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Lean management (LM) has been implemented in healthcare organisations, promising efficient operations, rapid patient access to care, improved staff satisfaction and lower costs. However, use of LM is questioned because there is no strong evidence of its outcomes, so proof of long-term and organisation-wide use is needed. The aim of the study is to increase understanding of the long-term effects of LM in healthcare. This is a case study done at the Helsinki University Hospital in Finland. A retrospective qualitative study was conducted in three sectors (A, B and C) of the hospital. Fourteen healthcare leaders from three sectors participated in interviews by answering structured and open-ended questions. The interviews were used to evaluate the outcomes that are experienced by the leaders in the hospital setting over a five-year period and evaluate indicators that they used to assess these outcomes. The interviews were analysed using qualitative and quantitative content analysis with ATLAS.ti analysis software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). The outcomes of LM can be grouped into three main categories (organisation, patient and staff) that are divided into six subcategories: experiential, care-related, work-related, economic, leadership and management, and image effects. The leaders experienced the greatest benefits on the organisation level, as it enhanced the effectiveness of the organisation's structure and operations, fostered continuous development, improved staff retention and attraction and promoted patient-centredness. According to the leaders, the most important benefits for patients included improved access to care, better care flow, enhanced safety of care and greater participation in improving operations. In addition, the leaders highlighted that the biggest benefits for staff, were increased work satisfaction, work competence, work commitment and ethical behaviour. We found that the use of LM also has disruptive and contradictory effects caused by the lack of organisation-wide Lean commitment and structure, and the media have bias towards negative portrayals of hospital efficiency. We found that six subcategories provide a comprehensive framework for qualitatively assessing organisation-wide experienced outcomes of LM in the hospital. Our findings emphasise that the organisation should be fully committed to the Lean method, and its structure should be clear so that the best benefits of LM can be achieved. We noticed that more qualitative LM research is needed to complement the Lean knowledge gained from quantitative research, develop more comprehensive and high-quality evaluation indicators and increase evidence for its use in healthcare.

Healthcare systems increasingly require nurse leaders who combine clinical expertise with business acumen. Traditional Master of Science in Nursing (MSN) and Doctor of Nursing Practice (DNP) programs emphasize clinical and leadership skills but offer limited education in finance, strategy, and management. The Master of Business Administration (MBA) provides business competencies but lacks clinical content. A dual Doctor of Nursing Practice/Master of Business Administration (DNP/MBA) integrates both domains. Nationally, only 8.96% of institutions offer such a program, despite growing interest in business education for nurse leaders. Cross-sectional descriptive national survey using convenience sampling. To explore perspectives of graduate nursing faculty, Chief Nursing Officers (CNOs), and Chief Executive Officers (CEOs) on the value of the MSN, DNP, MBA, and DNP/MBA degrees in preparing nurse leaders. An electronic survey (Nov 2022-May 2025) yielded 477 responses (292 faculty, 130 CNOs, 55 CEOs). Content validity was established via expert review. Data were analyzed descriptively and comparatively using SurveyMonkey functions. CEOs and CNOs expressed support for the DNP/MBA as integrating clinical and business competencies. Faculty strongly endorsed integrating business content. Findings reflect stakeholder preferences but should be interpreted cautiously given low response rates. The DNP/MBA was viewed as the most comprehensive preparation for nurse executives. While exploratory, stakeholder perspectives suggest the DNP/MBA may warrant consideration as a preferred credential and may eventually emerge as an expectation for C-Suite preparation.

To explore the barriers and facilitators influencing the use of point-of-care ultrasound (POCUS) for confirming the position of gastric tubes in preterm infants in the neonatal intensive care unit (NICU). Many research studies indicated that POCUS is an effective and repeatable technique for monitoring the tip position of gastric tubes; however, the application rate of this technique among nurses in the NICU for confirming the position of gastric tubes in preterm infants remains low. Using a qualitative descriptive research design, we conducted interviews with direct care nurses (n = 8), frontline doctors (n = 2), and nursing leaders (n = 2) at a tertiary-level hospital to explore the barriers and facilitators influencing nurses' use of POCUS for confirming the position of gastric tubes in preterm infants. The study identified two main themes: facilitators and barriers. The facilitators include the following six subthemes: adequate resource allocation and equipment; demonstrable safety and clinical efficacy; intrinsic motivation and professional development; supportive and innovative work environment; strong managerial and leadership support; and clear pathways for process optimization. The barriers also include six subthemes: deficiencies in competency development systems; complexity of neonatal clinical presentations; absence of institutional policies and standardized protocols; sociocultural and cognitive resistance; perceived legal and ethical risks; and unclear team collaboration dynamics. This study explored the main factors hindering and promoting the implementation of the POCUS for gastric tube position confirmation from the perspectives of direct care nurses, frontline doctors, and nursing leaders. Participants pointed out that there were issues with insufficient protection and support in areas such as training systems, institutional regulations, cognitive levels, and team collaboration. Therefore, it is necessary to formulate strategies and policies to address these obstacles.

Ethiopia has the fourth-highest number of zero-dose children globally. Negative experiences and perceptions of immunization are recognized barriers to vaccination uptake but warrant context-specific investigation. We explored barriers and enablers to immunization uptake in selected regions of Ethiopia. We conducted a formative qualitative study involving 18 focus group discussions with men and women, in-depth interviews with 23 mothers of children with varying immunization statuses, and 42 key informant interviews with religious and community leaders and health workers in eight districts in Amhara, Oromia, and Somali regions. We identified shared and regionally distinct barriers. Common barriers included limited access to services in hard-to-reach areas, low awareness of immunization, competing household responsibilities for mothers, fear of side effects, and a lack of compassionate and respectful care from health workers. Forgetting vaccination appointments was frequently reported in Amhara and Oromia. In Amhara and Somali, mistrust of vaccinators and infrequent vaccination sessions were salient challenges. In Amhara, some believed that envy or praise by vaccinators could bring harm or misfortune to children, and that vaccination should be delayed until after baptism. In Oromia, beliefs that vaccines aggravate illness and that infants should not leave home before six months of age were reported. In Somali, perceived parental negligence and beliefs that vaccines are unnecessary were described. Engaging community, traditional, and religious leaders and fathers in immunization activities in Oromia, and aligning vaccination sessions with local holidays in Amhara, emerged as promising practices. Our findings show that knowledge and perceptions of vaccines, cultural norms, service accessibility, and experiences with vaccine-preventable diseases (VPDs) and vaccination can either encourage or discourage uptake. We recommend enhancing service delivery, improving caregiver interactions, and implementing two-way community engagement involving religious and community leaders, and caregivers of fully vaccinated children, with a focus on highlighting reductions in VPD burden.

Pediatric hospital medicine (PHM) is a growing field with a unique scholarly perspective and evolving role in academic leadership. Since the last systematic assessment of PHM research in 2009, predating subspecialty certification in 2016 and fellowship accreditation in 2020, the research infrastructure within PHM has not been reevaluated. We sought to assess the current state of PHM research by assessing the number, scope, and scholarly domains of research faculty, as well as research funding and support. Using the Pediatrics Research in Inpatient Settings Network, we distributed a cross-sectional survey to PHM group leaders across the United States and Canada. The 16-item instrument, adapted from prior PHM and adult hospital medicine surveys, assessed program demographics, faculty effort allocation, research support, funding, and scholarly domains. Surveys were distributed via REDCap with follow-up reminders. Descriptive statistics were used. 49 programs responded (51% response rate), representing 1702 faculty (∼40% of US pediatric hospitalists). Fewer than half of programs (n = 21, 43%) reported faculty with more than 50% research effort. One-hundred and ninety faculty members (11%) had dedicated research time, and 72% of those conducting quality improvement research did so without any protected effort. Most PHM programs (n = 27, 55%) received less than $100 000 in total annual research funding. Despite recent PHM subspecialty designation and pediatric hospitalist desire to conduct research, dedicated time and associated supports are uncommon in PHM groups. Improvements in the PHM research pipeline will require understanding institutional financial constraints and diversifying and strengthening research funding.

Social care staff shortages are having a detrimental impact across the health and care system. There are reports of care homes closing, stopping nursing services and not admitting new residents because of challenges with staff shortages. To develop an explanatory framework of strategies used to attract, recruit, and retain registered nurses and care workers working in care homes. Explain how and why strategies work, for whom, the conditions needed and the costs involved. A realist synthesis approach was used. In step 1, strategies were identified and initial programme theories developed using data from stakeholder consultations (n = 10), theory gleaning interviews with registered nurses and care workers (n = 13), and evidence retrieved from scoping literature searches (n = 50). Strategies (and initial programme theories) prioritised by sector stakeholders focused on staff recruitment and retention, and were taken forward for testing/refinement. Step 2 involved searching academic databases and social care websites for evidence. Step 3 involved screening and selecting records relevant to the prioritised initial programme theories. Relevant data were extracted and analysed to identify context-mechanism-outcome configurations. To assess rigour, the appropriateness of research methods, and the plausibility/transparency of grey literature were assessed. Step 4 involved testing and refining the programme theories, with programme theories sense checked/refined by sector stakeholders. Existing and established theories were used to help further explain the programme theories and develop an overarching explanatory framework. During step 1, strategies used to attract, recruit, and retain registered nurses and care workers were identified and initial programme theories developed (n = 22). Ten strategies and initial programme theories were prioritised for testing/refining and were focused on recruitment and retention: staff recognition, flexible working, career development, salary package, early investment, induction, continuous feedback, caring community, effective interviewing and listening to all staff. From the focused literature searches, 153 papers were included and data from these were used to test and refine the prioritised strategies and initial programme theories, and throughout the process collated into five final theories: effective interviewing, career development, reward and recognition, promoting work-life balance and caring conversations. These strategies do not operate independently; they interact and work together. Effective interviewing sets accurate expectations, and loyalty starts to develop through setting an accurate 'psychological contract' which is fulfilled over time. Opportunities for career development, rewarding and recognising staff, providing flexible working options and supporting staff with caring conversations help staff to feel listened to, respected and valued, which in turn, develops job satisfaction. Supportive leaders and a sense of inclusion and fairness are needed for these strategies to work. These strategies provide staff with positive experiences, and these are reciprocated through employee commitment and loyalty. Supporting staff through providing caring conversations and opportunities for career development also help staff feel empowered. This is the first realist synthesis in this field. The findings provide practical strategies for improving staff recruitment and retention. Stakeholder consultations did not include the views of staff who had left care work. Understanding how to attract new staff to the social care workforce remains an important research gap. This study is registered as PROSPERO CRD42021261112. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131016) and is published in full in Health and Social Care Delivery Research; Vol. 14, No. 21. See the NIHR Funding and Awards website for further award information. We worked on understanding strategies which can help with attracting, recruiting, and retaining registered nurses and care workers in care homes. In the first step we interviewed registered nurses and care workers, talked to stakeholders (e.g. care home managers), and took insights from relevant research papers. The information was used to identify 22 practical strategies, and develop rough ideas around why the strategies work, for which staff, the conditions needed, and the costs involved. Registered nurses, care workers and wider sector stakeholders prioritised 10 strategies focused on staff recruitment and retention (and not on attracting new staff): staff recognition, flexible working, career development, salary package, early investment, induction, continuous feedback, caring community, effective interviewing and listening to all staff. These were taken forward for further testing and developing. In steps 2–4, we searched online library databases and social care websites for relevant papers (n = 153) and information from these papers was used to build on the rough ideas developed during step 1. Stakeholders helped with refining the final findings. The 10 prioritised strategies were combined into 5: effective job interviews, providing opportunities for career development, rewarding and recognising staff, promoting work–life balance, and caring conversations. The strategies interact and work together. The way staff are recruited is important for retaining staff. Setting accurate expectations during the job interview stage avoids creating false impressions, and this helps with developing staff commitment. Providing staff with career development opportunities, rewards and recognition, flexible working options, and caring conversations helps staff feel listened to, respected, and valued, and this creates job satisfaction. Giving staff opportunities for career development and supporting staff with caring conversations also helps with building staff confidence. Overall, providing staff with positive experiences means staff will also respond positively in return in terms of being committed and loyal to the employer. Supportive leaders and a sense of inclusion and fairness are needed for these strategies to work well. This research has described ways of improving staff recruitment and retention, understanding how to attract new staff remains an important research gap.

Cancer has become a major global public health threat, and individuals diagnosed with cancer and their family caregivers often seek to understand their illness experiences. Religious, spiritual, and sociocultural beliefs play a central role in shaping illness interpretations and care-seeking behaviors. However, in Ethiopia, limited attention has been paid to how these frameworks influence cancer experiences. This study explored religious narratives and interpretations of illness etiology among individuals diagnosed with cancer and their family caregivers and examined their influence on illness experiences and health-seeking practices. An interpretive phenomenological approach was employed using semi-structured, in-depth interviews with 41 participants, including individuals with cancer, family caregivers, and religious leaders. Data were transcribed, translated, and thematically analyzed to examine the processes of meaning-making. The findings showed that participants commonly conceptualized addiction as spiritually mediated rather than merely biologically determined. Illness was frequently interpreted as having a divine or supernatural origin, including punishment, a test of faith, God's will, or spiritual affliction. These interpretations were dynamic and shaped by religious teachings, sociocultural contexts and personal reflections. Religious frameworks influence emotional responses, coping strategies, and health-seeking behaviors, providing comfort and resilience while shaping treatment decisions. They functioned not only as explanatory frameworks for illness but also as practical resources that structured participants' responses to and negotiations with uncertainty, suffering, and responsibility. Religious meaning-making plays a central role in illness interpretations and overall experiences in cancer trajectories. Recognizing and engaging with these spiritual frameworks may enhance culturally responsive and patient-centered cancer care. Integrating spiritual sensitivity into clinical practice and collaborating with religious leaders may improve communication, trust, and psychosocial support for patients and their families.

Antimicrobial resistance (AMR) is a global health crisis requiring multisectoral responses that extend beyond biomedical interventions. Participatory approaches can ensure that policies and practices reflect community realities, yet evidence from low- and middle-income countries (LMICs) remains limited. To examine how the Responsive Dialogues (RD) framework was implemented in Malawi and Thailand, and to identify lessons on adapting participatory methods for AMR engagement, managing power dynamics, overcoming structural barriers, and supporting policy uptake. This cross-country evaluation applied the RD toolkit developed by the Wellcome Trust, which included three phases: groundwork, community conversations, and post-conversation sharing. Both countries followed this framework but adapted it to their social and political contexts. Data included field observations, facilitator reflections, participant feedback, and analysis of policy outcomes. Four themes emerged across both sites. First, adaptation was engagement process which shaped by trust, flexibility, and cultural sensitivity. Second, entrenched hierarchies influenced participation; strategies such as stakeholder briefings, ground rules, and rotating leadership roles helped mitigate imbalances, while in Malawi, village leaders' authority supported antibiotic regulation. Third, although Malawi's RD recommendations informed its revised National Action Plan on AMR, Thailand's community generated ideas were less visible in the national strategy, underscoring persistent gaps between local insights and high-level policy. Finally, reflective practice strengthened iterative learning and inclusivity. Overall, RD offers a promising model for facilitating participation in AMR mitigation plan. However, the differences in policy uptake in both countries highlight the limits of participatory approaches when not aligned with policy scale and resourcing. Main findings: Responsive Dialogues enabled inclusive dialogue across community and policy stakeholders in Malawi and Thailand, demonstrating how relational adaptation, power-aware facilitation, and reflective learning are essential for effective participatory AMR engagementAdded knowledge: This study offers new empirical evidence from LMIC settings on how participatory methods can surface community-generated solutions, navigate hierarchical constraints, and support pathways for policy influence in AMR policies.Global health impact for policy and action: Strengthening institutional support and resourcing for participatory engagement can help embed community insights into AMR policy design and implementation, promoting more equitable, sustainable, and context-responsive strategies worldwide.

This study evaluated how the State Resilience Initiative (SRI) uses a Collective Impact (CI) approach to strengthen community resilience to Adverse Childhood Experiences (ACEs) and distill transferable community collaborative strategies. A qualitative intrinsic case study design was employed, involving semi-structured interviews with five SRI staff and eight regional coalition leaders with data were analyzed using reflexive thematic analysis guided by CI core components and equity principles. Eleven themes emerged from the analysis; coalitions excelled in awareness-building, cross-sector engagement, and trauma-informed training, but lacked shared measurement, formal equity policies, consistent multi-county reach and resident co-leadership. Capacity constraints and rural resource gaps impeded scale-up, whereas diversified funding and strong backbone facilitation supported progress. SRI has established early CI conditions, yet achieving systemic impact will require installing a shared metrics system, codifying equity safeguards and deepening community participation; reinforcing backbone organizational infrastructure and data governance could accelerate sustainable change.

Student-run free clinics (SRFCs) enable medical students to care for communities disproportionately burdened by mental illness and health inequities. More literature is needed on the process of piloting psychiatric services in the SRFC setting. In 2021, a team of medical students piloted psychiatric services at an existing SRFC within a transitional housing facility for women affected by domestic violence. This article narratively describes and reflects on this process. The process of piloting psychiatric services included (1) assessing the need for psychiatric services; (2) establishing stakeholder and institutional support; (3) defining the mission, scope of practice, and liability coverage; (4) defining the roles and responsibilities of medical student volunteers; (5) training medical student volunteers to deliver psychiatric care; (6) establishing a clinic workflow; (7) establishing access to and protocols for prescribing for psychotropic medications; (8) partnering with community behavioral health providers; (9) planning for prospective program evaluation; (10) preparing the clinic for psychiatric care delivery; and (11) evaluating implementation and outcomes. The successful pilot of psychiatric services at this SRFC was facilitated by its use of existing infrastructure and the commitment of its student leaders and faculty mentors. That said, this initiative would have benefited from a formal needs assessment and literature review and faced challenges with prospective program evaluation. This article provides a roadmap for medical students and physicians at other SRFCs who aspire to fill gaps in access to psychiatric care for patients from underserved communities and enhance medical education in psychiatry at their institutions.

Since its founding in 1930, the American Academy of Pediatrics (AAP) has recognized that comprehensive child health requires not only primary care but also specialized procedural expertise. Beginning with the establishment of the Section on Surgery in 1948, pediatric surgical and procedural disciplines progressively organized within the academy to ensure that children's unique operative, anesthetic, radiologic, and dental needs were represented in policy, education, and advocacy. Over subsequent decades, sections devoted to anesthesiology and pain medicine, urology, orthopedics, otolaryngology-head and neck surgery, radiology, ophthalmology, plastic surgery, neurological surgery, and oral health were formed, each emerging from sustained advocacy by leaders who understood that children require standards distinct from adult-based models of care. Although subspecialty certification through American Board of Medical Specialties member boards strengthened professional identity in several disciplines, section status within the AAP provided a critical platform for multidisciplinary collaboration, guideline development, and national advocacy. The creation of the Surgical Advisory Panel in 1998 unified these sections and strengthened representation on the AAP Board of Directors. In 2023, organizational restructuring led to the formation of the Pediatric Surgical Specialties Alliance, which aligned 10 sections within a coordinated framework. Together, these specialists now represent more than 2000 members and shape national standards in trauma systems, perioperative safety, imaging, sedation, congenital anomaly management, injury prevention, and oral health, affirming that optimal pediatric care depends on integrated partnerships between general pediatricians and procedural experts.

To examine which elements of thriving and PERMA may be associated with thriving and intentions to leave both the job and profession among early career nurses. Retention of early career nurses is a global concern, with up to 60% leaving the profession within 2 years. While organisational factors have been widely examined, psychological constructs such as thriving and well-being are underexplored. A cross-sectional design. The study surveyed early career nurses (n = 90, response rate 34.1%) across Australia. Validated instruments assessed thriving, PERMA dimensions, organisational support and intention to leave. Multiple linear and logistic regressions identified key factors associated with thriving and intention to leave the job or profession. Reporting adhered to STROBE guidelines for observational studies. Thriving was a significant factor associated with engagement (β 0.039, p = 0.031), relationships with colleagues (β 0.167, p = 032), and occupational hardiness (β 0.502, p = 0.001), while accomplishment was a negative factor associated with thriving (β -0.163, p = 0.001). Intention to leave the job was linked to lower levels of thriving (β -1.303, p = 0.048), reduced perceived organisational support (β -0.180, p = 0.048), and higher negative emotions (β 0.747, p = 0.009). Intention to leave the profession was associated with accomplishment (β 0.222, p = 0.048), perceived organisational support (β 0.193, p = 0.001), and years since graduation (β 0.299, p = 0.016). Thriving was associated with engagement, peer support, and resilience, whereas attrition was associated with poor organisational support and negative affect. Accomplishment is negatively aligned with thriving and may reflect unmet expectations, increasing role strain, or other personal factors not directly related to organisational contexts. Results suggest psychologically supportive environments and PERMA-informed strategies may be important for enhancing early career nurse retention. Supporting nurses to thrive should be a key focus for managers seeking to sustain the nursing workforce. This study provides actionable insights for creating psychologically supportive environments that may be associated with improved early career nurse retention. By applying the PERMA framework, healthcare leaders may consider implementing targeted strategies, such as fostering engagement, informing the importance of collegial relationships, and promoting resilience, in order to positively inform well-being and achieve lower levels of attrition in clinical settings. No patient or public contribution.

In Saudi Arabia, mental health disorders are highly prevalent, but very few people seek treatment for these disorders. Rapid societal changes are also influencing the prevalence of mental illness and the types of illnesses experienced. The study aimed to explore current mental health trends in Saudi Arabia. An exploratory qualitative design was employed. The data were sourced from five publicly available YouTube videos that met the inclusion criteria. The videos were transcribed verbatim and translated to English. Content analysis was employed to analyze the data. Four themes emerged from the analysis: Islamic psychology, societal shift, knowing the self, and healthcare access and design. "Islamic psychology" focused on finding new perspectives to deal with mental illness inspired by the rich Islamic heritage. "Societal shift" portrayed the changes in Saudi society and their impact on mental well-being. "Knowing the self" depicted the key component in promoting mental wellness. "Healthcare access and design" shed light on present complexities and areas for improvement. Nurses' familiarity with and knowledge of the evolving mental health landscape can improve prevention and treatment in acute and community settings. This study's findings can inform nurse leaders seeking to equip nurses with the necessary training and resources to care for mentally ill patients. The findings can also be used as a source of information when reforming services to meet changing needs.