Professor Jill Maben OBE

BACKGROUNDThe COVID-19 global pandemic was declared in March 2020. By June 2022, the total deaths worldwide attributed to COVID-19 numbered over 6.3 million. Health professionals have been significantly impacted worldwide primarily those working on the frontline but also those working in other areas including nursing, midwifery, and paramedic higher education. Studies of occupational stress have focused on the clinical health professional roles but scant attention has been drawn to the pressures on university-based academic staff supporting and preparing professionals for frontline health work. DESIGN AND OBJECTIVESThis qualitative study sought to explore the challenges experienced by health academics (nurses, midwives and paramedics), during COVID-19 and identify strategies enlisted. SETTING AND PARTICIPANTSSix Australian and two United Kingdom universities collaborated, from which 34 health academics were individually interviewed via video or teleconference, using six broad questions. Ethical approval was obtained from the lead site and each participating University. DATA ANALYSISThematic analysis of the data was employed collaboratively across institutions, using Braun and Clarke's method. RESULTSData analysis generated four major themes describing academics': Experiences of change; perceptions of organisational responses; professional and personal impacts; and strategies to support wellbeing. Stress, anxiety and uncertainty of working from home and teaching in a different way were reported. Strategies included setting workday routine, establishing physical boundaries for home-working and regular online contact with colleagues. CONCLUSIONSThe ability of nursing, midwifery and, paramedic academic staff to adapt to a sudden increase in workload, change in teaching practices and technology, while being removed from their work environment, and collegial, academic and technological supports is highlighted. It was recognised that these changes will continue post-COVID and that the way academics deliver education is forever altered.

Aim: Nursing work has historically been difficult to specify. This has led to difficulties in determining safe staffing requirements and adequately supporting safe patient care. The aim of this qualitative interview study was to explore how nurses understand their work. Design: Qualitative interview study, using the interpretive description methodology. Methods: Twenty registered nurses and nursing students completed semi-structured interviews about their work. The researcher drew on the interpretive description methodology to analyse interview data and create a model that interprets participants’ experiences of their nursing work. Results: Nurses understand their work by its role in the healthcare system, rather than by the tasks or activities they complete. This understanding is significant because nurses adapt their work constantly, and rigid definitions of working would not support safe adaptation. Nurses report working across three broad roles: clinical work, which is patient-facing; managing work, which sustains the care environment; and enabling work, which provides supports like research and education that make nursing a profession. Conclusions: Clinical, managing and enabling work have different aims, but all serve the purpose of supporting safe patient care and sustaining healthcare systems. Adaptation is a constant feature of each of these roles. This model may be useful for nurses in structuring and explaining their work and informing nursing workforce policy.

Background: The introduction of ‘Freedom to Speak Up Guardians’ into every NHS trust in England was intended to support workers and trusts to better raise, respond to and learn from speaking-up concerns. However, only broad guidance was provided on how to implement the role. As a result, there is the potential for important local differences to emerge as the role is implemented across England. Objectives: The overall aim of this study was to better understand the implementation of Guardians in acute trusts and mental health trusts. Design: The Freedom to Speak Up Guardian role was conceptualised as a complex intervention consisting of several interacting and interlocking components spanning the macro level (national organisations), the meso level (individual trusts) and the micro level (employees, teams and wards/units). A mixed-methods study was designed, which consisted of three work packages: (1) a systematic narrative review of the international literature regarding interventions promoting ‘speaking up’ by health-care employees; (2) semistructured telephone interviews with Guardians working in acute hospital trusts and mental health trusts; and (3) qualitative case studies of Freedom to Speak Up Guardian implementation, consisting of observations and interviews undertaken in four acute trusts and two mental health trusts. Interviews were also undertaken with national stakeholders. Setting: Acute trusts and mental health NHS trusts in England. Participants: Work package 2: Freedom to Speak Up Guardians (n = 87) were interviewed. Work package 3: 116 interviews with key stakeholders involved in pre-implementation and early implementation decision-making, workers who had spoken up to the Guardian, and national stakeholders. Results: Wide variability was identified in how the Guardian role had been implemented, resourced and deployed by NHS trusts. ‘Freedom to Speak Up Guardian’ is best considered an umbrella term, and multiple versions of the role exist simultaneously across England. Any comparisons of Guardians’ effectiveness are likely to be possible or meaningful only when this variability is properly accounted for. Many Freedom to Speak Up Guardians identified how a lack of available resources, especially time scarcity, negatively and significantly affected their ability to effectively respond to concerns; their opportunities to collect, analyse and learn from speaking-up data; and, more generally, the extent to which they developed their role and speak-up culture. Limitations: It is possible that those whom we interviewed were more receptive of Freedom to Speak Up Guardians or may have been biased by ‘socially desirability’, and their answers may not always have represented respondents’ true perceptions. Conclusions: Optimal implementation of the Guardian role has five components: (1) establishing an early, collaborative and coherent strategy congruent with the values of Freedom to Speak Up fosters the implementation of (2) policies and robust, yet supportive, practices (3) informed by frequent and reflexive monitoring of Freedom to Speak Up implementation that is (4) underpinned by sufficient time and resource allocation that leads to (5) a positive implementation climate that is congruent with Freedom to Speak Up values and is well placed to engender positive and sustainable Freedom to Speak Up culture and the well-being of a Guardian. Future work: The following recommendations for future research are considered to be of equal priority. Studies of the speaking-up experiences of minority communities and ‘seldom-heard’ workforce groups are a priority requirement. There is also value in undertaking a similar study in non-hospital settings and where peripatetic working is commonplace, such as in ambulance services and in primary care settings. The role of human resources and ‘middle managers’ in the management of concerns is an area requiring further research, especially regarding concerns relating to unprofessional and transgressive behaviours. Devolved administrations in Scotland and Wales have adopted different approaches to speaking up; research undertaken in these contexts would offer valuable comparative insights. Researching the Guardian role ≥ 5 years post implementation is recommended to understand the medium-term impact and the longer-term sustainability of the role and well-being of Guardians. Study registration: This study is registered as ISRCTN38163690 and has the study registration CRD42018106311. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 23. See the NIHR Journals Library website for further project information.

People bereaved by suicide are affected psychologically and physically and may be at greater risk of taking their own lives. Whilst researchers have explored the impact of suicide on family members and friends, the area of colleague suicide has been neglected and postvention guidance for supporting surviving colleagues is often poorly developed. This critical integrative review explored the impact of colleague suicide on surviving co-workers and reviewed postvention guidance for workplaces. Systematic searches found 17 articles that met the inclusion criteria. Articles were appraised for quality and extracted data were analysed using a thematic network method. Article quality was moderate. Two global themes were developed: impact of a colleague suicide comprised themes of ‘suicide loss in the workplace’; ‘professional identities and workplace roles’; ‘perceptions of professional uniqueness’; and ‘professional abandonment and silencing’. Postvention following a colleague suicide comprised ‘individualised responses’; ‘the dual function of stigma’; and ‘complex pressure on managers’. A unifying global network ‘after a colleague suicide’ describes the relationships between all themes. A series of disconnects between existing postvention guidance and the needs of impacted workers are discussed. This review demonstrates the need for robust, systemic postvention for colleagues impacted by the complex issue of colleague suicide.

Nurses are the largest healthcare workforce and have had direct, intense and sustained contact with COVID-19 patients throughout the pandemic playing an essential and frontline role in the COVID-19 response. Nurses have worked tirelessly and undertaken multiple roles during the pandemic including education, treatment, prevention, vaccination and research often in uncertain situations and to the detriment of their physical and mental health. They have also managed and cared for distressed patients and their families, and many have been redeployed to other roles often outside of their usual duties, all factors which have affected their well-being. They have publicly been lauded as ‘heroes’. Yet, their voices and perspectives are seldom heard or included in COVID-19 decision-making and in the development of interventions and responses at all levels from individual health services to national policymaking. Indeed, it has felt like these voices have been muted and excluded. Nurses' unique knowledge, expertise, needs and lived experiences are vital to the COVID-19 response. Without their inclusion, COVID-19 decision-making and initiatives are unlikely to be successful and patient outcomes poorer.

Introduction Unprofessional behaviours encompass many behaviours including bullying, harassment and microaggressions. These behaviours between healthcare staff are problematic; they affect people’s ability to work, to feel psychologically safe at work and speak up and to deliver safe care to patients. Almost a fifth of UK National Health Service staff experience unprofessional behaviours in the workplace, with higher incidence in acute care settings and for staff from minority backgrounds. Existing analyses have investigated the effectiveness of strategies to reduce these behaviours. We seek to go beyond these, to understand the range and causes of such behaviours, their negative effects and how mitigation strategies may work, in which contexts and for whom. Methods and analysis This study uses a realist review methodology with stakeholder input comprising a number of iterative steps: (1) formulating initial programme theories drawing on informal literature searches and literature already known to the study team, (2) performing systematic and purposive searches for grey and peer-reviewed literature on Embase, CINAHL and MEDLINE databases as well as Google and Google Scholar, (3) selecting appropriate documents while considering rigour and relevance, (4) extracting data, (5) and synthesising and (6) refining the programme theories by testing the theories against the newly identified literature. Ethics and dissemination Ethical review is not required as this study is a secondary research. An impact strategy has been developed which includes working closely with key stakeholders throughout the project. Step 7 of our project will develop pragmatic resources for managers and professionals, tailoring contextually-sensitive strategies to reduce unprofessional behaviours, identifying what works for which groups. We will be guided by the ‘Evidence Integration Triangle’ to implement the best strategies to reduce unprofessional behaviours in given contexts. Dissemination will occur through presentation at conferences, innovative methods (cartoons, videos, animations and/or interactive performances) and peer-reviewed journals.

There are four core themes developed in this book which deal with critical issues, models, theories and frameworks. These expound understandings of patient centred care and the processes, practices and behaviours supporting its attainment: conceptions and cultures of patient-centred care, coordination, communication, innovation.

The study aimed to develop an understanding of health visitor recruitment and retention by examining what existing staff and new recruits wanted from their job, their professional aspirations and what would encourage them to start and stay in employment. Following a period of steady decline in numbers, the health visitor workforce in England has recently been invested in and expanded to deliver universal child public health. To capitalise on this large investment, managers need an understanding of factors influencing workforce retention and continuing recruitment of health visitors. The study was designed using an interpretive approach and involved students (n = 17) and qualified health visitors (n = 22) from the north and south of England. Appreciative inquiry (AI) exercises were used as methods of data collection during 2012. During AI exercises students and health visitors wrote about 'a practice experience you have felt excited and motivated by and briefly describe the factors that contributed to this'. Participants were invited to discuss their written accounts of practice with a peer during an audio-recorded sharing session. Participants gave consent for written accounts and transcribed recordings to be used as study data, which was examined using framework analysis. In exploring personal meanings of health visiting, participants spoke about the common aspiration to make a difference to children and families. To achieve this, they expected their job to allow them to: connect with families; work with others; use their knowledge, skills and experience; use professional autonomy. The study offers new insights into health visitors' aspirations, showing consistency with conceptual explanations of optimal professional practice. Psychological contract theory illustrates connections between professional aspirations and work commitment. Managers can use these findings as part of workforce recruitment and retention strategies and for building on the health visitor commitment to making a difference to children and families.

Objective: To explore barriers to early presentation and diagnosis with breast cancer among black women. Design: Systematic review. Methods: We searched multiple bibliographic databases (January 1991–February 2013) for primary research, published in English, conducted in developed countries and investigating barriers to early presentation and diagnosis with symptomatic breast cancer among black women (≥18 years). Studies were excluded if they did not report separate findings by ethnic group or gender, only reported differences in time to presentation/diagnosis, or reported on interventions and barriers to cancer screening. We followed Cochrane and PRISMA guidance to identify relevant research. Findings were integrated through thematic synthesis. Designs of quantitative studies made meta-analysis impossible. Results: We identified 18 studies (6183 participants). Delay was multifactorial, individual and complex. Factors contributing to delay included: poor symptom and risk factor knowledge; fear of detecting breast abnormality; fear of cancer treatments; fear of partner abandonment; embarrassment disclosing symptoms to healthcare professionals; taboo and stigmatism. Presentation appears quicker following disclosure. Influence of fatalism and religiosity on delay is unclear from evidence in these studies. We compared older studies (≥10 years) with newer ones (

Background People aged 75 years and over account for 1 in 4 of all hospital admissions. There has been increasing recognition of problems in the care of older people, particularly in hospitals. Evidence suggests that older people judge the care they receive in terms of kindness, empathy, compassion, respectful communication and being seen as a person not just a patient. These are aspects of care to which we refer when we use the term ‘relational care’. Healthcare assistants deliver an increasing proportion of direct care to older people, yet their training needs are often overlooked. Methods/Design This study will determine the acceptability and feasibility of a cluster randomised controlled trial of ‘Older People’s Shoes’ a 2-day training intervention for healthcare assistants caring for older people in hospital. Within this pilot, 2-arm, parallel, cluster randomised controlled trial, healthcare assistants within acute hospital wards are randomised to either the 2-day training intervention or training as usual. Registered nurses deliver ‘Older People’s Shoes’ over 2 days, approximately 1 week apart. It contains three components: experiential learning about ageing, exploration of older people’s stories, and customer care. Outcomes will be measured at the level of patient (experience of emotional care and quality of life during their hospital stay), healthcare assistant (empathy and attitudes towards older people), and ward (quality of staff/patient interaction). Semi-structured interviews of a purposive sample of healthcare assistants receiving the intervention, and all trainers delivering the intervention, will be undertaken to gain insights into the experiences of both the intervention and the trial, and its perceived impact on practice. Discussion Few training interventions for care staff have been rigorously tested using randomised designs. This study will establish the viability of a definitive cluster randomised controlled trial of a new training intervention to improve the relational care proided by healthcare assistants working with older people in hospital. Trial registration The study was registered as an International Standard Randomised Controlled Trial (ISRCTN10385799) on 29 December 2014.

Background Nurses and midwives make up almost 50% of the global healthcare shift working workforce. Shift work interferes with sleep and causes fatigue with adverse effects for nurses’ and midwives’ health, as well as on patient safety and care. Where other safety-critical sectors have developed Fatigue Risk Management Systems, healthcare is behind the curve; with published literature only focussing on the evaluation of discreet sleep-related/fatigue-management interventions. Little is known, however, about which interventions have been evaluated for nurses and midwives. Our review is a critical first step to building the evidence-base for healthcare organisations seeking to address this important operational issue. Objectives We address two questions: (1) what sleep-related/fatigue-management interventions have been assessed in nurses and midwives and what is their evidence-base? and (2) what measures are used by researchers to assess intervention effectiveness? Design and data sources The following databases were searched in November, 2018 with no limit on publication dates: MEDLINE, PsychINFO and CINAHL. Review methods We included: (1) studies conducted in adult samples of nurses and/or midwives that had evaluated a sleep-related/fatigue-management intervention; and (2) studies that reported intervention effects on fatigue, sleep, or performance at work, and on measures of attention or cognitive performance (as they relate to the impact of shift working on patient safety/care). Results The search identified 798 potentially relevant articles, out of which 32 met our inclusion criteria. There were 8619 participants across the included studies and all were nurses (88.6% female). We did not find any studies conducted in midwives nor any studies conducted in the UK, with most studies conducted in the US, Italy and Taiwan. There was heterogeneity both in terms of the interventions evaluated and the measures used to assess effectiveness. Napping could be beneficial but there was wide variation regarding nap duration and timing, and we need to understand more about barriers to implementation. Longer shifts, shift patterns including nights, and inadequate recovery time between shifts (quick returns) were associated with poorer sleep, increased sleepiness and increased levels of fatigue. Light exposure and/or light attenuation interventions showed promise but the literature was dominated by small, potentially unrepresentative samples. Conclusions The literature related to sleep-related/fatigue-management interventions for nurses and midwives is fragmented and lacks cohesion. Further empirical work is warranted with a view to developing comprehensive Fatigue Risk Management Systems to protect against fatigue in nurses, midwives, and other shift working healthcare staff.

Background Pre-COVID-19 research highlighted the nursing profession worldwide as being at high risk from symptoms of burnout, post-traumatic stress disorder (PTSD) and suicide. The World Health Organization declared a pandemic on 11th March 2020 due to the sustained risk of further global spread of COVID-19. The high healthcare burden associated with COVID-19 has increased nurses’ trauma and workload, thereby exacerbating pressure on an already strained workforce and causing additional psychological distress for staff. Objectives The Impact of COVID-19 on Nurses (ICON) interview study examined the impacts of the pandemic on frontline nursing staff's psychosocial and emotional wellbeing. Design Longitudinal qualitative interview study. Settings Nurses who had completed time 1 and 2 of the ICON survey were sampled to include a range of UK work settings including acute, primary and community care and care homes. Interviewees were purposively sampled for maximum variation to cover a broad range of personal and professional factors, and experiences during the COVID-19 pandemic, including redeployment. Methods Nurses participated in qualitative in-depth narrative interviews after the first wave of COVID-19 in July 2020 (n=27) and again at the beginning of the second wave in December 2020 (n=25) via video and audio platform software. Rigorous qualitative narrative analysis was undertaken both cross-sectionally (within wave) and longitudinally (cross wave) to explore issues of consistency and change. Results The terms moral distress, compassion fatigue, burnout and PTSD describe the emotional states reported by the majority of interviewees leading many to consider leaving the profession. Causes of this identified included care delivery challenges; insufficient staff and training; PPE challenges and frustrations. Four themes were identified: (1) ‘Deathscapes’ and impoverished care (2) Systemic challenges and self-preservation (3) Emotional exhaustion and (4) (Un)helpful support. Conclusions Nurses have been deeply affected by what they have experienced and are forever altered with the impacts of COVID-19 persisting and deeply felt. There is an urgent need to tackle stigma to create a psychologically safe working environment and for a national COVID-19 nursing workforce recovery strategy to help restore nurse's well-being and demonstrate a valuing of the nursing workforce and therefore support retention.

Background Understanding and improving ‘patient experience’ is essential to delivering high quality healthcare. However, little is known about the provision of education and training to healthcare staff in this increasingly important area. Objectives This study aims to ascertain the extent and nature of such provision in England and to identify how it might be developed in the future. Methods An on-line survey was designed to explore training provision relating to patient experiences. To ensure that respondents thought about patient experience in the same way we defined patient experience training as that which aims to teach staff: ‘How to measure or monitor the experience, preferences and priorities of patients and use that knowledge to improve their experience’. Survey questions (n = 15) were devised to cover nine consistently reported key aspects of patient experience; identified from the research literature and recommendations put forward by professional bodies. The survey was administered to (i) all 180 providers of Higher Education (HE) to student/qualified doctors, nurses and allied health professionals, and (ii) all 390 National Health Service (NHS) trusts in England. In addition, we added a single question to the NHS 2010 Staff Survey (n = 306,000) relating to the training staff had received to deliver a good patient experience. Results Two hundred and sixty-five individuals responded to the on-line survey representing a total of 159 different organizations from the HE and healthcare sectors. Respondents most commonly identified ‘relationships’ as an ‘essential’ aspect of patient experience education and training. The biggest perceived gaps in current provision related to the ‘physical’ and ‘measurement’ aspects of our conceptualization of patient experience. Of the 148,657 staff who responded to the Staff Survey 41% said they had not received patient experience training and 22% said it was not applicable to them. Conclusions While some relevant education courses are in place in England, the results suggest that specific training with regard to the physical needs and comfort of patients, and how patient experiences can be measured and used to improve services, should be introduced. Future developments should also focus, firstly, on involving a wider range of patients in planning and delivering courses and, secondly, evaluating whether courses impact on the attitudes and behaviors of different professional groups and might therefore contribute to improved patient experiences.

Background Diabetes affects around 3.6 million people in the UK. Previous research found that general practices employing more nurses delivered better diabetes care, but did not include data on individual patient characteristics or consultations received. Aim To examine whether the proportion of consultations with patients with diabetes provided by nurses in GP practices is associated with control of diabetes measured by levels of glycated haemoglobin (HbA1c). Design and setting A retrospective observational study using consultation records from 319 649 patients with diabetes from 471 UK general practices from 2002 to 2011. Method Hierarchical multilevel models to examine associations between proportion of consultations undertaken by nurses and attaining HbA1c targets over time, controlling for case-mix and practice level factors. Results The proportion of consultations with nurses has increased by 20% since 2002 but patients with diabetes made fewer consultations per year in 2011 compared with 2002 (11.6 versus 16.0). Glycaemic control has improved and was more uniformly achieved in 2011 than 2002. Practices in which nurses provide a higher proportion of consultations perform no differently to those where nurse input is lower (lowest versus highest nurse contact tertile odds ratio [OR] [confidence interval {95% CI}]: HbA1c ≤53 mmol/mol (7%) 2002, 1.04 [95% CI = 0.87 to 1.25] and 2011, 0.95 [95% CI = 0.87 to 1.03]; HbA1c ≤86 mmol/mol (10%) 2002, 0.97 [95% CI = 0.73 to 1.29] and 2011, 0.95 [95% CI = 0.86 to 1.04]). Conclusion Practices that primarily use GPs to deliver diabetes care could release significant resources with no adverse effect by switching their services towards nurse-led care.

Background The specific challenges experienced by the nursing and midwifery workforce in previous pandemics have exacerbated pre-existing professional and personal challenges, and triggered new issues. We aimed to determine the psychological impact of the COVID-19 pandemic on the UK nursing and midwifery workforce and identify potential factors associated with signs of post-traumatic stress disorder. Methods A United Kingdom national online survey was conducted at three time-points during the first wave of the COVID-19 pandemic between April and August 2020 (T1 and T2 during initial wave; T3 at three-months following the first wave). All members of the UK registered and unregistered nursing and midwifery workforce were eligible to participate. The survey was promoted via social media and through organisational email and newsletters. The primary outcome was an Impact of Events Scale-Revised score indicative of a post-traumatic stress disorder diagnosis (defined using the cut-off score ≥33). Multivariable logistic regression modelling was used to assess the association between explanatory variables and post-traumatic stress disorder. Results We received 7840 eligible responses (T1- 2040; T2- 3638; T3- 2162). Overall, 91.6% participants were female, 77.2% were adult registered nurses, and 28.7% were redeployed during the pandemic. An Impact of Events Scale-Revised score ≥33 (probable post-traumatic stress disorder) was observed in 44.6%, 37.1%, and 29.3% participants at T1, T2, and T3 respectively. At all three time-points, both personal and workplace factors were associated with probable post-traumatic stress disorder, although some specific associations changed over the course of the pandemic. Increased age was associated with reduced probable post-traumatic stress disorder at T1 and T2 (e.g. 41-50 years at T1 odds ratio (OR) 0.60, 95% confidence interval (CI) 0.42-0.86), but not at T3. Similarly, redeployment with inadequate/ no training was associated with increased probable post-traumatic stress disorder at T1 and T2, but not at T3 (T1 OR 1.37, 95% CI 1.06-1.77; T3 OR 1.17, 95% CI 0.89-1.55). A lack of confidence in infection prevention and control training was associated with increased probable post-traumatic stress disorder at all three time-points (e.g. T1 OR 1.48, 95% CI 1.11-1.97). Conclusion A negative psychological impact was evident 3-months following the first wave of the pandemic. Both personal and workplace are associated with adverse psychological effects linked to the COVID-19 pandemic. These findings will inform how healthcare organisations should respond to staff wellbeing needs both during the current pandemic, and in planning for future pandemics.

Background: Ever-growing demands on care systems have increased reliance on healthcare support workers. In the UK, their training has been variable, but organisation-wide failures in care have prompted questions about how this crucial section of the workforce should be developed. Their training, support and assessment has become a policy priority. Objectives: This paper examines: healthcare support workers’ access to training, support and assessment; perceived gaps in training provision; and barriers and facilitators to implementation of relevant policies in acute care. Design and settings: We undertook a qualitative study of staff caring for older inpatients at ward, divisional or organisational-level in three acute National Health Service hospitals in England in 2014. Participants: 58 staff working with older people (30 healthcare support workers and 24 staff managing or working alongside them) and 4 healthcare support worker training leads. Methods: One-to-one semi-structured interviews included: views and experiences of training and support; translation of training into practice; training, support and assessment policies and difficulties of implementing them. Transcripts were analysed to identify themes. Results: Induction training was valued, but did not fully prepare healthcare support workers for the realities of the ward. Implementation of hospital policies concerning supervision and formal assessment of competencies varied between and within hospitals, and was subject to availability of appropriate staff and competing demands on staff time. Gaps identified in training provision included: caring for people with cognitive impairment; managing the emotions of patients, families and themselves; and having difficult conversations. Access to ongoing training was affected by: lack of time; infrequent provision; attitudes of ward managers to additional support workforce training, and their need to balance this against patients’ and other staff members’ needs; and the use of e-learning as a default mode of training delivery. Conclusions: With the current and unprecedented policy focus on training, support and assessment of healthcare support workers, our study suggests improved training would be welcomed by them and their managers. Provision of training, support and assessment could be improved by organisational policy that promotes and protects healthcare support worker training; formalising the provision and availability of on-ward support; and training and IT support provided on a drop-in basis. Challenges in implementation are likely to be faced in all international settings where there is increased reliance on a support workforce. While recent policies in the UK offers scope to overcome some of these challenges there is a risk that some will be exacerbated.

Objectives: Understanding barriers to early diagnosis of symptomatic breast cancer among Black African, Black Caribbean and White British women in the UK. Design: In-depth qualitative interviews using grounded theory methods to identify themes. Findings validated through focus groups. Participants: 94 women aged 33-91 years; 20 Black African, 20 Black Caribbean and 20 White British women diagnosed with symptomatic breast cancer were interviewed. Fourteen Black African and 20 Black Caribbean women with (n=19) and without (n=15) breast cancer participated in six focus groups. Setting: Eight cancer centres/hospital trusts in London (n=5), Somerset (n=1), West Midlands (n=1) and Greater Manchester (n=1) during 2012-2013. Results: There are important differences and similarities in barriers to early diagnosis of breast cancer between Black African, Black Caribbean and White British women in the UK. Differences were influenced by country of birth, time spent in UK and age. First generation Black African women experienced most barriers and longest delays. Second generation Black Caribbean and White British women were similar and experienced fewest barriers. Absence of pain was a barrier for Black African and Black Caribbean women. Older White British women (≥70 years) and first generation Black African and Black Caribbean women shared conservative attitudes and taboos about breast awareness. All women viewed themselves at low risk of the disease, and voiced uncertainty over breast awareness and appraising non-lump symptoms. Focus group findings validated and expanded themes identified in interviews. Conclusions: Findings challenged reporting of Black women homogenously in breast cancer research. This can mask distinctions within and between ethnic groups. Current media and health promotion messages need reframing to promote early presentation with breast symptoms. Working with communities and developing culturally appropriate materials may lessen taboos and stigma, raise awareness, increase discussion of breast cancer and promote prompt help-seeking for breast symptoms among women with low cancer awareness.

Aim and objective.  To explore why innovations in service and delivery are adopted and how they are then successfully implemented and eventually assimilated into routine nursing practice. Background.  The ‘Productive Ward’ is a national quality improvement programme that aims to engage nursing staff in the implementation of change at ward level. Design.  Mixed methods (analysis of routine data, online survey, interviews) to apply an evidence-based diffusion of innovations framework. Method.  (1) Broad and narrow indicators of the timing of ‘decisions to adopt’ the Productive Ward were applied. (2) An online survey explored the perceptions of 150 respondents involved with local implementation. (3) Fifty-eight interviews in five organisational case studies to explore the process of assimilation in each context. Results.  Since the launch of the programme in May 2008 staff in approximately 85% of NHS acute hospitals had either downloaded Productive Ward materials or formally purchased a support package (as of March 2009). On a narrower measure, 40% (140) of all NHS hospitals had adopted the programme (i.e. purchased a support package) with large variation between geographical regions. Four key interactions in the diffusion of innovations framework appeared central to the rapid adoption of the programme. Despite widespread perception of significant benefits, frontline nursing staff report that more needs to be carried out to ensure that impact can be demonstrated in quantifiable terms and include patient perspectives. Conclusions.  The programme has been rapidly adopted by NHS hospitals in England. A variety of implementation approaches are being employed, which are likely to have implications for the successful assimilation of the programme into routine nursing practice. Relevance to clinical practice.  This paper summarises the perceived benefits of the Productive Ward programme and highlights important lessons for nurse leaders who are designing (or adapting) and then implementing quality improvement programmes locally, particularly in terms of how to frame such initiatives – and provide support to – ward-level staff.

Purpose: The purpose of this paper is to explore the nature and impact of leadership in relation to the local implementation of quality improvement interventions in health care organisations. Design/Methodology/Approach: Using empirical data from two studies of the implementation of The Productive Ward: Releasing Time to Care in English hospitals, the paper explores leadership in relation to local implementation. Data were attained from in-depth interviews with senior managers, middle managers and frontline staff (n = 79) in 13 NHS hospital case study sites. Framework Approach was used to explore staff views and to identify themes about leadership. Findings: Four overall themes were identified: different leadership roles at multiple levels of the organisation, experiences of "good and bad" leadership styles, frontline staff having a sense of permission to lead change, leader's actions to spread learning and sustain improvements. Originality/Value: This paper offers useful perspectives in understanding informal, emergent, developmental or shared "new" leadership because it emphasises that health care structures, systems and processes influence and shape interactions between the people who work within them. The framework of leadership processes developed could guide implementing organisations to achieve leadership at multiple levels, use appropriate leadership roles, styles and behaviours at different levels and stages of implementation, value and provide support for meaningful staff empowerment, and enable leader's boundary spanning activities to spread learning and sustain improvements.

Aim(s)  To examine the evidence of how poorly performing nurses and midwives are managed in the UK National Health Service (NHS). Background  Nurses and midwives form the largest clinical group in the NHS. There is little evidence, however, about poor performance and its management in nursing and midwifery literature. Method(s)  The present study comprised a literature search, analysis of recent Nursing and Midwifery Council (NMC) data and observation at NMC fitness to practice hearings. Results  Nurses and midwives are the clinical groups most likely to be suspended in the NHS; Trusts do not report data on suspensions therefore no data exist on numbers, reasons for suspensions, managerial processes, gender, area of work, or ethnicity of those suspended; the few major research projects identify variable management practices, the significant financial cost to the NHS and the personal cost to those suspended; there is evidence that inexperienced, poorly trained, or poorly supported managers use suspension inappropriately. Our observation supported this. Conclusion(s)  There is a need for robust data gathering and research in the field of NHS managerial practice. Implications for nursing management.  Managers should refrain from adopting punitive forms of performance management. Frontline staff and management need better training and support for dealing with poor performance.

Purpose The aim of this paper was to briefly describe how the experience-based co-design (EBCD) approach was used to identify and implement improvements in the experiences of breast and lung cancer patients before (1) comparing the issues identified as shaping patient experiences in the different tumour groups and (2) exploring participants' reflections on the value and key characteristics of this approach to improving patient experiences. Methods Fieldwork involved 36 filmed narrative patient interviews, 219 h of ethnographic observation, 63 staff interviews and a facilitated co-design change process involving patient and staff interviewees over a 12-month period. Four of the staff and five patients were interviewed about their views on the value of the approach and its key characteristics. The project setting was a large, inner-city cancer centre in England. Results Patients from both tumour groups generally identified similar issues (or 'touchpoints') that shaped their experience of care, although breast cancer patients identified a need for better information about side effects of treatment and end of treatment whereas lung cancer patients expressed a need for more information post-surgery. Although the issues were broadly similar, the particular improvement priorities patients and staff chose to work on together were tumour specific. Interviewees highlighted four characteristics of the EBCD approach as being key to its successful implementation: patient involvement, patient responsibility and empowerment, a sense of community, and a close connection between their experiences and the subsequent improvement priorities. Conclusion EBCD positions patients as active partners with staff in quality improvement. Breast and lung cancer patients identified similar touchpoints in their experiences, but these were translated into different improvement priorities for each tumour type. This is an important consideration when developing patient-centred cancer services across different tumour types.

Nurses and midwives make up almost 50% of the global healthcare shift working workforce. Shift work interferes with sleep and causes fatigue with adverse effects for nurses’ and midwives’ health, as well as on patient safety and care. Where other safety-critical sectors have developed Fatigue Risk Management Systems, healthcare is behind the curve; with published literature only focussing on the evaluation of discreet sleep-related/fatigue-management interventions. Little is known, however, about which interventions have been evaluated for nurses and midwives. Our review is a critical first step to building the evidence-base for healthcare organisations seeking to address this important operational issue.

Medication errors can occur at any stage of the medication process including prescribing, dispensing, preparation, administration and monitoring (Vincent et al 2009). Medication administration is acknowledged as a process in which patient safety can be compromised easily (Department of Health 2003) and it is argued that any distraction or interruption during medication administration can result in errors. This Policy+ reviews the contribution to medication administration errors of interruptions to nurses’ work and considers how such interruptions can be reduced.

Purpose – This paper aims to focus on facilitating large-scale quality improvement in health care, and specifically understanding more about the known challenges associated with implementation of lean innovations: receptivity, the complexity of adoption processes, evidence of the innovation, and embedding change. Lessons are drawn from the implementation of The Productive Ward: Releasing Time to Caree programme in English hospitals. Design/methodology/approach – The study upon which the paper draws was a mixed-method evaluation that aimed to capture the perceptions of three main stakeholder groups: national-level policymakers (15 semi-structured interviews); senior hospital managers (a national web-based survey of 150 staff); and healthcare practitioners (case studies within five hospitals involving 58 members of staff). The views of these stakeholder groups were analysed using a diffusion of innovations theoretical framework to examine aspects of the innovation, the organisation, the wider context and linkages. Findings – Although The Productive Ward was widely supported, stakeholders at different levels identified varying facilitators and challenges to implementation. Key issues for all stakeholders were staff time to work on the programme and showing evidence of the impact on staff, patients and ward environments. Research limitations/implications – To support implementation, policymakers should focus on expressing what can be gained locally using success stories and guidance from “early adopters”. Service managers, clinical educators and professional bodies can help to spread good practice and encourage professional leadership and support. Further research could help to secure support for the programme by generating evidence about the innovation, and specifically its clinical effectiveness and broader links to public expectations and experiences of healthcare. Originality/value – This paper draws lessons from the implementation of The Productive Ward programme in England, which can inform the implementation of other large-scale programmes of quality improvement in health care.

Background: Older people account for an increasing proportion of those receiving NHS acute care. The quality of health care delivered to older people has come under increased scrutiny. Health-care assistants (HCAs) provide much of the direct care of older people in hospital. Patients’ experience of care tends to be based on the relational aspects of that care including dignity, empathy and emotional support. Objective(s): We aimed to understand the relational care training needs of HCAs caring for older people, design a relational care training intervention for HCAs and assess the feasibility of a cluster randomised controlled trial to test the new intervention against HCA training as usual (TAU). Design: (1) A telephone survey of all NHS hospital trusts in England to assess current HCA training provision, (2) focus groups of older people and carers, (3) semistructured interviews with HCAs and other care staff to establish training needs and inform intervention development and (4) a feasibility cluster randomised controlled trial. Setting: (1) All acute NHS hospital trusts in England, and (2–4) three acute NHS hospital trusts in England and the populations they serve. Participants: (1) Representatives of 113 out of the total of 161 (70.2%) NHS trusts in England took part in the telephone survey, (2) 29 older people or carer participants in three focus groups, (3) 30 HCA and 24 ‘other staff’ interviewees and (4) 12 wards (four per trust), 112 HCAs, 92 patients during the prerandomisation period and 67 patients during the postrandomisation period. Interventions: For the feasibility trial, a training intervention (Older People’s Shoes™) for HCAs developed as part of the study was compared with HCA TAU. Main outcome measures: Patient-level outcomes were the experience of emotional care and quality of life during patients’ hospital stay, as measured by the Patient Evaluation of Emotional Care during Hospitalisation and the EuroQol-5 Dimensions questionnaires. HCA outcomes were empathy, as measured by the Toronto Empathy Questionnaire, and attitudes towards older people, as measured by the Age Group Evaluation and Description Inventory. Ward-level outcomes were the quality of HCA–patient interaction, as measured by the Quality of Interaction Scale. Results: (1) One-third of trust telephone survey participants reported HCA training content that we considered to be ‘relational care’. Training for HCAs is variable across trusts and is focused on new recruits. The biggest challenge for HCA training is getting HCAs released from ward duties. (2) Older people and carers are aware of the pressures that ward staff are under but good relationships with care staff determine whether or not their experience of hospital is positive. (3) HCAs have training needs related to ‘difficult conversations’ with patients and relatives; they have particular preferences for learning styles that are not always reflected in available training. (4) In the feasibility trial, 187 of the 192 planned ward observation sessions were completed; the response to HCA questionnaires at baseline and at 8 and 12 weeks post randomisation was 64.2%, 46.4% and 35.7%, respectively, and 57.2% of eligible patients returned completed questionnaires. Limitations: This was an intervention development and feasibility study so no conclusions can be drawn about the clinical effectiveness or cost-effectiveness of the intervention. Conclusions: The intervention had high acceptability among nurse trainers and HCA learners. Viability of a definitive trial is conditional on overcoming specific methodological (patient recruitment processes) and contextual (involvement of wider ward team) challenges.

Background An association between quality of care and staffing levels, particularly registered nurses, has been established in acute hospitals. Recently an association between nurse staffing and quality of care for several chronic conditions has also been demonstrated for primary care in English general practice. A smaller body of literature identifies organisational factors, in particular issues of human resource management, as being a dominant factor. However the literature has tended to consider staffing and organisational factors separately. Aims and objectives We aim to determine whether relationships between the quality of clinical care and nurse staffing in general practice are attenuated or enhanced when organisational factors associated with quality of care are considered. We further aim to determine the relative contribution and interaction between these factors. Method We used routinely collected data from 8409 English general practices. The data, on organisational factors and the quality of clinical care for a range of long term conditions, is gathered as part of “Quality and Outcomes Framework” pay for performance system. Regression models exploring the relationship of staffing and organisational factors with care quality were fitted using MPLUS statistical modelling software. Results Higher levels of nurse staffing, clinical recording, education and reflection on the results of patient surveys were significantly associated with improved clinical care for COPD, CHD, Diabetes and Hypothyroidism after controlling for organisational factors. There was some evidence of attenuation of the estimated nurse staffing effect when organisational factors were considered, but this was small. The effect of staffing interacted significantly with the effect of organisational factors. Overall however, the characteristics that emerged as the strongest predictors of quality of clinical care were not staffing levels but the organisational factors of clinical recording, education and training and use of patient experience surveys. Conclusions Organisational factors contribute significantly to observed variation in the quality of care in English general practices. Levels of nurse staffing have an independent association with quality but also interact with organisational factors. The observed relationships are not necessarily causal but a causal relationship is plausible. The benefits and importance of education, training and personal development of nursing and other practice staff was clearly indicated.

Schwartz Centre Rounds (Rounds), which originated in Boston, USA, are organisation-wide forums for healthcare staff which prompt reflection and discussion of the emotional, social or ethical challenges of healthcare work. Drawing on data from our UK National evaluation of Rounds we outline the unique features of Rounds as an organisational intervention, highlighting their differences to other wellbeing interventions and explain how Rounds work to influence organisational change and patient safety. As Rounds are open to all staff they are able to shine a spotlight on hidden organisational roles and staff groups, sparking greater insight and understanding of what peoples’ roles involve, resulting in reported reduced isolation and staff connection through sharing similar experiences. Rounds can help staff see and connect with the bigger picture of how the organisation functions helping to develop organisational cohesiveness and connectedness to the organisational mission and values and provide a space to process patient cases and learn from mistakes. Rounds can provide a counter-cultural space, allowing opportunities for staff to process and reflect upon difficult and satisfying aspects of their work as individuals, within teams and as an organisation. We reflect upon the challenges of implementing and sustaining Rounds including their evaluation and measuring organisational change resulting from Rounds provision.

Objectives: Schwartz Center Rounds (‘Rounds’) are a multidisciplinary forum in which healthcare staff within an organisation discuss the psychological, emotional and social challenges associated with their work in a confidential and safe environment. Implemented in over 375 North American organisations, since 2009, they have been increasingly adopted in England. This study aimed to establish how many and what types of organisations have adopted Rounds in England, and to explore why they did so. Setting: Public healthcare organisations in England. Participants: Secondary data analysis was used to map and profile all 116 public healthcare organisations that had adopted Rounds in England by July 2015. Semistructured telephone interviews were conducted with 45 Round coordinators within adopting organisations. Results: The rate of adoption increased after a major national report in 2013. Rounds were typically adopted in order to improve staff well-being. Adopting organisations scored better on staff engagement than non-adopters; among adopting organisations, those performing better on patient experience were more likely to adopt earlier. Most adoption decision-making processes were straightforward. A confluence of factors—a generally favourable set of innovation attributes (including low cost), advocacy from opinion leaders in different professional networks, active dissemination by change agents and a felt need to be seen to be addressing staff well-being—initially led to Rounds being seen as ‘an idea whose time had come’. More recent adoption patterns have been shaped by the timing of charitable and other agency funding in specific geographical areas and sectors, as well as several forms of ‘mimetic pressure’. Conclusions: The innate attributes of Rounds, favourable circumstances and the cumulative impact of a sequence of distinct informal and formal social processes have shaped the pattern of their adoption in England.

This article, the first in a four-part series about using research evidence to inform the delivery of nursing care, discusses four studies that were funded following the two Francis inquiries into care failings at Mid Staffordshire NHS Foundation Trust. Each study evaluated an intervention method in an acute hospital setting that aimed to improve patient care and protect the wellbeing of nursing staff; these included a team-based practice development programme, a relational care training intervention for healthcare assistants, a regular bedside ward round (intentional rounding), and monthly group meetings during which staff discussed the emotional challenges of care. The remaining articles in this series will explore the results of the studies and how they can be applied to nursing care during, and after, the coronavirus pandemic

This article examines the importance of some informal work practices among community nurses during a period of significant organizational change. Ethnographic fieldwork in two purposively selected adult community nursing services in England comprised 79 hours of observation of routine practice, 21 interviews with staff and 23 interviews with patients. We identified the informal work practice of ‘catching up’, informal work conversations between immediate colleagues, as an important but often invisible aspect of satisfying work relationships and of the relational care of patients. Drawing on anthropological literatures on ‘communities of practice’ the article examines two central issues concerning the practices of ‘catching up’: (1) how informal learning processes shape community nursing work; (2) how this informal learning is shaped both in relation to the ideals of community nursing work and the wider political and organizational contexts of community nursing practice. Our findings highlight the distinctive value of informal workplace ‘catch ups’ for nurses to manage the inherent challenges of good home care for patients and to develop a shared ethic of care and professional identity. Our findings also indicate the decline of ‘catching up’ between nurses along with diminishing time and opportunity for staff to care holistically for patients in present service climates.

Background Schwartz Center Rounds® (Rounds) were introduced into the UK in 2009 to support health-care staff to deliver compassionate care, something the Francis report (Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013) identified as lacking. Rounds are organisation-wide forums that prompt reflection and discussion of the emotional, social and ethical challenges of health-care work, with the aim of improving staff well-being and patient care. Objectives How, in which contexts and for whom Rounds participation affects staff well-being at work, increases social support for staff and improves patient care. Design (1) A scoping review of Rounds literature and comparison with alternative interventions; (2) mapping Rounds providers via a survey, telephone interviews and secondary data; (3) a two-wave survey of (i) new attenders/non-attenders in 10 sites to determine the impact on staff engagement and well-being; and (ii) interviews with Rounds attenders, non-attenders, facilitators, clinical leads, steering group members, board members and observations in nine case study sites to (4) describe experiences and (5) test candidate programme theories by which Rounds ‘work’ (realist evaluation). Setting (1) International literature (English); (2) all Rounds providers (acute/community NHS trusts and hospices) at 1 September 2014 (survey/interview) and 15 July 2015 (secondary data); (3) 10 survey sites; and (4 and 5) nine organisational case study sites (six of which also took part in the survey). Participants (1) Ten papers were reviewed for Rounds and 146 were reviewed for alternative interventions. (2) Surveys were received from 41 out of 76 (54%) providers and interviews were conducted with 45 out of 76 (59%) providers. (3) Surveys were received from 1140 out of 3815 (30%) individuals at baseline and from 500 out of 1140 (44%) individuals at follow-up. (4 and 5) A total of 177 interviews were conducted, as were observations of 42 Rounds, 29 panel preparations and 28 steering group meetings. Results (1) The evidence base is limited; compared with 11 alternative interventions, Rounds offer a unique organisation-wide ‘all staff’ forum in which disclosure/contribution is not essential. (2) Implementation rapidly increased between 2013 and 2015; Rounds were implemented variably; challenges included ward staff attendance and the workload and resources required to sustain Rounds; and costs were widely variable. (3) There was no change in engagement, but poor psychological well-being (12-item General Health Questionnaire) reduced significantly (p 

Abstract It has long been known that nursing work is challenging and has the potential for negative impacts. During the COVID-19 pandemic most nurses’ working landscapes altered dramatically and many faced unprecedented challenges. Resilience is a contested term that has been used with increasing prevalence in healthcare with health professionals encouraging a ‘tool-box’ of stress management techniques and resilience-building skills. Drawing on narrative interview data (n=27) from the Impact of Covid on Nurses (ICON) qualitative study we examine how nurses conceptualised resilience during COVID-19 and the impacts this had on their mental wellbeing. We argue here that it is paramount that nurses are not blamed for experiencing workplace stress when perceived not to be resilient ‘enough’, particularly when expressing what may be deemed to be normal and appropriate reactions given the extreme circumstances and context of the COVID-19 pandemic.  

Aim To understand nurses' perceptions and experiences of work role transitions. Background Globally an uncertain healthcare landscape exists and when changing work roles nurses experience periods of transition when they may not cope well. A greater understanding of work role transitions may help facilitate workforce retention and successful careers. Design Mixed methods systematic review. Data sources Six data bases were searched for peer reviewed primary empirical research, published in English language between January 1990 and December 2014, supplemented by hand and citation searching. Review methods Evidence for Policy and Practice Information and Co-ordinating Centre methods for systematic reviews principles were followed. Analysis and synthesis of the qualitative and quantitative papers was conducted separately using thematic analysis. A third synthesis combined the narrative findings and a narrative synthesis of results is presented. Results Twenty-six papers were included. Across nurses' work role transitions two pathways were found: Novice and Experienced. ‘Novice’ comprises pre-registration and newly qualified nurses. ‘Experienced’ comprises, Enrolled/Licensed Practical Nurse to Registered Nurse, experienced to specialist nurse and clinical role changes. Each pathway results in different emphasizes of two themes; ‘Striving for a new professional self’ includes emotional upheaval and identity while ‘Know how’ includes competence and boundaries. Novice nurses are more susceptible to the extremes of emotional upheaval while experienced nurses' competence eases aspects of transitions while boundary issues pervade. Conclusion Informed work and educational environments are required for all groups of nurses. Using existing models of transition can facilitate successful individual transitions and develop the workplace.

Objectives A wide range of patient benefits have been attributed to single room hospital accommodation including a reduction in adverse patient safety events. However, studies have been limited to the US with limited evidence from elsewhere. The aim of this study was to assess the impact on safety outcomes of the move to a newly built all single room acute hospital. Methods A natural experiment investigating the move to 100% single room accommodation in acute assessment, surgical and older people’s wards. Move to 100% single room accommodation compared to ‘steady state’ and ‘new build’ control hospitals. Falls, pressure ulcer, medication error, meticillin-resistant Staphylococcus aureus and Clostridium difficile rates from routine data sources were measured over 36 months. Results Five of 15 time series in the wards that moved to single room accommodation revealed changes that coincided with the move to the new all single room hospital: specifically, increased fall, pressure ulcer and Clostridium difficile rates in the older people’s ward, and temporary increases in falls and medication errors in the acute assessment unit. However, because the case mix of the older people’s ward changed, and because the increase in falls and medication errors on the acute assessment ward did not last longer than six months, no clear effect of single rooms on the safety outcomes was demonstrated. There were no changes to safety events coinciding with the move at the new build control site. Conclusion For all changes in patient safety events that coincided with the move to single rooms, we found plausible alternative explanations such as case-mix change or disruption as a result of the re-organization of services after the move. The results provide no evidence of either benefit or harm from all single room accommodation in terms of safety-related outcomes, although there may be short-term risks associated with a move to single rooms.

Aims. To synthesize evidence and knowledge from published research about nurses’ experiences of nurse-patient relationships with adult patients in general,acute inpatient hospital settings.Background. While primary research on nurses’ experiences has been reported, it has not been previously synthesized.Design. Meta-ethnography.Data sources. Published literature from Australia, Europe, and North America,written in English between January 1999–October 2009 was identified from databases: CINAHL, Medline, British Nursing Index and PsycINFO.Review methods. Qualitative studies describing nurses’ experiences of the nurse-patient relationship in acute hospital settings were reviewed and synthesized using the meta-ethnographic method.Results. Sixteen primary studies (18 papers) were appraised as high quality and met the inclusion criteria. The findings show that while nurses aspire to develop therapeutic relationships with patients, the organizational setting at a unit level is strongly associated with nurses’ capacity to build and sustain these relationships.The organizational conditions of critical care settings appear best suited to forming therapeutic relationships, while nurses working on general wards are more likely to report moral distress resulting from delivering unsatisfactory care. General ward nurses can then withdraw from attempting to emotionally engage with patients.Conclusion. The findings of this meta-ethnography draw together the evidence from several qualitative studies and articulate how the organizational setting at a unit level can strongly influence nurses’ capacity to build and sustain therapeutic relationships with patients. Service improvements need to focus on how to optimize the organizational conditions that support nurses in their relational work with patients.

A global shortage of health care workers has led to an increase in international migration, often from low-income ‘sending’ countries in Africa, India and the Phillipines (Lorenzo et al., 2007; Seboni, 2009; Hamada et al., in press) to high income ‘receiving’ countries including the UK and the US (Bach, 2007; Brush and Sochalski, 2007; Smith et al., 2006). In the Middle East, many countries have come to rely on international recruitment to staff their burgeoning health care facilities but they are now forced to compete with other countries in an increasingly global market.

Introduction Healthcare workforces are currently facing multiple challenges, including aging populations; increasing prevalence of long-term conditions; and shortfall of registered nurses. Employing non-registered support workers is common across many countries to expand service capacity of nursing teams. One task delegated to non-registered support workers is medication administration, which is considered a complex task, with associated risks. This is an important topic given the predicted global increase in patients requiring assistance with medication in community settings. This review explores the evidence on delegation of medication administration from registered nurse to non-registered support workers within community settings to better understand factors that influence the process of delegation and its impact on service delivery and patient care. Methods The review followed key principles of Critical Interpretative Synthesis and was structured around Preferred Reporting Items for Systematic Reviews and Meta‐analysis guidelines. Literature searches were conducted in MEDLINE, CINAHL, Embase, and ProQuest-British Nursing Index databases. Twenty studies were included. Results Findings are reported under four themes: 1, Regulatory and contextual factors; 2, Individual and team level factors; 3, Outcomes of delegation; and 4, Process of implementation and evaluation. Delegation was found to be a complex phenomenon, influenced by a myriad of interconnecting factors at the macro, meso, micro level. At the macro level, the consistency and clarity of government and state level regulations was found to facilitate or impede delegation of medication administration. Lack of clarity at the macro level, impacted at meso and micro levels, resulting in confusion around what medication administration could be delegated and who held responsibility. At the micro level, central to the interpretation of success was the relationship between the delegator and delegate. This relationship was influenced by personal views, educational and systems factors. Many benefits were reported as an outcome of delegation, including service efficiency and improved patient care. The implementation of delegating medication administration was influenced by regulatory factors, communication, stakeholder engagement, and service champions. Conclusion Delegation of medication administration is a complex process influenced by many interrelating factors. Due to the increased risk associated with medication administration, clear and consistent regulatory and governance frameworks and procedures are crucial. Delegation of medication administration is more acceptable within a framework that adequately supports the process, backed by appropriate policy, skills, training, and supervisory arrangements. There is a need for further research around implementation, clinical outcomes and medication errors associated with delegation of medication administration.

Healthcare organisations reap significant benefits when workers’ concerns are adequately listened and responded to, including improved patient safety, reduced costs and improved staff experience. Although many concerns are dealt with satisfactorily, compelling evidence suggests that problems of silence (where employees do not speak up) and deafness (where organisations do not hear concerns or act) remain pervasive worldwide. In the English National Health Service (NHS) the response to these problems includes numerous policy initiatives and the introduction in 2016 of the “Freedom to Speak Up Guardian” (FTSUG) role. This globally unique role is described as potentially leading to huge improvements in the way staff concerns are handled and responded to leading to improvements in organisational learning and patient safety. Following their introduction thousands of NHS staff have already spoken up via FTSUGs. The majority of FTSUGs time is spent on bullying and harassment concerns, rather than direct patient safety concerns, which appears to have confounded FTSUGs’ and others’ expectations. This chapter opens by describing the background to the development of the FTSUG role. We then outline the literature on bullying and harassment; its shocking prevalence within healthcare workplaces and the damaging consequences of bullying borne by organisations and individual staff and patients. We also discuss our analysis of semi-structured interviews (n = 87) undertaken with FTSUGs, which illustrates the realities of dealing with colleagues’ concerns about bullying and harassment and how these realities are often overlooked in national, regional and local workplace guidance and training materials currently available to support the implementation of the role.

Background Work stress and compassion fatigue are prevalent among healthcare staff and their negative effects on staff well-being and patient care are well-known. This paper reports on the implementation and evaluation of Schwartz Rounds® (Rounds) in UK healthcare organizations, predominantly part of the National Health Service (NHS). Rounds are one-hour, typically monthly, multidisciplinary forums during which clinical and nonclinical healthcare staff discuss the emotional and social demands of delivering patient care. The purpose of this research was to evaluate the effectiveness of Rounds attendance on the psychological distress, work engagement, compassion and self-reflection of healthcare staff. Methods We used a pre-post control design to assess the effect of Rounds attendance across 10 UK healthcare organizations. This design was most appropriate given the voluntary nature of Rounds and ensured the study had ecological validity. Self-reported data were collected from attenders and non-attenders at baseline and at eight-months follow-up. The outcomes were psychological distress, work engagement, compassion and self-reflection. Results During the 8 months’ study duration, regular attenders (N = 51) attended Rounds on average 4 times (2–8). Attenders showed a significantly greater decrease in psychological distress (as measured with the General Health Questionnaire (GHQ)) than non-attenders (N = 233; odds ratio of 0.197; 95% confidence interval (0.047–0.823)). However, Rounds attendance had no significant effect on work engagement, compassion and self-reflection. Conclusions Rounds attendance was linked to a 19% reduction in psychological distress adjusting for covariates. As an organization-wide intervention, Rounds thus constitute an effective, relatively low-cost intervention to assist staff in dealing with the demands of their work and to improve their well-being.

Background : There is ample evidence that modern nurses are under strain and that interventions to support the nursing workforce have not recognised the complexity inherent in nursing work. Creating a modern model of nursing work may assist nurses in developing workable solutions to professional problems. A new model may also foster cohesion among broad and diverse nursing roles. Aim : The aim of this meta-narrative review was to investigate how researchers, using different methods and theoretical approaches, have contributed to the understanding of nursing work. Methods : A meta-narrative review was done to evaluate the trajectory of nursing work research, from 1953 to present. This review progressed through the stages of planning, searching, mapping, appraisal, and synthesis. Findings A total of 121 articles were included in this meta-narrative review. These articles revealed five narratives of nursing work, where work is conceptualised as labour. These narratives were physical labour (n=14), emotional (n=53), cognitive (n=24), and organisational (n=1), and combinations of more than one type of labour (n=29 articles). The paradigms identified in the meta-narrative were the positivist, interpretive, critical, and evidence-based paradigms. Each article in the review corresponded with a paradigm and a labour narrative, creating a comprehensive model. Conclusions : Nursing work can be understood as a model of physical, emotional, cognitive, and organisational labour. These different types of labour may be hidden and taken for granted. Nurses can use this model to articulate what they do and how it supports patient safety. Nurses can also advocate for staffing allocations that consider all types of nursing labour. Tweetable abstract: Nursing work is complex and includes physical, emotional, cognitive, and organisational labour. Staffing needs to take all nursing labour into account.

The altered landscape surrounding commissioning of public health provision has affected the nature and range of health visitor services across England. This is the first of two papers reporting evidence from a programme of research that focused on how health visiting works, also reporting service user and workforce perspectives. Evidence for a service model is offered, based on universal principles and maximising the capacity of the health visiting resource. Where service specifications fail to give careful attention to this evidence, the reshaped services for children and families may miss core ingredients that enable health visitors to make a difference, delivering a proportionate and successful child health programme for the early years.

Background Schwartz Center Rounds® (henceforce Rounds) were developed in the United States (US) in 1995 to provide a regular, structured time and safe place for staff to meet to share the emotional, psychological and social challenges of working in healthcare. Rounds were adopted in the United Kingdom (UK) in 2009 and have been subsequently implemented in over 180 healthcare organisations. Using Rounds as a case study, we aim to inform current debates around maintaining fidelity when an intervention developed in one country is transferred and implemented in another. Methods Interpretive design using nine qualitative interviews (UK = 3, US = 6) and four focus groups (UK: Focus group 1 (4 participants), Focus group 2 (5 participants; US: focus group 1 (5 participants) focus group 2 (2 participants) with participants involved in Rounds design and implementation, for example, programme architects, senior leaders, mentors and trainers. We also conducted non-participant observations of Rounds (UK = 42: USA = 2) and training days (UK = 2). Data were analysed using thematic analysis. Results We identified four core and seven sub-core Rounds components, based upon the US design, and seven peripheral components, based on our US and UK fieldwork. We found high core component fidelity and examples of UK adaptations. We identified six strategies used to maintain high fidelity during Rounds transfer and implementation from the US to UK settings: i) having a legal contract between the two national bodies overseeing implementation, ii) requiring adopting UK healthcare organisations to sign a contract with the national body, iii) piloting the intervention in the UK context, iv) emphasising the credibility of the intervention, v) promoting and evaluating Rounds, and vi) providing implementation support and infrastructure. Conclusions This study identifies how fidelity to the core components of a particular intervention was maintained during transfer from one country to another by identifying six strategies which participants argued had enhanced fidelity during transfer of Rounds to a different country, with contractual agreements and legitimacy of intervention sources key. Potential disadvantages include limitations to further innovation and adaptation.

Background: Patients’ experiences have become central to assessing the performance of healthcare systems worldwide and are increasingly being used to inform quality improvement processes. This paper explores the relative value of surveys and detailed patient narratives in identifying priorities for improving breast cancer services as part of a quality improvement process. Methods: One dataset was collected using a narrative interview approach, (n = 13) and the other using a postal survey (n = 82). Datasets were analyzed separately and then compared to determine whether similar priorities for improving patient experiences were identified. Results: There were both similarities and differences in the improvement priorities arising from each approach. Day surgery was specifically identified as a priority in the narrative dataset but included in the survey recommendations only as part of a broader priority around improving inpatient experience. Both datasets identified appointment systems, patients spending enough time with staff, information about treatment and side effects and more information at the end of treatment as priorities. The specific priorities identified by the narrative interviews commonly related to ‘relational’ aspects of patient experience. Those identified by the survey typically related to more ‘functional’ aspects and were not always sufficiently detailed to identify specific improvement actions. Conclusions: Our analysis suggests that whilst local survey data may act as a screening tool to identify potential problems within the breast cancer service, they do not always provide sufficient detail of what to do to improve that service. These findings may have wider applicability in other services. We recommend using an initial preliminary survey, with better use of survey open comments, followed by an in-depth qualitative analysis to help deliver improvements to relational and functional aspects of patient experience.

Resilient healthcare emphasises the importance of adaptive capacity in quality healthcare. This theory has had extensive theoretical development, but comparatively limited translation for clinicians in practice. This study is the first to present resilient healthcare principles in a serious video game. Serious games are an effective tool for engaging users, sharing ideas and eliciting reflections. The aim of this study was to communicate principles from resilient healthcare to clinicians through a serious video game, and to evaluate the game’s feasibility as a prompt to reflect on practice. The game, Resilience Challenge, is scenario-based and requires players to resolve dilemmas in clinical practice. It was disseminated online, and was played 1,949 times during the four-month study. The game was evaluated using an immediate cross-sectional survey, which included both Likert-style and free text responses. Participants reported that the game was engaging (93%) and that they would recommend it to others (89%). Fewer participants reported learning about resilient healthcare concepts (64%). Resilience Challenge is a promising way to prompt reflections about clinical work, and demonstrates mixed outcomes in communicating resilient healthcare principles to clinicians.

Background.  Few empirical studies have directly examined the relationship between staff experiences of providing healthcare and patient experience. Present concerns over the care of older people in UK acute hospitals – and the reported attitudes of staff in such settings – highlight an important area of study. Aims and objectives.  To examine the links between staff experience of work and patient experience of care in a ‘Medicine for Older People’ (MfOP) service in England. Methods.  A mixed methods case study undertaken over 8 months incorporating a 149-item staff survey (66/192 – 34% response rate), a 48-item patient survey (26/111 – 23%), 18 staff interviews, 18 patient and carer interviews and 41 hours of non-participant observation. Results.  Variation in patient experience is significantly influenced by staff work experiences. A high-demand/low-control work environment, poor staffing, ward leadership and co-worker relationships can each add to the inherent difficulties staff face when caring for acutely ill older people. Staff seek to alleviate the impact of such difficulties by finding personal satisfaction from caring for ‘the poppets’; those patients they enjoy caring for and for whom they feel able to ‘make a difference’. Other patients – noting dehumanising aspects of their care – felt like ‘parcels’. Patients are aware of being seen by staff as ‘difficult’ or ‘demanding’ and seek to manage their relationships with nursing staff accordingly. Conclusions.  The work experiences of staff in a MfOP service impacted directly on patient care experience. Poor ward and patient care climates often lead staff to seek job satisfaction through caring for ‘poppets’, leaving less favoured – and often more complex patients – to receive less personalised care. Implications for practice.  Investment in staff well-being and ward climate is essential for the consistent delivery of high-quality care for older people in acute settings.

Background Healthcare work is known to be stressful and challenging, and there are recognised links between the psychological health of staff and high-quality patient care. Schwartz Center Rounds® (Rounds) were developed to support healthcare staff to re-connect with their values through peer reflection, and to promote more compassionate patient care. Research to date has focussed on self-report surveys that measure satisfaction with Rounds but provide little analysis of how Rounds ‘work’ to produce their reported outcomes, how differing contexts may impact on this, nor make explicit the underlying theories in the conceptualisation and implementation of Rounds. Methods Realist evaluation methods aimed to identify how Rounds work, for whom and in what contexts to deliver outcomes. We interviewed 97 key informants: mentors, facilitators, panellists and steering group members, using framework analysis to organise and analyse our data using realist logic. We identified mechanisms by which Rounds lead to outcomes, and contextual factors that impacted on this relationship, using formal theory to explain these findings. Results Four stages of Rounds were identified. We describe how, why and for whom Schwartz Rounds work through the relationships between nine partial programme theories. These include: trust safety and containment; group interaction; counter-cultural/3rd space for staff; self-disclosure; story-telling; role modelling vulnerability; contextualising patients and staff; shining a spotlight on hidden stories and roles; and reflection and resonance. There was variability in the way Rounds were run across organisations. Attendance for some staff was difficult. Rounds is likely to be a ‘slow intervention’ the impact of which develops over time. We identified the conditions needed for Rounds to work optimally. These contextual factors influence the intensity and therefore degree to which the key ingredients of Rounds (mechanisms) are activated along a continuum, to produce outcomes. Outcomes included: greater tolerance, empathy and compassion for self and others; increased honesty, openness, and resilience; improved teamwork and organisational change. Conclusions Where optimally implemented, Rounds provide staff with a safe, reflective and confidential space to talk and support one another, the consequences of which include increased empathy and compassion for colleagues and patients, and positive changes to practice.

Background: The introduction of “Freedom to Speak Up Guardians” (FTSUGs) into every NHS England Trust was intended to support workers and Trusts to better raise, respond and learn from speaking-up concerns. However, only broad guidance was provided on how to implement the role. As a result, there is the potential for important local differences to emerge as the role is implemented across England. Objectives: The overall aim of this study was to better understand the implementation of Guardians in Acute Trusts and Mental Health Trusts. Design: The FTSUG role was conceptualized as a complex intervention consisting of several interacting and interlocking components spanning the macro level (national organisations), the meso level (individual Trusts) and micro level (employees, teams, wards/units). A mixed methods study was designed, consisting of three work packages: (1) a systematic narrative review of the international literature regarding interventions promoting ‘speaking-up’ by healthcare employees; (2) semi-structured telephone interviews with Guardians working in Acute Hospital Trusts and Mental Health Trusts; (3) qualitative case studies of FTSUG implementation, consisting of observations and interviews undertaken in four Acute Trusts and two Mental Health Trusts. Interviews were also undertaken with national stakeholders. Setting: Acute Trusts and Mental Health NHS Trusts in England Participants: Work package 2: FTSUGs (n=87) were interviewed. Work package 3: 116 interviews with key stakeholders involved in pre and early implementation decision-making and workers who had spoken-up to the Guardian and national stakeholders. Results: Wide variability was identified in how the Guardian role had been implemented, resourced and deployed by NHS Trusts. The role title “Freedom to Speak Up Guardian” is best considered an umbrella term, under which multiple versions of the role exist simultaneously across England. Any comparisons of Guardians’ effectiveness are only likely to be possible, or meaningful, when this variability is properly accounted for. Many FTSUGs identified how a lack of available resources, especially time scarcity, negatively and significantly impacted on their ability to effectively respond 3 to concerns and on their opportunities to collect, analyse and learn from speaking-up data and more generally the extent to which they developed their role and speak-up culture. Limitations: It is possible that those we interviewed were more receptive of FTSUGs, or may have been biased by ‘socially desirability’ and their answers may not always have represented respondents’ true perceptions. Conclusions: Optimal implementation of the Guardian role has six components: 1) establishing early, collaborative and coherent strategy congruent to the values of FTSU fosters the implementation of 2) policies and robust, yet supportive practices 3) informed by frequent and reflexive monitoring of FTSU implementation, which is 4) underpinned by sufficient time and resource allocation, that leads to 5) a positive implementation climate, which is congruent with FTSU values, and best placed to engender positive and sustainable FTSU culture and the well-being of a Guardian.

Objective Several systematic reviews have suggested that greater nurse staffing as well as a greater proportion of registered nurses in the health workforce is associated with better patient outcomes. Others have found that nurses can substitute for doctors safely and effectively in a variety of settings. However, these reviews do not generally consider the effect of nurse staff on both patient outcomes and costs of care, and therefore say little about the cost-effectiveness of nurse-provided care. Therefore, we conducted a scoping literature review of economic evaluation studies which consider the link between nurse staffing, skill mix within the nursing team and between nurses and other medical staff to determine the nature of the available economic evidence. Design Scoping literature review. Data sources English-language manuscripts, published between 1989 and 2009, focussing on the relationship between costs and effects of care and the level of registered nurse staffing or nurse–physician substitution/nursing skill mix in the clinical team, using cost-effectiveness, cost-utility, or cost–benefit analysis. Articles selected for the review were identified through Medline, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Google Scholar database searches. Review methods After selecting 17 articles representing 16 unique studies for review, we summarized their main findings, and assessed their methodological quality using criteria derived from recommendations from the guidelines proposed by the Panel on Cost-Effectiveness in Health Care. Results In general, it was found that nurses can provide cost effective care, compared to other health professionals. On the other hand, more intensive nurse staffing was associated with both better outcomes and more expensive care, and therefore cost effectiveness was not easy to assess. Conclusions Although considerable progress in economic evaluation studies has been reached in recent years, a number of methodological issues remain. In the future, nurse researchers should be more actively engaged in the design and implementation of economic evaluation studies of the services they provide.

Objectives There is an international policy trend for building government hospitals with greater proportions of single‐occupancy rooms. The study aim was to identify advantages and disadvantages for patients and nursing staff of a pending move to 100% single room hospital, in anticipation of the challenges for nurse managers of a different ward environment. This paper presents these findings, summarising potential advantages and disadvantages as well as comparison with findings from similar studies in England. Methods Mixed method case study design was undertaken in four wards of a large hospital with multi‐bed rooms. Three components of a larger study are reported here: nurse surveys and interviews, patient interviews of their experiences of the current multi‐bedroom environment and expectations of new single room environment. Integration was achieved via data transformation where results of the nursing staff survey and interviews and patient interviews were coded as narrative allowing for quantitative and qualitative data to be merged. Results Four constructs were derived: physical environment; patient safety and comfort; staff safety; and importance of interaction. Conclusion There are important factors that inform nurse managers when considering a move to an all single room design. These factors are important for nurses’ and patients’ well‐being. Implications for nursing management This study identified for nurse managers key factors that should consider when contributing to the design of a 100% single room hospital. Nurses’ voices are critically important to inform the design for a safe and efficient ward environment.

Background Supplementary prescribing (SP) is a drug therapy management model implemented in the United Kingdom since 2003. It is a voluntary partnership between an independent prescriber; a supplementary prescriber, for example, nurse or pharmacist; and the patient, to implement an agreed patient-specific clinical management plan (CMP). Objective To investigate pharmacist prescribers' views and experiences of the early stages of SP implementation. Methods A qualitative, longitudinal study design was used. A purposive, maximum variability sample of 16 pharmacist supplementary prescribers, trained in Southern England, participated. Eleven were hospital pharmacists, owing to the overrepresentation of hospital pharmacists in the first cohort. Two semistructured interviews were conducted with each participant, at 3 and 6 months after their registration as prescribers. The Framework approach was used for data collection, management, and analysis. Results Three typologies of pharmacists' experiences were identified: “a blind alley”, “a stepping stone” and “a good fit”. Despite some delays in its implementation, SP was seen as a step forward. Some participants also believed that it improved patient care and pharmacists' integration in the health care team and increased their job satisfaction. However, there was a concern that SP, as first implemented, was bureaucratic and limited pharmacists' freedom in their decision making. Hence, pharmacists were more supportive of the then imminent introduction of a pharmacist independent prescribing (IP) role. Conclusions Despite challenges, the SP role represented a step forward for pharmacists in the United Kingdom. It is possible that pharmacist SP can coexist with IP in the areas suitable for CMP use. Elsewhere, SP is likely to become more of a “stepping stone” to an IP role than the preferred model for pharmacist prescribing. Future research needs to objectively assess the outcomes of pharmacist SP, preferably in comparison with IP, to inform decision making among pharmacists regarding the adoption of such an innovative role.

Background: Twenty-four hour nursing care involves shift work including 12-h shifts. England is unusual in deploying a mix of shift patterns. International evidence on the effects of such shifts is growing. A secondary analysis of data collected in England exploring outcomes with 12-h shifts examined the association between shift length, job satisfaction, scheduling flexibility, care quality, patient safety, and care left undone. Methods: Data were collected from a questionnaire survey of nurses in a sample of English hospitals, conducted as part of the RN4CAST study, an EU 7th Framework funded study. The sample comprised 31 NHS acute hospital Trusts from 401 wards, in 46 acute hospital sites. Descriptive analysis included frequencies, percentages and mean scores by shift length, working beyond contracted hours and day or night shift. Multi-level regression models established statistical associations between shift length and nurse self-reported measures. Results: Seventy-four percent (1898) of nurses worked a day shift and 26% (670) a night shift. Most Trusts had a mixture of shifts lengths. Self-reported quality of care was higher amongst nurses working ≤8 h (15.9%) compared to those working longer hours (20.0 to 21.1%). The odds of poor quality care were 1.64 times higher for nurses working ≥12 h (OR = 1.64, 95% CI 1.18–2.28, p = 0.003). Mean ‘care left undone’ scores varied by shift length: 3.85 (≤8 h), 3.72 (8.01–10.00 h), 3.80 (10.01–11.99 h) and were highest amongst those working ≥12 h (4.23) (p < 0.001). The rate of care left undone was 1.13 times higher for nurses working ≥12 h (RR = 1.13, 95% CI 1.06–1.20, p < 0.001). Job dissatisfaction was higher the longer the shift length: 42.9% (≥12 h (OR = 1.51, 95% CI 1.17–1.95, p = .001); 35.1% (≤8 h) 45.0% (8.01–10.00 h), 39.5% (10.01–11.99 h). Conclusions: Our findings add to the growing international body of evidence reporting that ≥12 shifts are associated with poor ratings of quality of care and higher rates of care left undone. Future research should focus on how 12-h shifts can be optimised to minimise potential risks.

In its first edition, Practice Development in Nursing made an important contribution to understanding practice development and its core components. Now fully updated to take into account the many developments in the field, the second edition continues to fill an important gap in the market for an accessible, practical text on what remains a key issue for all members of the healthcare team globally. Practice Development in Nursing and Healthcare explores the basis of practice development and its aims, implementation and impact on healthcare, to enable readers to be confident in their approaches to practice development. It is aimed at healthcare professionals in a variety of roles (for example clinical practice, education, research and quality improvement) and students, as well as those with a primary practice development role, in order to enable them to effectively and knowledgeably develop practice and the practice of others.

Objectives: The objectives of this study were to identify: 1) the extent to which final year chiropractic students used components of person-centred care in a clinical setting; and 2) determine the effect of chiropractic students’ use of person-centred care on musculoskeletal pain. Design/setting: An observational study was conducted at three Western Australian chiropractic teaching clinics. Interventions: Pragmatic individualised chiropractic care was delivered to 108 adults who experienced non-specific spinal pain. Main outcome measures: The instruments used in this study were the Consultation and Relational Empathy questionnaire, Picker Musculoskeletal Disorder Questionnaire, and Numerical Rating scale for Pain intensity. Results: Participants experienced reductions in pain that exceeded the level required for minimal clinically reported improvement. In addition, high levels of empathy and patient-centred care were reported. Ceiling effects for the measures assessing empathy and patient-centred care precluded analyses examining the relationship between changes in pain intensity, empathy, and patient-centred care. Conclusions: The participants in this study displayed very positive attitudes about most aspects of the chiropractic students’ person-centred care skills. Person-centred care processes for which there was considerable scope for improvement included advice about alternative treatment options, and the adaptation of lifestyle and workplace situations to alleviate pain and enhance health. Our findings also showed that the participants experienced clinically important improvement in pain. However, the skewed nature of our dataset precluded identifying whether the students’ person-centred care skills influenced such improvement.

As the population ages, there is a pressing need to cost-effectively manage the care of increasing numbers of people with long-term conditions and prevent unnecessary hospitalisation. If we are to meet these needs as efficiently as possible in the future, we need to better understand the potential contribution of nurses working in general practice, and ask what we know about the efficacy and cost benefits of their contribution. In the 10 years since the introduction of the Quality and Outcomes Framework (QOF), the reported number of registered nurses employed in GP practices is estimated to have increased by 15%, and stands at 23 833 nurses in the equivalent of 14 943 full-time posts (Figure 1).1 Practice nurses make up over one-third (37%) of the clinicians in general practice. Yet little is known about the ways in which practice nurses are deployed within each practice: their numbers, the mix relative to other practice staff, or level of specialist skills and experience. Although the NHS in England has started to collect and publish more data on the numbers of nursing staff employed by practices1 the information is sparse. The GP workforce census for 2013 included …

We trace the legacies of filmed patient narratives that were edited and screened to encourage engagement with a participatory quality improvement project in an acute hospital setting in England. Using Gabriel’s theory of “narrative contract,” we examine the initial success of the films in establishing common grounds for participatory project and later, and more varied, interpretations of the films. Over time, the films were interpreted by staff as either useful sources of learning by critical reflection, dubious (invalid or unreliable) representations of patient experience, or as “closed” items available as auditable evidence of completed quality improvement work. We find these interpretations of the films to be shaped by the effect of social distance, the differential outcomes of project work, and changing organizational agendas. We consider the wider conditions of patient narrative as a form of quality improvement knowledge with immediate potency and fragile or fluid legitimacy over time.

Background It is the responsibility of healthcare regulators to ensure healthcare professionals remain fit for practice in healthcare settings. If there are concerns about an individual healthcare professional they may undergo a fitness to practice investigation. This process is known to be hugely stressful for doctors and social workers, but little is known about the impact of this experience on other professions. This study explores the experiences of registrants going through the process of being reported to the UK’s Health and Care Professions Council (HCPC) and attending fitness to practice (FTP) hearings. We discuss the implications of this process on registrants’ wellbeing and, from our findings, present recommendations based on registrants experiences. In doing so we articulate the structural processes of the HCPC FTP process and the impact this has on individuals. Methods This study uses semi-structured interviews and framework analysis to explore the experiences of 15 registrants who had completed the FTP process. Participants were sampled for maximum variation and were selected to reflect the range of possible processes and outcomes through the FTP process. Results The psychological impact of undergoing a FTP process was significant for the majority of participants. Their stories described influences on their wellbeing at both a macro (institutional/organisational) and micro (individual) level. A lack of information, long length of time for the process and poor support avenues were macro factors impacting on the ability of registrants to cope with their experiences (theme 1). These macro factors led to feelings of powerlessness, vulnerability and threat of ruin for many registrants (theme 2). Suggested improvements (theme 3) included better psychological support (e.g. signposting or provision); proportional processes to the incident (e.g. mediation instead of hearings); and taking context into account. Conclusions Findings suggest that improvements to both the structure and conduct of the FTP process are warranted. Implementation of better signposting for support both during and after a FTP process may improve psychological wellbeing. There may also be value in considering alternative ways of organising the FTP process to enable greater consideration of and flexibility for registrants’ context and how they are investigated.

This article draws from sociological and socio-legal studies of dispute between patients and doctors to examine how healthcare professionals made sense of patients’ complaints about healthcare. We analyse 41 discursive interviews with professional healthcare staff working in eight different English National Health Service settings to explore how they made sense of events of complaint and of patients’ (including families’) motives for complaining. We find that for our interviewees, events of patients’ complaining about care were perceived as a breach in fundamental relationships involving patients’ trust or patients’ recognition of their work efforts. We find that interviewees ationalised patients’ motives for complaining in ways that marginalised the content of their concerns. Complaints were most often discussed as coming from patients who were inexpert, distressed or advantage-seeking; accordingly, care professionals hearing their concerns about care positioned themselves as informed decision-makers, empathic listeners or service gate-keepers. We find differences in our interviewees’ rationalisation of patients’ complaining about care to be related to local service contingences rather than to fixed professional differences. We note that it was rare for interviewees to describe complaints raised by patients as grounds for improving the quality of care. Our findings indicate that recent health policy directives promoting a view of complaints as learning opportunities from critical patient/consumers must account for sociological factors that inform both how the agency of patients is envisaged and how professionalism exercised contemporary healthcare work.

Despite the scope and sophistication of contemporary health care, there is increasing international concern about the perceived lack of compassion in its delivery. Citing evidence that when the basic needs of patients are attended to with kindness and understanding, recovery often takes place at a faster level, patients cope more effectively with the self-management of chronic disorders and can more easily overcome anxiety associated with various disorders, this book looks at how good care can be put back into the process of caring. Beginning with an introduction to the historical values associated with the concept of compassion, the text goes on to provide a bio-psycho-social theoretical framework within which the concept might be further explained. The third part presents thought-provoking case studies and explores the implementation and impact of compassion in a range of healthcare settings. The fourth part investigates the role that organizations and their structures can play in promoting or hindering the provision of compassion. The book concludes by discussing how compassion may be taught and evaluated, and suggesting ways for increasing the attention paid to compassion in health care. Developing a multi-disciplinary theory of compassionate care, and underpinned by empirical examples of good practice, this volume is a valuable resource for all those interesting in understanding and supporting compassion in health care, including advanced students, academics and practitioners within medicine, nursing, psychology, allied health, sociology and philosophy.

Background and objectives There is little strong evidence relating to the impact of single-room accommodation on healthcare quality and safety. We explore the impact of all single rooms on staff and patient experience; safety outcomes; and costs. Methods Mixed methods pre/post ‘move’ comparison within four nested case study wards in a single acute hospital with 100% single rooms; quasi-experimental before-and-after study with two control hospitals; analysis of capital and operational costs associated with single rooms. Results Two-thirds of patients expressed a preference for single rooms with comfort and control outweighing any disadvantages (sense of isolation) felt by some. Patients appreciated privacy, confidentiality and flexibility for visitors afforded by single rooms. Staff perceived improvements (patient comfort and confidentiality), but single rooms were worse for visibility, surveillance, teamwork, monitoring and keeping patients safe. Staff walking distances increased significantly post move. A temporary increase of falls and medication errors in one ward was likely to be associated with the need to adjust work patterns rather than associated with single rooms per se. We found no evidence that single rooms reduced infection rates. Building an all single-room hospital can cost 5% more with higher housekeeping and cleaning costs but the difference is marginal over time. Conclusions Staff needed to adapt their working practices significantly and felt unprepared for new ways of working with potentially significant implications for the nature of teamwork in the longer term. Staff preference remained for a mix of single rooms and bays. Patients preferred single rooms. This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

Background: In many UK general practices, nurses have been used to deliver results against the indicators of the Quality and Outcomes Framework (QOF), a ‘pay for performance’ scheme. Aim: To determine the association between the level of nurse staffing in general practice and the quality of clinical care as measured by the QOF. Design of the study: Cross-sectional analysis of routine data. Setting: English general practice in 2005/2006. Method: QOF data from 7456 general practices were linked with a database of practice characteristics, nurse staffing data, and census-derived data on population characteristics and measures of population density. Multi-level modelling explored the relationship between QOF performance and the number of patients per full-time equivalent nurse. The outcome measures were achievement of quality of care for eight clinical domains as rated by the QOF, and reported achievement of 10 clinical outcome indicators derived from it. Results: A high level of nurse staffing (fewer patients per full-time equivalent practice-employed nurse) was significantly associated with better performance in 4/8 clinical domains of the QOF (chronic obstructive pulmonary disease, coronary heart disease, diabetes, and hypertension, P = 0.004 to P

The ‘Care Certificate’ was introduced in April 2015 as a new training programme that all new care workers (Health Care Assistants and Social Support Workers) should achieve before working unsupervised. This research aimed to evaluate the effectiveness of the Care Certificate in achieving an improved induction and training so that care workers are better-prepared to provide high quality care. We carried out a national telephone survey with 401 staff who have responsibility for the induction of care workers in care organisations. We also interviewed 68 care staff and 24 managers at 10 different care organisations to get a more detailed understanding of their experiences of the Care Certificate training. We found that the uptake of the Care Certificate has been good, and it is widely welcomed as providing a standardised approach to improving the care skills and confidence of those new to care. However, there is a proportion of smaller care organisations where the Care Certificate has not been implemented, largely due to lack of resources and capacity. The Care Certificate was not widely used as a transferable qualification to support the movement of care staff between organisations. Most organisations required new recruits who had completed the Care Certificate elsewhere to repeat some or all of this training due to scepticism about the quality of any prior training. There has been considerable variation in how the Care Certificate is being used which has undermined the credibility and portability of the Care Certificate, leading to calls for greater regulation and standardisation in its provision. Organisational size, leadership, capacity and resources were major factors in determining the effectiveness of Care Certificate. Where organisations had the resources to devote particular staff to develop the training or adapt it into their existing induction programmes, then the potential benefits of the Care Certificate were most likely to be reported.

The rise of managerialism within healthcare systems has been noted globally. This paper uses the findings of a scoping study to investigate the management of poor performance among nurses and midwives in the United Kingdom within this context. The management of poor performance among clinicians in the NHS has been seen as a significant policy problem. There has been a profound shift in the distribution of power between professional and managerial groups in many health systems globally. We examined literature published between 2000 and 10 to explore aspects of poor performance and its management. We used Web of Science, CINAHL, MEDLINE, British Nursing Index, HMIC, Cochrane Library and PubMed. Empirical data are limited but indicate that nurses and midwives are the clinical groups most likely to be suspended and that poor performance is often represented as an individual deficit. A focus on the individual as a source of trouble can serve as a distraction from more complex systematic problems.

Objectives This paper draws on a narrative review of the literature, commissioned to support the Health Visitor Implementation Plan, and aimed at identifying messages about the knowledge, skills, and abilities needed by health visitors to work within the current system of health care provision. Design The scoping study and narrative review used three complementary approaches: a broad search, a structured search, and a seminal paper search to identify empirical papers from the health visitor literature for review. The key inclusion criteria were messages of relevance for practice. Data Sources 378 papers were reviewed. These included empirical papers from the United Kingdom (UK) from 2004 to February 2012, older research identified in the seminal paper search and international literature from 2000 to January 2016. Review Methods The review papers were read by members of the multidisciplinary research team which included health visitor academics, social scientists, and a clinical psychologist managed the international literature. Thematic content analysis was used to identify main messages. These were tabulated and shared between researchers in order to compare emergent findings and to confirm dominant themes. Results The analysis identified an ‘orientation to practice’ based on salutogenesis (health creation), human valuing (person-centred care), and viewing the person in situation (human ecology) as the aspirational core of health visitors' work. This was realised through home visiting, needs assessment, and relationship formation at different levels of service provision. A wide range of knowledge, skills, and abilities were required, including knowledge of health as a process and skills in engagement, building trust, and making professional judgments. These are currently difficult to impart within a 45 week health visitor programme and are facilitated through ad hoc post-registration education and training. The international literature reported both similarities and differences between the working practices of health visitors in the UK and public health nurses worldwide. Challenges related to the education of each were identified. Conclusions The breadth and scope of knowledge, skills, and abilities required by health visitors make a review of current educational provision desirable. Three potential models for health visitor education are described.

Although investment in staff development is a prerequisite for high-quality and innovative care, the training needs of front line care staff involved in direct care have often been neglected, particularly within dementia care provision. The Care Certificate, which was fully launched in England in April 2015, has aimed to redress this neglect by providing a consistent and transferable approach to the training of the front line health and social care workforce. This article describes the early stages of an 18-month evaluation of the Care Certificate and its implementation funded by the Department of Health Policy Research Programme.

At the time of writing (11th April 2020) there are 1.72 million Covid‐19 infections and 104,889 deaths worldwide. In the UK the first recorded death was on the 5th of March 2020 and in just 37 days 9,875 deaths in hospital have been recorded. The 10th of April saw the highest number of UK daily deaths (980) to date. These UK figures do not include those who died in care homes or in the community. Similar death rates have been experienced in China earlier this year (3,339) and are rising globally with particularly high death rates in the US (18,761 with over half of deaths in New York State), Italy (18,939), Spain (16,353) and France (13,197). As the Coronavirus disease 2019 (Covid-19) pandemic takes hold, nurses are on the front line of health and social care in the most extreme of circumstances. We reflect during a moment in time (week three of lockdown in the UK and week 5/6 across Europe) to highlight the issues facing nurses at this unprecedented time. At the bedside 24 hours a day seven days a week, in similar outbreaks, nurses have had the highest levels of occupational stress and resulting distress compared to other groups (Cheong and Lee, 2004, Maunder et al., 2006, Nickell et al., 2004). Nurses are already a high-risk group, with the suicide rate among nurses 23% higher than the national average (ONS 2017). Despite this, the RCN (Royal College of Nursing in the UK) has reported that nurses feel “repeatedly” ignored by their employers when they raise concerns about their mental health (Mitchell 2019). A focus on personal responsibility for psychological health and well-being and an over-emphasis on nurses being ‘resilient’ in the face of under-staffing and often intense emotional work is consistently challenged by nurses and nurse academics (Traynor 2018). Treating resilience as an individual trait is seen to ‘let organisations off the hook’ (Traynor 2018); yet has often been the focus of organisational strategies to date. This does not work at the best of times and certainly is not appropriate now in these most difficult of circumstances. Here we discuss the stressors and challenges and present evidence-informed guidance to address the physical and psychological needs of nurses during the Covid-19 pandemic. We stress the importance of peer and team support to enable positive recovery after acutely stressful and emotionally draining experiences, and outline what managers, organisations and leaders can do to support nurses at this most critical of times.

Objectives To first, validate in English hospitals the internal structure of the ‘Patient Evaluation of Emotional Care during Hospitalisation’ (PEECH) survey tool which was developed in Australia and, second, to examine how it may deepen the understanding of patient experience through comparison with results from the Picker Patient Experience Questionnaire (PPE-15). Design A 48-item survey questionnaire comprising both PEECH and PPE-15 was fielded. We performed exploratory factor analysis and then confirmatory factor analysis using a number of established fit indices. The external validity of the PEECH factor scores was compared across four participating services and at the patient level, factor scores were correlated with the PPE-15. Setting Four hospital services (an Emergency Admissions Unit; a maternity service; a Medicine for the Elderly department and a Haemato-oncology service) that contrasted in terms of the reported patient experience performance. Participants Selection of these acute service settings was based on achieving variation of the following factors: teaching hospital/district general hospital, urban/rural locality and high-performing/low-performing organisations (using results of annual national staff and patient surveys). A total of 423 surveys were completed by patients (26% response rate). Results A different internal structure to the PEECH instrument emerged in English hospitals. However, both the existing and new factor models were similar in terms of fit. The correlations between the new PEECH factors and the PPE-15 were all in the expected direction, but two of the new factors (personal interactions and feeling valued) were more strongly associated with the PPE-15 than the remaining two factors (feeling informed and treated as an individual). Conclusions PEECH can help to build an understanding of complex interpersonal aspects of quality of care, alongside the more transactional and functional aspects typically captured by PPE-15. Further testing of the combined instrument should be undertaken in a wider range of healthcare settings.

Objective: Schwartz Center Rounds (‘Rounds’) are multidisciplinary forum where healthcare staff come together to reflect upon the emotional impact of their work. A small number of staff (panellists) share experiences through stories to trigger reflection in audience members. Previous research has identified impacts associated with Rounds attendance but little is known about the experience and impact of Rounds from panellists’ perspectives. Drawing on interview data from a national evaluation of Rounds in the UK this study is the first to explore the role of disclosure and reflection through storytelling in Rounds specifically exploring panellists’ motivations, experience and reported impacts associated with panel participation. Methods: Interviews with 39 panellists, from nine case study sites, representing acute, community, mental health NHS trusts and hospices. Data were analysed using thematic analysis. Results: Most panellists spoke positively about their experience of sharing their stories in Rounds. Reported impacts included increased emotional resilience and acceptance of past experiences; reduced negative assumptions about colleagues and increased approachability and trust increasing tolerance and compassion; a space to stop and think and to reframe negative patient experiences facilitating greater empathy, and emotional disclosure becoming more visible and normative helping change culture. The extent of panel preparation and audience characteristics (e.g. size, composition, and response to their stories) influenced panellist’s experiences and outcomes. Conclusions: Rounds highlight the important role of disclosure and reflection through storytelling to support panellists with the emotional aspects of their work, providing a space for support with the emotional demands of healthcare, reducing the need for employees to be stoic. Panel participation also offers an important source of validation in organisations marked by scrutiny.

Background The ‘Productive Ward: Releasing Time to Care’ programme is a quality improvement (QI) intervention introduced in English acute hospitals a decade ago to: (1) Increase time nurses spend in direct patient care. (2) Improve safety and reliability of care. (3) Improve experience for staff and patients. (4) Make changes to physical environments to improve efficiency. Objective To explore how timing of adoption, local implementation strategies and processes of assimilation into day-to-day practice relate to one another and shape any sustained impact and wider legacies of a large-scale QI intervention. Design Multiple methods within six hospitals including 88 interviews (with Productive Ward leads, ward staff, Patient and Public Involvement representatives and senior managers), 10 ward manager questionnaires and structured observations on 12 randomly selected wards. Results Resource constraints and a managerial desire for standardisation meant that, over time, there was a shift away from the original vision of empowering ward staff to take ownership of Productive Ward towards a range of implementation ‘short cuts’. Nonetheless, material legacies (eg, displaying metrics data; storage systems) have remained in place for up to a decade after initial implementation as have some specific practices (eg, protected mealtimes). Variations in timing of adoption, local implementation strategies and contextual changes influenced assimilation into routine practice and subsequent legacies. Productive Ward has informed wider organisational QI strategies that remain in place today and developed lasting QI capabilities among those meaningfully involved in its implementation. Conclusions As an ongoing QI approach Productive Ward has not been sustained but has informed contemporary organisational QI practices and strategies. Judgements about the long-term sustainability of QI interventions should consider the evolutionary and adaptive nature of change processes.

This article, the first in a four-part series about using research evidence to inform the delivery of nursing care, discusses four studies that were funded following the two Francis inquiries into care failings at Mid Staffordshire NHS Foundation Trust. Each study evaluated an intervention method in an acute hospital setting that aimed to improve patient care and protect the wellbeing of nursing staff; these included a team-based practice development programme, a relational care training intervention for healthcare assistants, a regular bedside ward round (intentional rounding), and monthly group meetings during which staff discussed the emotional challenges of care. The remaining articles in this series will explore the results of the studies and how they can be applied to nursing care during, and after, the coronavirus pandemic

This article, the second in a four-part series about using research evidence to support nursing teams, discusses the learning opportunities generated from four studies that followed the two Francis inquiries into care failings at Mid Staffordshire NHS Foundation Trust. We discuss how four different interventions, directly or indirectly use learning to enable nursing teams to optimise care in acute hospital settings. We argue that the profound impact of the Covid-19 pandemic may have overshadowed the need for measures to support nursing staff learning at a time when care quality is more important than ever.

This article is the last in a four-part series about using research evidence to support nursing teams. It examines four studies that were undertaken following the two Francis inquiries into care failings at Mid Staffordshire NHS Foundation Trust and highlights the evidence about the importance of promoting team members’ wellbeing to optimise care in acute hospital settings, particularly in light of the coronavirus pandemic.

This is the second of two papers reporting evidence from a programme of research that focused on how health visiting works, including service user and workforce perspectives. Evidence and professional expertise indicate that a set of essential features enable health visitors to achieve the desired impact of improving child public health. These include organising services in a way that enables positive parent/health visitor relationships, continuity and co-ordination and the flexibility to use professional knowledge and autonomy in practice. Where service specifications give careful attention to this evidence, it is more likely that health visitors will be able to deliver a successful child health programme for the early years.

Background: The ‘Productive Ward: Releasing Time to Care’™ programme (Productive Ward; PW) was introduced in English NHS acute hospitals in 2007 to give ward staff the tools, skills and time needed to implement local improvements to (1) increase the time nurses spend on direct patient care, (2) improve the safety and reliability of care, (3) improve staff and patient experience and (4) make structural changes on wards to improve efficiency. Evidence of whether or not these goals were met and sustained is very limited. Objective: To explore if PW had a sustained impact over the past decade. Design: Multiple methods, comprising two online national surveys, six acute trust case studies (including a secondary analysis of local audit data) and telephone interviews. Data sources: Surveys of 56 directors of nursing and 35 current PW leads; 88 staff and patient and public involvement representative interviews; 10 ward manager questionnaires; structured observations of 12 randomly selected wards and documentary analysis in case studies; and 14 telephone interviews with former PW leads. Results: Trusts typically adopted PW in 2008–9 on their wards using a phased implementation approach. The average length of PW use was 3 years (range < 1 to 7 years). Financial and management support for PW has disappeared in the majority of trusts. The most commonly cited reason for PW’s cessation was a change in quality improvement (QI) approach. Nonetheless, PW has influenced wider QI strategies in around half of the trusts. Around one-third of trusts had impact data relating specifically to PW; the same proportion did not. Early adopters of PW had access to more resources for supporting implementation. Some elements of local implementation strategies were common. However, there were variations that had consequences for the assimilation of PW into routine practice and, subsequently, for the legacies and sustainability of the programme. In all case study sites, material legacies (e.g. display of metrics data; storage systems) remained, as did some processes (e.g. protected mealtimes). Only one case study site had sufficiently robust data collection systems to allow an objective assessment of PW’s impact; in that site, care processes had improved initially (in terms of patient observations and direct care time). Experience of leading PW had benefited the careers of the majority of interviewees. Starting with little or no QI experience, many went on to work on other initiatives within their trusts, or to work in QI at regional or national level within the NHS or in the private sector. Limitations: The research draws on participant recall over a lengthy period characterised by evolving QI approaches and system-level change. Conclusions: Little robust evidence remains of PW leading to a sustained increase in the time nurses spend on direct patient care or improvements in the experiences of staff and/or patients. PW has had a lasting impact on some ward practices. As an ongoing QI approach continually used to make ongoing improvements, PW has not been sustained, but it has informed current organisational QI practices and strategies in many trusts. The design and delivery of future large-scale QI programmes could usefully draw on the lessons learnt from this study of the PW in England over the period 2008–18. Funding: This National Institute for Health Research Health Services and Delivery Research programme.

The embodied experience of nursing practice is rarely studied. Drawing on data from an internationally relevant larger study conducted in 2013–14, here we explore the sensory dimension of the embodied experiences of nursing staff working on two acute NHS hospital wards before and after a move to all-single room inpatient accommodation. We undertook a secondary analysis of 25 interviews with nursing staff (12 before and 13 after the move with half [13/25] using photographs taken by participants) from a mixed-method before-and-after study. This analysis focused on the sensory dimensions of nursing staff's experiences of their working practices and the effect of the built environment upon these. Drawing on Pallasmaa's theoretocal insights, we report how the all-single room ward design prioritises ‘focused vision’ and hinders peripheral perception, whilst the open ward environment is rich in contextual and preconscious information. We suggest all-single room accommodation may offer staff an impoverished experience of caring for patients and of working with each other.

Background Releasing Time to Care: The Productive Ward™ (RTC) is a method for conducting continuous quality improvement (QI). The Saskatchewan Ministry of Health mandated its implementation in Saskatchewan, Canada between 2008 and 2012. Subsequently, a research team was developed to evaluate its impact on the nursing unit environment. We sought to explore the influence of the unit’s existing QI capacity on their ability to engage with RTC as a program for continuous QI. Methods We conducted interviews with staff from 8 nursing units and asked them to speak about their experience doing RTC. Using qualitative content analysis, and guided by the Organizing for Quality framework, we describe the existing QI capacity and impact of RTC on the unit environment. Results The results focus on 2 units chosen to highlight extreme variation in existing QI capacity. Unit B was characterized by a strong existing environment. RTC was implemented in an environment with a motivated manager and collaborative culture. Aided by the structural support provided by the organization, the QI capacity on this unit was strengthened through RTC. Staff recognized the potential of using the RTC processes to support QI work. Staff on unit E did not have the same experience with RTC. Like unit B, they had similar structural supports provided by their organization but they did not have the same existing cultural or political environment to facilitate the implementation of RTC. They did not have internal motivation and felt they were only doing RTC because they had to. Though they had some success with RTC activities, the staff did not have the same understanding of the methods that RTC could provide for continuous QI work. Conclusions RTC has the potential to be a strong tool for engaging units to do QI. This occurs best when RTC is implemented in a supporting environment. One size does not fit all and administrative bodies must consider the unique context of each environment prior to implementing large-scale QI projects. Use of an established framework, like Organizing for Quality, could highlight the distinctive supports needed in particular care environments to increase the likelihood of successful engagement.

Background: 'Older People's Shoes' is a training intervention designed for healthcare assistants (HCAs) to improve the relational care of older people in hospital. The intervention formed part of a broader evaluation, in this paper we describe its development from a learning design and methodological perspective.

Background Healthcare systems worldwide increasingly value the contribution of employee voice in ensuring the quality of patient care. Although employees’ concerns are often dealt with satisfactorily, considerable evidence suggests that some employees may feel unable to speak-up, and even when they do their concerns may be ignored. As a result, in addition to trans-national and national policies, workplace interventions that support employees to speak-up about their concerns have recently increased. Methods A systematic narrative review, informed by complex systems perspectives addresses the question: “What workplace strategies and/or interventions have been implemented to promote speaking-up by employees”? Results Thirty-four studies were included in the review. Most studies reported inconclusive results. Researchers explanations for the successful implementation, or otherwise, of speak-up interventions were synthesised into two narrative themes (Braithwaite et al., 2018 (a)) hierarchical, interdisciplinary and cultural relationships and (Francis, 2015 (b)) psychological safety. Conclusions We strengthen the existing evidence base by providing an in-depth critique of the complex system factors influencing the implementation of speak-up interventions within the healthcare workforce. Although many of the studies were locally unique, there were international similarities in workplace cultures and norms that created contexts inimical to speaking-up interventions. Changing communication behaviours and creating a climate that supports speaking-up is immensely challenging. Interventions can be usurped in practice by complex, emergent and contextual issues, such as pre-existing socio-cultural relationships and workplace hierarchies.

Introduction There is increasing international interest in universal, health promoting services for pregnancy and the first three years of life and the concept of proportionate universalism. Drawing on a narrative review of literature, this paper explores mechanisms by which such services might contribute to health improvement and reducing health inequalities. Objectives Through a narrative review of empirical literature, to identify: (1) What are the key components of health visiting practice? (2) How are they reflected in implementing the universal service/provision envisaged in the English Health Visitor Implementation Plan (HVIP)? Design The paper draws upon a scoping study and narrative review. Review methods We used three complementary approaches to search the widely dispersed literature: (1) broad, general search, (2) structured search, using topic-specific search terms, (3) seminal paper search. Our key inclusion criterion was information about health visiting practice. We included empirical papers from United Kingdom (UK) from 2004 to February 2012 and older seminal papers identified in search (3), identifying a total of 348 papers for inclusion. A thematic content analysis compared the older (up to 2003) with more recent research (2004 onwards). Results The analysis revealed health visiting practice as potentially characterized by a particular ‘orientation to practice.’ This embodied the values, skills and attitudes needed to deliver universal health visiting services through salutogenesis (health creation), person-centredness (human valuing) and viewing the person in situation (human ecology). Research about health visiting actions focuses on home visiting, needs assessment and parent–health visitor relationships. The detailed description of health visitors’ skills, attitudes, values, and their application in practice, provides an explanation of how universal provision can potentially help to promote health and shift the social gradient of health inequalities. Conclusions Identification of needs across an undifferentiated, universal caseload, combined with an outreach style that enhances uptake of needed services and appropriate health or parenting information, creates opportunities for parents who may otherwise have remained unaware of, or unwilling to engage with such provision. There is a lack of evaluative research about health visiting practice, service organization or universal health visiting as potential mechanisms for promoting health and reducing health inequalities. This paper offers a potential foundation for such research in future.

National Nursing Research Unit director Jill Maben reveals how research findings show a strong connection between staff happiness and patient satisfaction Boosting staff morale may be one of the best things senior leaders can do to improve patient care, according to recent findings by the National Nursing Research Unit (NNRU) at King’s College London

Background Research on Indian nurses has focused on their participation as global migrant workers for whom opportunities abroad act as an incentive for many to migrate overseas. However, little is known about the careers of Indian nurses, or the impact of a globalized health care market on nurses who remain and on the profession itself in India. Objectives To explore nurses’ accounts of entry into nursing in the context of the globalisation of the nursing profession in India, and the salience of ‘migration’ for nurses’ individual careers. Design Qualitative interview study (n = 56). Settings and participants The study drew on interviews with 56 nurses from six sites in Bangalore, India. These included two government hospitals, two private hospitals, a Christian mission hospital, a private outpatient clinic and two private nursing colleges. Participants were selected purposively to include nurses from Christian and Hindu backgrounds, a range of home States, ages and seniority and to deliberately over-recruit (rare) male nurses. Methods Interviews covered how and why nurses entered nursing, their training and career paths to date, plans for the future, their experiences of providing nursing care and attitudes towards migration. Data analysis drew on grounded theory methods. Results Nursing is traditionally seen as a viable career particularly for women from Christian communities in India, where it has created inter-generational ‘nurse families’. In a globalizing India, nursing is becoming a job ‘with prospects’ transcending traditional caste, class and gender boundaries. Almost all nurses interviewed who intended seeking overseas employment envisaged migration as a short term option to satisfy career objectives – increased knowledge, skills and economic rewards – that could result in long-term professional and social status gains ‘back home’ in India. For others, migration was not part of their career plan: yet the increases in status that migration possibilities had brought were crucial to framing nursing as a ‘suitable job’ for a growing number of entrants. Conclusions The possibility of migration has facilitated collective social mobility for Indian nurses. Migration possibilities were important not only for those who migrate, but for improving the status of nursing in general in India, making it a more attractive career option for a growing range of recruits.

Background In 2011–2012, we carried out a programme of research to inform the Department of Health's strategy for strengthening health visiting services in England. Our research included a study of parents' views of their experiences with health visiting services in two geographical areas in England. Here, we draw upon data from this work to illustrate valuable aspects of family support outside the home reported in parents' accounts of their experiences of health visiting. We also explore the usefulness of relational autonomy as a theoretical lens for understanding the mechanisms through which this support operates. Design We draw upon data from semi-structured interviews with 44 parents across two ‘Early Implementer Sites’ of the ‘new service vision’ in England. Our thematic analysis of the data was informed by grounded theory principles. Findings and discussion Parents valued being able to attend child health clinics and group activities outside the home; this helped them to avoid social isolation and to identify, choose and use the forms of advice and support that best suited them. We suggest that health visiting outside the home and children's centres services may also foster parental autonomy, especially when this is understood in relational terms. Conclusions Health visiting outside the home and children's centres services are an important complement to health visiting in the home; both dimensions of family support should be available in the community. Relational readings of autonomy can help illuminate the ways in which these services can foster (or undermine) parents' autonomy.

Background: New hospital design includes more single room accommodation but there is scant and ambiguous evidence relating to the impact on patient safety and staff and patient experiences. Objectives: To explore the impact of the move to a newly built acute hospital with all single rooms on care delivery, working practices, staff and patient experience, safety outcomes and costs. Design: (1) Mixed-methods study to inform a pre-/post-‘move’ comparison within a single hospital, (2) quasi-experimental study in two control hospitals and (3) analysis of capital and operational costs associated with single rooms. Setting: Four nested case study wards [postnatal, acute admissions unit (AAU), general surgery and older people’s] within a new hospital with all single rooms. Matched wards in two control hospitals formed the comparator group. Data sources: Twenty-one stakeholder interviews; 250 hours of observation, 24 staff interviews, 32 patient interviews, staff survey (n = 55) and staff pedometer data (n = 56) in the four case study wards; routinely collected data at ward level in the control hospitals (e.g. infection rates) and costs associated with hospital design (e.g. cleaning and staffing) in the new hospital. Results: (1) There was no significant change to the proportion of time spent by nursing staff on different activities. Staff perceived improvements (patient comfort and confidentiality), but thought the new accommodation worse for visibility and surveillance, teamwork, monitoring, safeguarding and remaining close to patients. Giving sufficient time and attention to each patient, locating other staff and discussing care with colleagues proved difficult. Two-thirds of patients expressed a clear preference for single rooms, with the benefits of comfort and control outweighing any disadvantages. Some patients experienced care as task-driven and functional, and interaction with other patients was absent, leading to a sense of isolation. Staff walking distances increased significantly after the move. (2) A temporary increase in falls and medication errors within the AAU was likely to be associated with the need to adjust work patterns rather than associated with single rooms, although staff perceived the loss of panoptic surveillance as the key to increases in falls. Because of the fall in infection rates nationally and the low incidence at our study site and comparator hospitals, it is difficult to conclude from our data that it is the ‘single room’ factor that prevents infection. (3) Building an all single room hospital can cost 5% more but the difference is marginal over time. Housekeeping and cleaning costs are higher. Conclusions: The nature of tasks undertaken by nurses did not change, but staff needed to adapt their working practices significantly and felt ill prepared for the new ways of working, with potentially significant implications for the nature of teamwork in the longer term. Staff preference remained for a mix of single rooms and bays. Patients preferred single rooms. There was no strong evidence that single rooms had any impact on patient safety but housekeeping and cleaning costs are higher. In terms of future work, patient experience and preferences in hospitals with different proportions of single rooms/designs need to be explored with a larger patient sample. The long-term impact of single room working on the nature of teamwork and informal learning and on clinical/care outcomes should also be explored.

Calls by the Royal College of Physicians (RCP) for more research in NHS trusts and the Care Quality Commission’s (CQC) decision to award extra points to trusts doing research, seem to signal a new era for research in the NHS. The RCP statement Delivering Research for All says every NHS clinician should be supported to take part in research. Highlighting evidence that research active trusts have better patient outcomes, the college calls for protected time for doctors, nurses, and other clinicians to undertake research. In collaboration with the National Institute for Health Research, the CQC will add questions to the leadership inspection framework for providers (the well led framework) that recognise the role of research in high quality patient care and strengthen the assessment of research activity. An increase in research capacity is welcome, but there are serious challenges to implementation. Substantial change, some might say a revolution, will be required in the way research is conducted in the NHS.

Objectives: (i) To synthesise the evidence-base for Schwartz Center Rounds® (Rounds) to assess any impact on healthcare staff and identify key features; (ii) to scope evidence for interventions with similar aims, and compare effectiveness and key features to Rounds. Design: Systematic review of Rounds literature; scoping reviews of comparator interventions (Action Learning Sets; After Action Reviews; Balint Groups; Caregiver Support Programme; Clinical Supervision; Critical Incident Stress Debriefing; Mindfulness-Based Stress Reduction; Peer Supported Storytelling; Psychosocial Intervention Training; Reflective Practice Groups; Resilience Training). Data Sources: PsychINFO, CINAHL, MEDLINE, and EMBASE, internet search engines; consultation with experts. Eligibility criteria: Empirical evaluations (qualitative or quantitative); any healthcare staff in any healthcare setting; published in English. Results: The overall evidence base for Rounds is limited. We developed a composite definition to aid comparison with other interventions from 41 documents containing a definition of Rounds. Twelve (ten studies) were empirical evaluations. All were of low/moderate quality (weak study designs including lack of control groups). Findings showed the value of Rounds to attenders, with a self-reported positive impact on individuals, their relationships with colleagues and patients, and wider cultural changes. The evidence for the comparative interventions was scant and also low/moderate quality. Some features of Rounds were shared by other interventions, but Rounds offer unique features including being open to all staff and having no expectation for verbal contribution by attenders : Evidence of effectiveness for all interventions considered here remains limited. Methods that enable identification of core features related to effectiveness are needed to optimise benefit for individual staff members and organisations as a whole. A systems approach conceptualising workplace wellbeing as arising from both individual and environmental/structural factors, and comprising interventions both for assessing and improving the wellbeing of healthcare staff, is required. Schwartz Rounds could be considered as one strategy to enhance staff wellbeing.

Background: High rates of poor mental health in healthcare staff threatens the quality and sustainability of healthcare delivery. Multi-factorial causes include the nature and structure of work. We conducted a critical review of UK NHS (England) data pertaining to: doctors, nurses, midwives and paramedics. Sources of data: Key demographic, service architecture (structural features of work) and wellbeing indicators were identified and reviewed by a stakeholder group. Data searching prioritised NHS whole workforce sources (focusing on hospital and community health services staff), which were rated according to strength of evidence. Findings: Key differences between professions were: (i) Demographics: gender (nursing and midwifery female-dominated, doctors and paramedics more balanced); age (professions other than doctors had ageing workforces); ethnicity (greater diversity among doctors and nurses); (ii) Service architecture: despite net staffing growth, turnover and retention were problematic in all professions; 41.5% doctors were consultants but smaller proportions held high grade/band roles in other professions; salaries were higher for doctors; (iii) Wellbeing: all reported high job stress, particularly midwives and paramedics; sickness absence rates for nurses, midwives and paramedics were three times those of doctors, and presenteeism nearly double. Growing points: Socio-cultural factors known to increase risk of poor mental health may explain some of the differences reported between professions. These factors and differences in service architecture are vital considerations when designing strategies to improve wellbeing. Areas timely for developing research: Multi-level systems approaches to wellbeing are required that consider intersectionality and structural differences between professions; together with interprofessional national databases to facilitate monitoring.