health and the arts and this is reflected in its collections, special exhibitions, public engagement, and lecture programme. The object handing sessions took place in a well-lit, comfortable conference room with windows on a high floor. Facilitators and participants were seated around a rectangular table and close enough to allow for the easy passing of objects. The physical environment of the room was considered and the decision to hold the sessions in a private space rather than a gallery room was made to allow quiet for listening, fewer distractions to support engagement and confidentiality for audio recording.”  5.    P4 What was the intervention in the Ander study?Response: They used museum objects from London and Oxford museums in inpatient neurological rehabilitation (London), outpatient neurological rehabilitation (Oxford), and inpatient mental health care (Reading). Objects were brought to the respective location and occupational therapy clinicians engaged one-on-one with participants. Forty-two museum objects comprising specimens from anthropology, archaeology, art, geology and zoology collections were compiled and brought in boxes, each box contained 6 different objects. 6.    P4 Paddon, what objects were used?Response:  Objects comprised archaeological and ethnographic artefacts, etchings and printing plates, fossils, mineral samples and zoology specimens that varied in their tactile, visual and kinaesthetic properties .7.    P4 The questions at the end of the paragraph referencing Keady seem confusing. Is the inference meant to be that these questions are less relevant? Response: Apologies if we were not clear. We meant to imply that these questions are more relevant and have added the following (underlined): “More relevant questions for a dementia population include, How long do these moments last? What comes before and after them? Can different moments be linked together? .”8.    P5 Stakeholder involvement – not sure this paragraph is needed. Response: We feel it is relevant for the following reasons: Very few psychometric questionnaires have involved people with dementia in their development. Most often, researchers decide which questions are the most important to ask with the assumption that they know best. The Canterbury Wellbeing Scales (CWS) were developed with direct input from people with dementia and caregivers, along with older adult specialist psychologists and Alzheimer’s Society staff. Secondly, the length and structure of the sessions in the present study were based on feedback from participants (people living with a dementia and caregivers) in previous studies, consulting with members of the Rare Dementia Support charity (https://www.raredementiasupport.org/) and talking to museum staff at multiple musuems. In addition to these reasons, we concur with the (UK) Health Research Authority that states, “Public involvement in research means research that is done ‘with’ or ‘by’ the public, not 'to', 'about' or 'for' them. It means that patients or other people with relevant experience contribute to how research is designed, conducted and disseminated” (https://www.hra.nhs.uk/planning-and-improving-research/best-practice/public-involvement/ ). 9.    With the thematic map I wondering about the overlap/connection with socialization and group collaboration as socialization tends to be a key factors in activities such as yours. Facilitators sharing, sharing responsibility and participants sharing, are these components of socialization? This is touched upon in summary of findings “shared focus” but again is this at least in part socialization? Response: This is an insightful comment, and we agree socialisation is potentially part of what is described in the thematic map in that the sessions were formed by people socially interacting with others around a specific task and may have adapted to behave in a way acceptable to the group. How to socialise in a group setting is something most people likely learn in school at a young age. However, the thematic map describes and attempts to tease apart some of the processes associated with what is specific to object handling, and socialisation, for us, is an overly broad construct that would need to be further broken down and measured , in our opinion, to be useful. Considering that two people had a type of dementia that can make socialising quite challenging (FTD), the responses and interactions of participants across the three sessions provide support that object handling—as a focal activity—has some potential in dementia care.10.    P14 discussion of the olfactory experience. I wonder if this and description of the objects could be earlier in the paper – methods. Response: Thank you for this suggestion. We have added the following sentence to the Methods section in the Object handing sessions, subsection: “The second session also involved smelling four spices contained in small glass bottles (passed one at a time to participants) that were part of the museum’s collection. Olfactory experiences in dementia care have been shown to be potentially engaging experiences that can evoke personal responses an reflection.”11.    With the pandemic occurring and impacting in person gatherings and in person events for persons with dementia (even post Covid) I wonder if it would be helpful to postulate how this process may be done via video with participants having the same object in hand to discuss? Response: Thank you for this. The first author is currently engaged with other colleagues as part of a funded study which examines personal objects within the context of on-line support group sessions with dementia caregivers who are caring for someone with a rare form of dementia. We feel the information we have to date, while promising, requires additional development. The study reported here was completed before the pandemic but it is interesting to ponder, however, about how object handling sessions may be done via video. It is could be important to explore this as a way to increase accessibility, but this would forgo important aspects of the museum setting .         Facilitators could video from a carefully selected space in the museum (interesting but not too busy background that conveys the presence of a museum), orienting people to the room they can see on the screen and to each other, allowing for pauses after each person speaks for any delays and some time at the start for any technical issues to be problem solved. Facilitators might consider presenting visually some objects and generate discussion  but may limit who can participate (sight/hearing/staying focused when on a screen and other things going on in the setting they are joining from) and may require the support of someone at home to navigate the technology. Participants could share objects from home or all be asked to bring something such as a spice so all have the same object to touch/smell/discuss. Items could be posted out beforehand but unsure how this would work in practice. Just some thoughts. The article “Subjective wellbeing in people living with dementia: exploring processes of multiple object handling sessions in a museum setting. Version 1” describes a study that expands on previous research and explores the potential processes underlying the effect of multiple small group sessions on handling objects, carried out in a museum. A mixed design was used to assess the subjective wellbeing of participants with dementia, using a quantitative self-report measurement, the Canterbury Wellbeing Scales (CWS). A thematic analysis of the transcripts of the previously recorded sessions and the observers' field-notes was also carried out. The article begins with a good contextualization of the research on the role of art-based interventions to improve the quality of life of people with dementia. The most relevant and recent research on the subject is mentioned and, after commenting on it, the basic hypothesis of the study is presented: that the sessions of handling objects in the museum will increase the wellbeing of participants with dementia. The method section describes the aspects relating both to the quantitative measures used and the qualitative approaches. The results of this study indicate an average increase in participants' wellbeing when comparing the measures taken before the sessions with those carried out afterwards, although this increase does not reach statistical significance. The topics and sub-topics identified through the analysis of the session transcriptions and the field-notes suggest that wellbeing may have increased through facilitation processes that could have empowered the participants by facilitating their self-expression. Among the most important aspects of the work, its authors highlight that it provides a greater understanding of the processes through which handling object activities in a museum can promote the wellbeing of people with dementia. The main limitation of the work, also acknowledged by the authors, is the small sample size of people with dementia participating in this study, four people, which considerably reduces the applicability possibilities of the study's findings. It is true that the small sample size allows an in-depth analysis of issues that would not be possible with a larger sample. Still, given the social relevance of the issue of caring for and improving the quality of life of people with dementia, the study lacks more people, which would provide the authors' findings with a more solid basis. Despite this limitation, the adequate conceptual and methodological basis of the work inclines me to recommend its publication. Subsequent studies may refer to this research and use a larger sample of participants with dementia.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Art Education for people with dementiaI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. possibly due to other circumstances. These include the required commitment to come to three sessions, difficulty arranging transport from home to the museum in a busy part of central London, and any uncertainty people may have had about coming to a new place (the museum). The study also coincided with a dramatic reduction of funding for a charity we had partnered with. They had to close their local day and drop in facility, which was a close walk from the museum.We would like to thank Dr Anna Ullán for taking the time to review our manuscript. We appreciate her comments and agree, a larger number of participants would have strengthened the study. Unfortunately, recruitment was challenging, perhaps due to the time of year (winter) but


In recent years, graphene has found its use in numerous industrial applications due to its unique properties. While its impermeable and conductive nature can replace currently used anticorrosive toxic pigments in coating systems, due to its large strength to weight ratio, graphene can be an important component as a next-generation additive for automotive, aerospace and construction applications. The current bottlenecks in using graphene and graphene oxide and other two-dimensional materials are the availability of cost-effective, high-quality materials and their effective incorporation  into the product matrices. On overcoming these factors, graphene may attract significant demands in terms of volume consumption. Graphene can be produced on industrial scales and through cost-effective top-down routes such as chemical, electrochemical and/or high-pressure mechanical exfoliation. Graphene, depending on end applications, can be chemically tuned and modified via functionalization so that easy incorporation into product matrices is possible. This paper discusses different production methods and their impact on the quality of graphene produced in terms of energy input. Graphene with an average thickness below five layers was produced by both methods with varied defects. However, a higher yield of graphene with a lower number of layers was produced via the high-pressure exfoliation route.This article is part of a discussion meeting issue ‘A cracking approach to inventing new tough materials: fracture stranger than friction’. Durin lattice  and ther lattice , and dem lattice , coverin lattice ,9, gas a lattice ,11, fiel lattice , transpa lattice , coating lattice ,14 and p lattice ,16. Howe lattice . Thus, i(a)In general, the synthesis methods consist of two main categories : bottom-(b)a). During the sonication process, bubbles generated by the ultrasound grow and then collapse generating cavitation's, which in turn give rise to shear forces (figure 1b). Still, when more bubbles are formed on the lateral side, the shear force controls the separation process [One of the most classic categories of this approach is the physical exfoliation (PE) of graphite, which includes the mechanical ‘scotch-tape’ exfoliation . While tfigure 1 process . By cont process . Both of process ,29 and t process . Figure Earlier studies focused on the chemical exfoliation (CE) of graphite ,2, but ta); the mechanism can be described by a three-step ‘intercalation–expansion–exfoliation’ process; OH− created by water reduction attacks the edge sites, expands the graphite layers and allows sulfate ions to intercalate; then the reduction of sulfate ions releases gas to further separate layers. Figure 3b demonstrates a typical EE process using sulfate salts solution as electrolyte [Due to their considerable merits, electrochemical exfoliation  approachfigure 3ctrolyte .Figure There remain major challenges to the commercialization of graphene, such as the quality and yield of the produced graphene. As a result, exfoliation methods and related process parameters urgently need to be further optimized to achieve a low-cost and scalable production.(c)In a broader sense, cracking in solid materials is seen as a process that imparts a negative impact on material properties. However, understanding how the mechanism and energy transition of relevant cracking processes affect layered materials is paramount to achieving reduced energy usage, optimum product yield and process efficiency for successful commercial two-dimensional materials production. This is because the highest cost contribution of the top-down routes comes from energy usage.(i)the exfoliation energy is equal to the difference between the ground-state energy of the bulk per layer and that of an isolated layer’. Assuming only van der Waals interactions between layers, the team has deduced the exfoliation energy for several materials . The underlying principles were extended to the materials with interactions such as hydrogen bonds.The internal energy of the system in the context of exfoliation is dominated by the interlayer interaction, and it is suggested that theoretically, the exfoliation energy is defined as the energy required to peel off a single layer from the surface of the bulk materials or to separate all the layers of the bulk and divide the number of layers. One research group  has simp(ii)However, knowing the energy required to overcome interlayer interaction is only a part of the story. The energy applied into the system is used for two different types of cracking, interlayer cracking, otherwise known as exfoliation, and fragmentation, which leads to a reduction in lateral particle size. Fragmentation has double-faced tactics. On the one hand, it can reduce the lateral size of graphene. This is not desirable for achieving large-area graphene. On the other hand, it facilitates exfoliation because smaller graphite flakes are easier to exfoliate than larger ones because of smaller collective van der Waals interaction forces between the layers in smaller graphite flakes.The type and extent of the forces exerted during the exfoliation determine which process will be effective and efficient. Various forms of forces and energy transfers can occur in the system, depending on the process of choice. For example, sonication generates cavitation and micro bubble explosions, and as a result, compressive forces and normal tensile forces work against each other to slip layers over each other. On the other hand, in the high shear exfoliation process, it is the shock waves, random collisions and flow channels that lead to shear forces that help the layer exfoliation and fragmentations.(iii)et al. [Once exfoliated, isolated two-dimensional layers should be stabilized against re-aggregation. Stability of the two-dimensional dispersions is typically enforced by introducing dispersing agents, such as surfactant molecules and polymers, to generate new forces such as π–π conjugation, hydrophobic force and Coulomb attraction and match the surface energy of graphene layers to that of the exfoliation media . The orget al. , becauseet al. .(iv)m), the energy required to separate all molecules (solvent/graphene sheet) to infinity (DHα) and the energy to bring them back together in the form of a solvent-graphite dispersion (DHo), but with flakes of different thickness [m), should compensate for the difference between the (DHα) and (DHo).The underlying scientific principle of the energy distribution of graphite/graphene dispersion is similar to the Griffith Theory of Crack propagation. To keep the new reality in check, a reduction in potential energy from the old state should be greater than or equal to an increase in surface energy due to the creation of a new state. Energy terms pertaining to a graphene dispersion can be defined as the enthalpy of mixing for graphite in the solvent (DHhickness . The ene. 2(a)Electrochemical treatment resulting in expanded graphite. An electrochemical cell with two electrodes is used to exfoliate high purity compressed graphite pellets (HQ graphene). The graphite anode and platinum gauge cathode were mounted using copper crocodile clips and immersed completely in the aqueous electrolyte, which was 0.5 M ammonium thiosulphate, pH adjusted with alkaline media to 8–9. A voltage of 8 V was applied, and the graphite was allowed to expand for 1 h (a). Further details on the reaction mechanism can be found in Achee et al. [ for 1 h a. Furthee et al. .Intercalation by soaking in intercalant solution. Intercalant (2% tetrabutylammonium sulfate) was added to the resultant expanded graphite dispersion (5 mg ml−1) for a few days. The mixture was subjected to bath sonication for 30 min to get a homogeneous solution. After soaking for 5 days, the solution was then sprayed (Graco Magnum 262805 X7 HiBoy Cart Airless Paint Sprayer) into a container at a high-pressure of 2000 psi. This cycle was repeated three times. The solution was then subjected to bath sonication (30 min) and centrifugation (10 000 r.p.m. for 30 min). The supernatant (containing the few-layer graphene) was separated for further processing (b). Further details are described in Nemala et al. [ocessing b. Furthea et al. .Synthesis: Exfoliation of graphite into few-layer graphene (FLG) was achieved through a number of consecutive steps.Characterization. Several characterization techniques were used to assess the quality of graphene produced.X-ray diffraction (XRD). X-ray diffractograms were collected on a Bruker D2 phaser. High purity (99.999%) Ceylon vein graphite was micronized and deposited on an XRD sample holder. Measurements were taken at 22°C and 2θ between 10° and 70°.Raman spectroscopy. The Raman spectroscopy of the exfoliated samples was carried out using Lab Raman, Jobin Vyon spectrometer: model HR800 using Argon laser of wavelength 514.5 nm. The sample preparation was done by spreading the exfoliated aqueous solution uniformly over a glass substrate and then positioning it below the infrared (IR) lamp for 10 min. A particular area of the sample was then selected and focused on the laser beam.Scanning electron microscopy (SEM). SEM images were recorded using an LEO Gemini 1525 FEG SEM using a 30 µm aperture and operated at 5 kV. Aliquots of 10 µl of the electrochemically exfoliated and pressure exfoliated inks were drop casted onto an ozone-treated silicon wafer and dried.Transmission electron microscopy (TEM). High-resolution transmission electron microscopy (HR-TEM) images were recorded using an JOEL JEM 2100 F field emission gun-transmission electron microscope operated at 200 kV. The sample preparation was carried out by ultrasonication of the aqueous solution in water for about an hour. The homogeneous dispersion of the sample was then drop casted onto a carbon lacey grid for about 2 h before imaging.X-ray photoelectron spectroscopy (XPS). XPS data were obtained using an AXIS Supra instrument from Kratos Analytical having Al Kα source (hν = 1486.6 eV) in the range of 1–1000 eV to investigate the surface chemical composition of the exfoliated graphene sample. The XPS data fitting and analysis was carried out using the software ESCApe.. 3High purity (99.999%) Ceylon vein graphite was used to produce graphene in this study. An X-ray diffractogram  was useda,b [Figure 6a shows the Raman spectra of the high-pressure exfoliated graphene, which consists of D band, G band and two-dimensional band related to various vibrational modes. The G band comes from in-plane vibrational mode of sp2 carbon atoms associated with the E2 g phonon. The D band is associated with the breathing mode of A1 g symmetry of sp2-hybridized carbon rings. This D band corresponds to the defects present in the graphene sheet. The two-dimensional band arises due to the second-order Raman scattering process, which signals at double the frequency of the D band [The quality of samples was studied using Raman spectroscopy and is compared with graphite shown in figure 6a,b . Figure e D band ,42. In ne D band , are tabThe Raman spectra clearly showed the difference between the two-dimensional peaks obtained from the two exfoliation routes. The two-dimensional band of high-pressure exfoliated graphene is symmetric in shape, whereas multiple peaks are visible in the two-dimensional band of electrochemically exfoliated graphene. The low D/G intensity ratio for the high-pressure exfoliated sample as compared to the electrochemically exfoliated material is an indication of low defect concentrations in graphene produced. The symmetric shape and the position of the two-dimensional peak reveal that fewer layers of graphene are produced by high-pressure exfoliation.a) than electrochemical exfoliation (b). Follow up morphological investigations by the TEM study revealed the presence of graphene sheets, as shown in figures 8b and 9b. Compared to patterns in 8b, the hexagon is more defined in figure 9b, indicating that the high-pressure exfoliation further reduced the number of layers in the flakes. The magnified image in figure 9c confirms that the flakes contain only 1–2 layers of graphene. The TEM images and spot patterns of the selected area diffraction and HR-TEM images of the high-pressure exfoliated graphene shown in Scanning electron micrographs indicate that graphene obtained through the pressure exfoliation route achieved higher concentrations a than eloliation b. FollowThe XPS survey spectra conducted on the high-pressure exfoliated graphene sample is shown in . 4We have investigated the quality of graphene produced by a novel production method combining electrochemical exfoliation and high-pressure shear exfoliation, in aqueous media using characterization techniques; Raman spectroscopy and HR-TEM. Our results show that the proposed method produces a high yield of few layer graphene flakes with less than five atomic layers. The electrochemical exfoliation process does not introduce notable defects or additional oxidation in the graphene sheets, whereas high pressure creates minor defects. The main advantages of this method are its high efficiency and the controlled quality of exfoliated graphene sheets with a high yield of FLG obtained. We explored the impact of type, energy input and mechanisms involved with different exfoliation processes. We describe various factors that can influence the choice of the exfoliation process. This work strengthens the field of liquid phase exfoliation and bridges the gap between electrochemical and mechanical exfoliation proposing a low-cost, highly efficient process for large-scale production of high quality few layers graphene.