搜索结果：Health care analysis : HCA : journal of health philosophy and policy

Background Hospital discharge is a vulnerable stage in the patient pathway. Research highlights communication failures and the problems of co-ordination as resulting in delayed, poorly timed and unsafe discharges. The complexity of hospital discharge exemplifies the threats to patient safety found ‘between’ care processes and organisations. In developing this perspective, safe discharge is seen as relying upon enhanced knowledge sharing and collaboration between stakeholders, which can mitigate system complexity and promote safety. Aim To identify interventions and practices that support knowledge sharing and collaboration in the processes of discharge planning and care transition. Setting The study was undertaken between 2011 and 2013 in two English health-care systems, each comprising an acute health-care provider, community and primary care providers, local authority social services and social care agencies. The study sites were selected to reflect known variations in local population demographics as well as in the size and composition of the care systems. The study compared the experiences of stroke and hip fracture patients as exemplars of acute care with complex discharge pathways. Design The study involved in-depth ethnographic research in the two sites. This combined (a) over 180 hours of observations of discharge processes and knowledge-sharing activities in various care settings; (b) focused ‘patient tracking’ to trace and understand discharge activities across the entire patient journey; and (c) qualitative interviews with 169 individuals working in health, social and voluntary care sectors. Findings The study reinforces the view of hospital discharge as a complex system involving dynamic and multidirectional patterns of knowledge sharing between multiple groups. The study shows that discharge planning and care transitions develop through a series of linked ‘situations’ or opportunities for knowledge sharing. It also shows variations in these situations, in terms of the range of actors, forms of knowledge shared, and media and resources used, and the wider culture and organisation of discharge. The study also describes the threats to patient safety associated with hospital discharge, as perceived by participants and stakeholders. These related to falls, medicines, infection, clinical procedures, equipment, timing and scheduling of discharge, and communication. Each of these identified risks are analysed and explained with reference to the observed patterns of knowledge sharing to elaborate how variations in knowledge sharing can hinder or promote safe discharge. Conclusions The study supports the view of hospital discharge as a complex system involving tightly coupled and interdependent patterns of interaction between multiple health and social care agencies. Knowledge sharing can help to mitigate system complexity through supporting collaboration and co-ordination. The study suggests four areas of change that might enhance knowledge sharing, reduce system complexity and promote safety. First, knowledge brokers in the form of discharge co-ordinators can facilitate knowledge sharing and co-ordination; second, colocation and functional proximity of stakeholders can support knowledge sharing and mutual appreciation and alignment of divergent practices; third, local cultures should prioritise and value collaboration; and finally, organisational resources, procedures and leadership should be aligned to fostering knowledge sharing and collaborative working. These learning points provide insight for future interventions to enhance discharge planning and care transition. Future research might consider the implementation of interviews to mediate system complexity through fostering enhanced knowledge sharing across occupational and organisational boundaries. Research might also consider in more detail the underlying complexity of both health and social care systems and how opportunities for knowledge sharing might be engendered to promote patient safety in other areas. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Background Health-care systems are increasingly moving towards more integrated approaches. Shared decision-making (SDM) is central to these models but may be complicated by the need to negotiate and communicate decisions between multiple providers, as well as patients and their family carers; this is particularly the case for older people with complex needs. Objectives To provide a context-relevant understanding of how models to facilitate SDM might work for older people with multiple health and care needs and how they might be applied to integrated care models. Design Realist synthesis following Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) publication standards. Participants Twenty-four stakeholders took part in interviews. Data sources Electronic databases including MEDLINE (via PubMed), The Cochrane Library, Scopus, Google and Google Scholar (Google Inc., Mountain View, CA, USA). Lateral searches were also carried out. All types of evidence were included. Review methods Iterative stakeholder-driven, three-stage approach, involving (1) scoping of the literature and stakeholder interviews ( n = 13) to develop initial programme theory/ies, (2) systematic searches for evidence to test and develop the theories and (3) validation of programme theory/ies with stakeholders ( n = 11). Results We included 88 papers, of which 29 focused on older people or people with complex needs. We identified four theories (context–mechanism–outcome configurations) that together provide an account of what needs to be in place for SDM to work for older people with complex needs: understanding and assessing patient and carer values and capacity to access and use care; organising systems to support and prioritise SDM; supporting and preparing patients and family carers to engage in SDM; and a person-centred culture of which SDM is a part. Programmes likely to be successful in promoting SDM are those that create trust between those involved, allow service users to feel that they are respected and understood, and engender confidence to engage in SDM. Limitations There is a lack of evidence on interventions to promote SDM in older people with complex needs or on interprofessional approaches to SDM. Conclusions Models of SDM for older people with complex health and care needs should be conceptualised as a series of conversations that patients, and their family carers, may have with a variety of different health and care professionals. To embed SDM in practice requires a shift from a biomedical focus to a more person-centred ethos. Service providers are likely to need support, both in terms of the way services are organised and delivered and in terms of their own continuing professional development. Older people with complex needs may need support to engage in SDM. How this support is best provided needs further exploration, although face-to-face interactions and ongoing patient–professional relationships are key. Future work There is a need for further work to establish how organisational structures can be better aligned to meet the requirements of older people with complex needs. This includes a need to define and evaluate the contribution that different members of health and care teams can make to SDM for older people with complex health and care needs. Study registration This study is registered as PROSPERO CRD42016039013. Funding The National Institute for Health Research Health Services and Delivery Research programme.

<p>New Zealand’s Primary Health Care Strategy (PHCS) has a stated commitment to defined populations who suffer disproportionately from ill health. This thesis examines whether some prevailing discourses actually decrease the focus on health inequalities. Words and ideas shared by a group can be considered a discourse when the underpinning values serve a social and political function for that group. To examine whether discourse was constraining health care I considered the nursing and medical media pertaining to both the PHCS and the primary health care nursing framework and sought their dominant discourses. I found that the nursing and medical media focused on predominantly professional and industrial issues. These were expressed very differently with the medical media reacting to the ramifications of the PHCS especially Primary Health Organisations (PHOs), while the nursing media had a visioning quality, imagining how nursing could function in primary health care (PHC). The result was that, in the media studied, the upheaval of the PHCS left professionals mainly wondering about their own professional interests, rather than considering what those who suffer from health inequalities needed. The discourse of the PHCS may also serve political rather then altruistic purposes. I found historical examples of where discourse had underpinned health policy and I suggest that current (Ministry of Health) MOH discourse values decentralised community health decision making. The decentralised community health model of small community PHOs situates the responsibility for health locally. This health responsibility may gloss over factors in community health which are affected by Government policy such as employment policy, and thus should be dealt with centrally by legislation. These factors have been found to be the most pertinent in health inequalities. So while models of community partnerships may seem to place communities as agents in their own health, this downplays the determinants of health which are beyond their control. Moreover the multiple PHOs through the country, while costly in the repetition of bureaucracy, also make analysis of the PHCS difficult, since there is in effect multiple Primary Health Care Strategies being played out in each area, as interventions of various qualities are implemented. Having shown that discourse can decrease the focus on health inequalities due to other professional and political drivers. I then looked at health initiative concepts which are effective, efficient and equitable given the current set up of PHOs and nursing innovations.</p>

BACKGROUND: Healthcare aides (HCAs) are the primary caregivers for vulnerable older persons. They have many titles and are largely unregulated, which contributes to their relative invisibility. The objective of this scoping review was to evaluate the breadth and depth of the HCA workforce literature. METHODS: We conducted a search of seven online bibliographic databases. Studies were included if published since 1995 in English, peer-reviewed journals. Results were iteratively synthesized within and across the following five categories: education, supply, use, demand and injury and illness. RESULTS: Of 5,045 citations screened, 82 studies met inclusion criteria. Few examined HCA education; particularly trainee characteristics, program location, length and content. Results in supply indicated that the average HCA was female, 36-45 years and had an education level of high school or less. Home health HCAs were, on average, older and were more likely to be immigrants than those working in other settings. The review of studies exploring HCA use revealed that their role was unclear - variation in duties, level of autonomy and work setting make describing "the" role of an HCA near impossible. Projected increased demand for HCAs and high rates of turnover, both at the profession and facility-level, elicit predictions of future HCA shortages. Home health HCAs experienced comparatively lower job stability, earned less, worked the fewest hours and were less likely to have fringe benefits than HCAs employed in hospitals and nursing homes. The review of studies related to HCA illness and injury revealed that they were at comparatively higher risk of injury than registered nurses and licensed practical nurses. CONCLUSIONS: This is the largest, most comprehensive scoping review of HCA workforce literature to date. Our results indicate that the HCA workforce is both invisible and ubiquitous; as long as this is the case, governments and healthcare organizations will be limited in their ability to develop and implement feasible, effective HCA workforce plans. The continued undervaluation of HCAs adversely impacts care providers, the institutions they work for and those who depend on their care. Future workforce planning and research necessitates national HCA registries, or at minimum, directories.

Purpose This paper aims to share the findings of a realist evaluation study that set out to identify how to strengthen nursing, midwifery and allied health professions (NMAHP) leadership across all health-care contexts in the UK conducted between 2018 and 2019. The collaborative research team were from the Universities of Bangor, Ulster, the University of the West of Scotland and Canterbury Christ Church University. Design/methodology/approach Realist evaluation and appreciative inquiry were used across three phases of the study. Phase 1 analysed the literature to generate tentative programme theories about what works, tested out in Phase 2 through a national social media Twitter chat and sense-making workshops to help refine the theories in Phase 3. Cross-cutting themes were synthesised into a leadership framework identifying the strategies that work for practitioners in a range of settings and professions based on the context, mechanism and output configuration of realist evaluation. Stakeholders contributed to the ongoing interrogation, analysis and synthesis of project outcomes. Findings Five guiding lights of leadership, a metaphor for principles, were generated that enable and strengthen leadership across a range of contexts. – “The Light Between Us as interactions in our relationships”, “Seeing People’s Inner Light”, “Kindling the Spark of light and keeping it glowing”, “Lighting up the known and the yet to be known” and “Constellations of connected stars”. Research limitations/implications This study has illuminated the a-theoretical nature of the relationships between contexts, mechanisms and outcomes in the existing leadership literature. There is more scope to develop the tentative programme theories developed in this study with NMAHP leaders in a variety of different contexts. The outcomes of leadership research mostly focussed on staff outcomes and intermediate outcomes that are then linked to ultimate outcomes in both staff and patients (supplemental). More consideration needs to be given to the impact of leadership on patients, carers and their families. Practical implications The study has developed additional important resources to enable NMAHP leaders to demonstrate their leadership impact in a range of contexts through the leadership impact self-assessment framework which can be used for 360 feedback in the workplace using the appreciative assessment and reflection tool. Social implications Whilst policymakers note the increasing importance of leadership in facilitating the culture change needed to support health and care systems to adopt sustainable change at pace, there is still a prevailing focus on traditional approaches to individual leadership development as opposed to collective leadership across teams, services and systems. If this paper fails to understand how to transform leadership policy and education, then it will be impossible to support the workforce to adapt and flex to the increasingly complex contexts they are working in. This will serve to undermine system integration for health and social care if the capacity and capability for transformation are not attended to. Whilst there are ambitious global plans (WHO, 2015) to enable integrated services to be driven by citizen needs, there is still a considerable void in understanding how to authentically engage with people to ensure the transformation is driven by their needs as opposed to what the authors think they need. There is, therefore, a need for systems leaders with the full skillset required to enable integrated services across place-based systems, particularly clinicians who are able to break down barriers and silo working across boundaries through the credibility, leadership and facilitation expertise they provide. Originality/value The realist evaluation with additional synthesis from key stakeholders has provided new knowledge about the principles of effective NMAHP leadership in health and social care, presented in such a way that facilitates the use of the five guiding lights to inform further practice, education, research and policy development.

This study has investigated the formal and informal ways pre-registration students from four healthcare professions learn about patient safety in order to become safe practitioners. The study aims to understand some of the issues which impact upon teaching, learning and practising patient safety in academic, organisational and practice „knowledge? contexts. In Stage 1 we used a convenience sample of 13 educational providers across England and Scotland linked with five universities running traditional and innovative courses for doctors, nurses, pharmacists and physiotherapists. We gathered examples of existing curriculum documents for detailed analysis, and interviewed course directors and similar informants. In Stage 2 we undertook 8 case studies to develop an in-depth investigation of learning and practice by students and newly qualified practitioners in universities and practice settings in relation to patient safety. Data were gathered to explore the planning and implementation of patient safety curricula; the safety culture of the places where learning and working take place; the student teacher interface; and the influence of role models and organisational culture on practice. Data from observation, focus groups and interviews were transcribed and coded independently by more than one of the research team. Analysis was iterative and ongoing throughout the study. NHS policy is being taken seriously by course leaders, and Patient Safety material is being incorporated into both formal and informal curricula. Patient safety in the curriculum is largely implicit rather than explicit. All students very much value the practice context for learning about patient safety. However, resource issues, peer pressure and client factors can influence safe practice. Variations exist in students? experience, in approach between university tutors, different placement locations – the experience each offers – and the quality of the supervision available. Relationships with the mentor or clinical educator are vital to student learning. The role model offered and the relationship established affects how confident students feel to challenge unsafe practice in others. Clinicians are conscious of the tension between their responsibilities as clinicians (keeping patients safe), and as educators (allowing students to learn under supervision). There are some apparent gaps in curricular content where relevant evidence already exists – these include the epidemiology of adverse events and error, root cause analysis and quality assessment. Reference to the organisational context is often absent from course content and exposure limited. For example, incident reporting is not being incorporated to any great extent in undergraduate curricula. Newly qualified staff were aware of the need to be seen to practice in an evidence based way, and, for some at least, the need to modify „the standard? way of doing things to do „what?s best for the patient?. A number of recommendations have been made, some generic and others specific to individual professions. Regulators? expectations of courses in relation to patient 9 safety education should be explicit and regularly reviewed. Educators in all disciplines need to be effective role models who are clear about how to help students to learn about patient safety. All courses should be able to highlight a vertical integrated thread of teaching and learning related to patient safety in their curricula. This should be clear to staff and students. Assessment for this element should also be identifiable as assessment remains important in driving learning. All students need to be enabled to constructively challenge unsafe or non-standard practice. Encounters with patients and learning about their experiences and concerns are helpful in consolidating learning. Further innovative approaches should be developed to make patient safety issues 'real' for students.

Background Support workers make up the majority of the workforce in health and social care services for older people. There is evidence to suggest that support workers are not deployed as effectively as possible, are often undervalued, and that there are gaps in understanding support worker roles across different care settings. In the context of a population that is growing older, having a skilled and knowledgeable workforce is an imperative. Workforce development includes the support required to equip those providing care to older people with the right skills, knowledge and behaviours to deliver safe and high-quality services. Objective The review answered the question ‘how can workforce development interventions improve the skills and the care standards of support workers within older people’s health and social care services?’. Design A realist synthesis was conducted. In realist synthesis, contingent relationships are expressed as context–mechanism–outcomes (CMOs), to show how particular contexts or conditions trigger mechanisms to generate outcomes. The review was conducted in four iterative stages over 18 months: (1) development of a theoretical framework and initial programme theory; (2) retrieval, review and synthesis of evidence relating to interventions designed to develop the support workforce, guided by the programme theories; (3) ‘testing out’ the synthesis findings to refine the programme theories and establish their practical relevance/potential for implementation; and (4) forming recommendations about how to improve current workforce development interventions to ensure high standards in the care of older people. Participants Twelve stakeholders were involved in workshops to inform programme theory development, and 10 managers, directors for training/development and experienced support workers were interviewed in phase 4 of the study to evaluate the findings and inform knowledge mobilisation. Results Eight CMO configurations emerged from the review process, which provide a programme theory about ‘what works’ in developing the older person’s support workforce. The findings indicate that the design and delivery of workforce development should consider and include a number of starting points. These include personal factors about the support worker, the specific requirements of workforce development and the fit with broader organisational strategy and goals. Conclusions and recommendations The review has resulted in an explanatory account of how the design and delivery of workforce development interventions work to improve the skills and care standards of support workers in older people’s health and social care services. Implications for the practice of designing and delivering older person’s support workforce development interventions are directly related to the eight CMO configuration of the programme theory. Our recommendations for future research relate both to aspects of research methods and to a number of research questions to further evaluate and explicate our programme theory. Limitations We found that reports of studies evaluating workforce development interventions tended to lack detail about the interventions that were being evaluated. We found a lack of specificity in reports about what were the perceived and actual intended impacts from the workforce development initiatives being implemented and/or evaluated. Study registration This study is registered as PROSPRERO CRD42013006283. Funding The National Institute for Health Research Health Services and Delivery Research programme.

OBJECTIVES: To develop an understanding of health professionals' experiences of working at the point of care during the COVID-19 pandemic, the impact on their health and well-being and their support needs. DESIGN: A qualitative study using semistructured interviews. Data were analysed using framework analysis. SETTING: One large National Health Service integrated care trust. PARTICIPANTS: A purposive sample of 19 qualified health professionals (doctors, nurses or allied health professionals), working with patients with COVID-19 admitted to the hospitals between March and May 2020 were eligible to take part. RESULTS: Eight major categories were identified: (1) Working in a 'war zone', (2) 'Going into a war zone without a weapon', (3) 'Patients come first', (4) Impact of COVID-19, (5) Leadership and management, (6) Support systems, (7) Health professionals' support needs, and (8) Camaraderie and pride. Health professionals reported increased levels of stress, anxiety and a lack of sleep. They prioritised their patients' needs over their own and felt a professional obligation to be at work. A key finding was the reported camaraderie among the health professionals where they felt that they were 'fighting this war together'. CONCLUSIONS: This study provides a valuable insight into the experiences of some of the frontline health professionals working in a large London-based hospital trust during the first COVID-19 peak. Findings from this study could be used to inform how managers, leaders and organisations can better support their health professional staff during the current pandemic and beyond.

BACKGROUND: In most developed countries, Health Care Assistants comprise a significant, and growing, proportion of the residential aged care workforce. Despite the fact that they provide the majority of direct care for residents, little is known about a key care aspect of their work, namely their experience of caring for dying residents. METHODS: Twenty-six Health Care Assistants working in aged residential care facilities in Auckland, New Zealand participated in six focus group discussions. Focus groups were designed to explore the experiences of Health Care Assistants caring for imminently dying residents in aged care facilities and to identify barriers and facilitators to their work in this area. The focus groups were digitally recorded, transcribed verbatim and analysed using a general inductive approach. RESULTS: Participants confirmed that Health Care Assistants provide the majority of hands on care to dying residents and believed they had a valuable role to play at this time due to their unique 'familial' relationship with residents and families. However, it was apparent that a number of barriers existed to them maximising their contribution to supporting dying residents, most notably the lack of value placed on their knowledge and experience by other members of the multidisciplinary team. Whilst a need for additional palliative and end of life care education was identified, a preference was identified for hands on education delivered by peers, rather than the didactic education they currently receive. CONCLUSION: Given ageing populations internationally coupled with a constrained health budget, the role of Health Care Assistants in most developed countries is likely to become even more significant in the short to medium term. This study makes a unique contribution to the international literature by identifying the barriers to caring for dying residents experienced by this valuable sector of the aged care workforce. These data have the potential to inform new, innovative, interventions to address the urgent need identified to improve palliative and end of life care management in aged care internationally.

AIMS AND OBJECTIVES: To report the findings from interviews conducted as part of a wider study on interventions to support dignified care in older people in acute hospital care. The data in this study present the interview data. BACKGROUND: Dignity is a complex concept. Despite a plethora of recommendations on how to achieve dignified care, it remains unclear how to attain this in practice and what the priorities of patients and staff are in relation to dignity. DESIGN: A purposive sample of older patients and staff took part in semi-structured interviews and gave their insight on the meaning of dignity and examples of what sustains and breaches a patient's dignity in acute hospital care. METHOD: Thirteen patients and 38 healthcare professionals in a single metropolitan hospital in the UK interviewed. Interviews were transcribed verbatim and underwent a thematic analysis. RESULTS: The meaning of dignity was broadly agreed on by patients and staff. Three broad themes were identified: the meaning of dignity, staffing level and its impact on dignity, and organisational culture and dignity. Registered staff of all healthcare discipline and student nurses report very little training on dignity or care of the older person. CONCLUSION: There remain inconsistencies in the application of dignified care. Staff behaviour, a lack of training and the organisational processes continue to result in breaches to dignity of older people. Clinical nurses have a major role in ensuring dignified care for older people in hospital. RELEVANCE TO CLINICAL PRACTICE: There needs to be systematic dignity-related training with regular refreshers. This education coupled with measures to change the cultural attitudes in an organisation towards older peoples' care should result in long-term improvements in the level of dignified care. Hospital managers have an important role in changing system to ensure that staff deliver the levels of care they aspire to.

Background Concerns about the degree of compassion in health care have become a focus for national and international attention. However, existing research on compassionate care interventions provides scant evidence of effectiveness or the contexts in which effectiveness is achievable. Objectives To assess the feasibility of implementing the Creating Learning Environments for Compassionate Care (CLECC) programme in acute hospital settings and to evaluate its impact on patient care. Design Pilot cluster randomised trial (CRT) and associated process and economic evaluations. Setting Six inpatient ward nursing teams (clusters) in two English NHS hospitals randomised to intervention ( n = 4) or control ( n = 2). Participants Patients ( n = 639), staff ( n = 211) and visitors ( n = 188). Intervention CLECC is a workplace educational intervention focused on developing sustainable leadership and work team practices (dialogue, reflective learning, mutual support) theorised to support the delivery of compassionate care. The control setting involved no planned staff team-based educational activity. Main outcome measures Quality of Interaction Schedule (QuIS) for staff–patient interactions, patient-reported evaluations of emotional care in hospital (PEECH) and nurse-reported empathy (as assessed via the Jefferson Scale of Empathy). Data sources Structured observations of staff–patient interactions; patient, visitor and staff questionnaires and qualitative interviews; and qualitative observations of CLECC activities. Results The pilot CRT proceeded as planned and randomisation was acceptable to teams. There was evidence of potential contamination between wards in the same hospital. QuIS performed well, achieving a 93% recruitment rate, with 25% of the patient sample cognitively impaired. At follow-up there were more positive (78% vs. 74%) and fewer negative (8% vs. 11%) QuIS ratings for intervention wards than for control wards. In total, 63% of intervention ward patients achieved the lowest possible (i.e. more negative) scores on the PEECH connection subscale, compared with 79% of control group patients. These differences, although supported by the qualitative findings, are not statistically significant. No statistically significant differences in nursing empathy were observed, although response rates to staff questionnaire were low (36%). Process evaluation: the CLECC intervention is feasible to implement in practice with medical and surgical nursing teams in acute care hospitals. Strong evidence of good staff participation was found in some CLECC activities and staff reported benefits throughout its introductory period and beyond. Further impact and sustainability were limited by the focus on changing ward team behaviours rather than wider system restructuring. Economic evaluation: the costs associated with using CLECC were identified and it is recommend that an impact inventory be used in any future study. Limitations Findings are not generalisable outside hospital nursing teams, and this feasibility work is not powered to detect differences attributable to the CLECC intervention. Conclusions Use of the experimental methods is feasible. The use of structured observation of staff–patient interaction quality is a promising primary outcome that is inclusive of patient groups often excluded from research, but further validation is required. Further development of the CLECC intervention should focus on ensuring that it is adequately supported by resources, norms and relationships in the wider system by, for instance, improving the cognitive participation of senior nurse managers. Funding is being sought for a more definitive evaluation. Trial registration Current Controlled Trials ISRCTN16789770. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research ; Vol. 6, No. 33. See the NIHR Journals Library website for further project information. The systematic review reported in Chapter 2 was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, the University of Örebro and the Karolinska Institutet.

Background The Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations. Objectives The three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables. Design There were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components. Main outcome measures The quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience. Data sources Searches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence. Review methods A realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities. Results Delivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models. Strengths and limitations The project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change. Conclusions Multispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working. Future work A set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience. Study registration This study is registered as PROSPERO CRD42016039552. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Well-being inequalities arising from different healthcare expenditure public policies is currently a hot topic at a national scale, but especially so at a sub-national level because the inequalities in question are among citizens of the same country. Spain is an optimal study area to carry out research on this topic because it is considered to have one of the best health systems in the world, it is one of the top-ranking countries in terms of life expectancy rates (the indicators we use for well-being), and it has a decentralized public health system with significantly different regional healthcare expenditure public policies. Given that the factors involved in the complex direct, indirect, and second-order relationships between well-being and health spending are latent in nature, and that there are more hypotheses than certainties regarding these relationships, we propose a partial least squares structural equation modeling specification to test the research hypotheses and to estimate the corresponding impacts. These constructs are proxied by a set of 26 indicators, for which annual values at a regional scale were used for the period 2005-2018. From the estimation of this model, it can be concluded that mortality, expenditure and resources are the factors that have the greatest impact on well-being. In addition, a cluster analysis of the indicators for the constructs included in this research reveals the existence of three clearly differentiated groups of autonomous communities: the northern part of the country plus Extremadura (characterized by the lowest well-being and the highest mortality rates), Madrid (with the best results in well-being and mortality, the lowest public health expenditure per inhabitant and percentage of pharmaceutical spending, and the highest percentage in specialty care services and medical staff spending), and the rest of the country (south-eastern regions, with similar well-being values to those of the first group but with less health expenditure). Finally, a principal component analysis reveals that "healthiness" and "basic spending" are the optimal factors for mapping well-being and health spending in Spain.

The application of artificial intelligence (AI) may revolutionize the healthcare system, leading to enhance efficiency by automatizing routine tasks and decreasing health-related costs, broadening access to healthcare delivery, targeting more precisely patient needs, and assisting clinicians in their decision-making. For these benefits to materialize, governments and health authorities must regulate AI, and conduct appropriate health technology assessment (HTA). Many authors have highlighted that AI health technologies (AIHT) challenge traditional evaluation and regulatory processes. To inform and support HTA organizations and regulators in adapting their processes to AIHTs, we conducted a systematic review of the literature on the challenges posed by AIHTs in HTA and health regulation. Our research question was: What makes artificial intelligence exceptional in HTA? The current body of literature appears to portray AIHTs as being exceptional to HTA. This exceptionalism is expressed along 5 dimensions: 1) AIHT’s distinctive features; 2) their systemic impacts on health care and the health sector; 3) the increased expectations towards AI in health; 4) the new ethical, social and legal challenges that arise from deploying AI in the health sector; and 5) the new evaluative constraints that AI poses to HTA. Thus, AIHTs are perceived as exceptional because of their technological characteristics and potential impacts on society at large. As AI implementation by governments and health organizations carries risks of generating new, and amplifying existing, challenges, there are strong arguments for taking into consideration the exceptional aspects of AIHTs, especially as their impacts on the healthcare system will be far greater than that of drugs and medical devices. As AIHTs begin to be increasingly introduced into the health care sector, there is a window of opportunity for HTA agencies and scholars to consider AIHTs’ exceptionalism and to work towards only deploying clinically, economically, socially acceptable AIHTs in the health care system.

Stresses on healthcare systems and moral distress among clinicians are urgent, intertwined bioethical problems in contemporary healthcare. Yet conceptualizations of moral distress in bioethical inquiry often overlook a range of routine threats to professional integrity in healthcare work. Using examples from our research on frontline physicians working during the COVID-19 pandemic, this article clarifies conceptual distinctions between moral distress, moral injury, and moral stress and illustrates how these concepts operate together in healthcare work. Drawing from the philosophy of healthcare, we explain how moral stress results from the normal operations of overstressed systems; unlike moral distress and moral injury, it may not involve a sense of powerlessness concerning patient care. The analysis of moral stress directs attention beyond the individual, to stress-generating systemic factors. We conclude by reflecting on how and why this conceptual clarity matters for improving clinicians’ professional wellbeing, and offer preliminary pathways for intervention.

BACKGROUND: People with long term conditions (LTCs) make most of the daily decisions and carry out the activities which affect their health and quality of life. Only a fraction of each contact with a health care professional (HCP) is spent supporting this. This paper describes how care and support planning (CSP) and an implementation framework to redesign services, were developed to address this in UK general practice. Focussed on what is important to each individual, CSP brings together traditional clinical issues and the person's lived experience in a solution focussed, forward looking conversation with an emphasis on 'people not diseases'. METHODS: The components of CSP were developed in three health communities using diabetes as an exemplar. This model was extended and refined for other single conditions and multimorbidity across 40 sites and two nations, over 15 years. Working with local teams and communities the authors used theoretical models of care, implementation and spread, developing and tailoring training, support and resources to embed CSP as usual care, sharing learning across a community of practice. RESULTS: The purpose, content, process, developmental hurdles and impact of this CSP model are described, alongside an implementation strategy. There is now a robust, reproducible five step model; preparation, conversation, recording, actions and review. Uniquely, preparation, involving information sharing with time for reflection, enables an uncluttered conversation with a professional focussed on what is important to each person. The components of the Year of Care House act as a checklist for implementation, a metaphor for their interdependence and a flexible framework. Spreading CSP involved developing exemplar practices and building capacity across local health communities. These reported improved patient experience, practitioner job satisfaction, health behaviours and outcomes, teamwork, practice organisation, resource use, and links with wider community activities. CONCLUSIONS: Tested in multiple settings, CSP is a reproducible and practical model of planned care applicable to all LTCs, with the capacity to be transformative for people with LTCs and health care professionals. It recaptures relational dimensions of care with transactional elements in the background. Options for applying this model and implementation framework at scale now need to be explored.

BACKGROUND: This study was undertaken to understand the role of the Health Care Assistants and how they negotiate roles and responsibilities with Registered Nurses in adult acute hospitals. METHODS: The qualitative approach of focused ethnography used non-participant observation and interviews with staff from four acute wards. Field notes and interview data, analysed using NVIVO10, moved data from description through explanation, interpretation and identification of themes. RESULTS: 148 h of observations and 108 interviews were conducted in dyads comprising 22 Health Care Assistants and 33 Registered Nurses. Health Care Assistants worked non-dependently from, and inter-dependently with Registered Nurse dyad partners. Dyads relied on demarcation of responsibilities by task, established and reinforced by ward culture. Demarcation enabled Registered Nurses to oversee care but could create false divides between observing and recording patients' conditions and interpreting findings. Interdependent working only happened when two staff members were needed for care. Involvement in fundamental care by the Registered Nurse was unpredictable and discretionary. There was limited evidence of how dyads supported person-centred approaches. CONCLUSION: The physically-boundaried, close working of the Health Care Assistant and Registered Nurse had an isolating, task driven impact on Health Care Assistants' work. Recognising the dyad did not foster shared goals, learning or review of care.

An interpretive qualitative study was conducted to examine public health nurses' (PHNs') practice in fostering citizen participation and collaborative practice and the impact of a decade (1992–2002) of health care restructuring. This article presents the perspectives of public health management and a public policy analysis as they relate to PHNs' primary health care practice in Nova Scotia, a province in Eastern Canada. Seven face-to-face interviews were conducted with public health management from across Nova Scotia and 26 relevant public policy documents were analyzed. Three major themes emerged from the coded transcripts and the document analysis: (1) opportunistic shifts in values: constraining structures, operations, and governance; (2) insufficient funding and infrastructure support; (3) opportunities and challenges to PHN capacity and competency. The emergent themes illustrate the unique population health perspective and day-to-day contested realities of public health and PHN practice. The study provides preliminary understanding of PHNs' primary health care practice in Nova Scotia that may resonate with other national and international settings. This knowledge can form a basis for more research to explore the PHNs' practice in the organizational context in which it is embedded. This study was undertaken at a pivotal time in Nova Scotia as the provincial government embarked on primary health care renewal to improve the health of Nova Scotians. The success of this study is in large part attributable to the collaborative effort of university researchers and public health decision makers.

Many interventions were sought in the past to address the human health and aquatic life implications associated with poor Municipal Solid Waste Management (MSWM) practices. Majority of such interventions failed to recognise that such human health risks and threats to aquatic life are to a large extent moderated by unique characteristics of different urban and rural spaces where such waste is generated. They failed to employ multiple criteria-based evaluation models that are appropriate in depicting the complex and often interrelated criteria inherently associated with MSWM. This study used the Hierarchical Cluster Analysis (HCA) to evaluate several interdependent variables that define human health and aquatic life hazards associated with poor MSWM practices. Specifically, HCA was used to identify relative similarities among, and distances between a sample of 26 Ethiopian cities and towns in terms of MSWM health threats. Results indicated that threats to human health and aquatic life are surmountable for cities whose economies are relatively low and lacking capacity in terms of SWM infrastructure, acceptable institutional arrangements and better health-care facilities to deal with associated SWM-induced human health risks. Risk of flood waters owing to low altitude has also compounded the urban health conditions in such cities. Despite being better positioned, the analysis observed that some bigger cities still face problems in terms of effective land use planning policies, commitment towards implementing effective SWM programmes as well as the absence of water safety management plans. It concluded by proposing a number of targeted interventions seeking to improve the human health conditions of cities failing to cope with uncollected waste.