Publications by authors named "Janet E Anderson"

37 Publications

What is nursing work? A meta-narrative review and integrated framework.

Int J Nurs Stud 2021 Oct 28;122:103944. Epub 2021 Mar 28.

School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Duke of Kent Building, Guildford, GU2 7XH UK. Electronic address:

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.
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http://dx.doi.org/10.1016/j.ijnurstu.2021.103944DOI Listing
October 2021

Priorities and opportunities for palliative and end of life care in United Kingdom health policies: a national documentary analysis.

BMC Palliat Care 2021 Jul 14;20(1):108. Epub 2021 Jul 14.

Faculty of Nursing, Midwifery and Palliative Care, King's College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK.

Background: Access to high-quality palliative care is inadequate for most people living and dying with serious illness. Policies aimed at optimising delivery of palliative and end of life care are an important mechanism to improve quality of care for the dying. The extent to which palliative care is included in national health policies is unknown. We aimed to identify priorities and opportunities for palliative and end of life care in national health policies in the UK.

Methods: Documentary analysis consisting of 1) summative content analysis to describe the extent to which palliative and end of life care is referred to and/or prioritised in national health and social care policies, and 2) thematic analysis to explore health policy priorities that are opportunities to widen access to palliative and end of life care for people with serious illness. Relevant national policy documents were identified through web searches of key government and other organisations, and through expert consultation. Documents included were UK-wide or devolved (i.e. England, Scotland, Northern Ireland, Wales), health and social care government strategies published from 2010 onwards.

Results: Fifteen policy documents were included in the final analysis. Twelve referred to palliative or end of life care, but details about what should improve, or mechanisms to achieve this, were sparse. Policy priorities that are opportunities to widen palliative and end of life care access comprised three inter-related themes: (1) integrated care - conceptualised as reorganisation of services as a way to enable improvement; (2) personalised care - conceptualised as allowing people to shape and manage their own care; and (3) support for unpaid carers - conceptualised as enabling unpaid carers to live a more independent lifestyle and balance caring with their own needs.

Conclusions: Although information on palliative and end of life care in UK health and social care policies was sparse, improving palliative care may provide an evidence-based approach to achieve the stated policy priorities of integrated care, personalised care, and support for unpaid carers. Aligning existing evidence of the benefits of palliative care with the three priorities identified may be an effective mechanism to both strengthen policy and improve care for people who are dying.
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http://dx.doi.org/10.1186/s12904-021-00802-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8279030PMC
July 2021

Understanding adaptive teamwork in health care: Progress and future directions.

J Health Serv Res Policy 2021 07 16;26(3):208-214. Epub 2020 Dec 16.

Reader in Clinical Education, Faculty of Life Sciences and Medicine, King's College London, UK.

Health care teamwork is a vital part of clinical work and patient care but is poorly understood. Despite poor teamwork being cited as a major contributory factor to adverse events, we lack vital knowledge about how teamwork can be improved. Teams in health care are diverse in structure and purpose, and most patient care depends on the ability of different professionals to coordinate their actions. Research in this area has narrowly defined health care teams, focused mainly on a small range of settings and activities and addressed a limited range of research questions. We argue that a new approach to teamwork research is needed and make three recommendations. First, the temporal and dynamic features of teamwork should be studied to understand how teamwork unfolds sequentially. Second, contextual influences should be integrated into study designs, including the organization of work, tasks, patients, organisational structures, and health care system factors. Finally, exploratory, rather than confirmatory, research designs are needed to analyse the complex patterns of social interaction inherent in health care work, to build our theoretical understanding of health care teams and their work, and ultimately to develop effective interventions to support better teamwork for the benefit of patients.
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http://dx.doi.org/10.1177/1355819620978436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182291PMC
July 2021

Multilevel influences on resilient healthcare in six countries: an international comparative study protocol.

BMJ Open 2020 12 4;10(12):e039158. Epub 2020 Dec 4.

SHARE-Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway

Introduction: Resilient healthcare (RHC) is an emerging area of theory and applied research to understand how healthcare organisations cope with the dynamic, variable and demanding environments in which they operate, based on insights from complexity and systems theory. Understanding adaptive capacity has been a focus of RHC studies. Previous studies clearly show why adaptations are necessary and document the successful adaptive actions taken by clinicians. To our knowledge, however, no studies have thus far compared RHC across different teams and countries. There are gaps in the research knowledge related to the multilevel nature of resilience across healthcare systems and the team-based nature of adaptive capacity.This cross-country comparative study therefore aims to add knowledge of how resilience is enabled in diverse healthcare systems by examining adaptive capacity in hospital teams in six countries. The study will identify how team, organisational and national healthcare system factors support or hinder the ability of teams to adapt to variability and change. Findings from this study are anticipated to provide insights to inform the design of RHC systems by considering how macro-level and meso-level structures support adaptive capacity at the micro-level, and to develop guidance for organisations and policymakers.

Methods And Analysis: The study will employ a multiple comparative case study design of teams nested within hospitals, in turn embedded within six countries: Australia, Japan, the Netherlands, Norway, Switzerland and the UK. The design will be based on the Adaptive Teams Framework placing adaptive teams at the centre of the healthcare system with layers of environmental, organisational and system level factors shaping adaptive capacity. In each of the six countries, a focused mapping of the macro-level features of the healthcare system will be undertaken by using documentary sources and interviews with key informants operating at the macro-level.A sampling framework will be developed to select two hospitals in each country to ensure variability based on size, location and teaching status. Four teams will be selected in each hospital-one each of a structural, hybrid, responsive and coordinating team. A total of eight teams will be studied in each country, creating a total sample of 48 teams. Data collection methods will be observations, interviews and document analysis. Within-case analysis will be conducted according to a standardised template using a combination of deductive and inductive qualitative coding, and cross-case analysis will be conducted drawing on the Qualitative Comparative Analysis framework.

Ethics And Dissemination: The overall Resilience in Healthcare research programme of which this study is a part has been granted ethical approval by the Norwegian Centre for Research Data (Ref. No. 8643334 and Ref. No. 478838). Ethical approval will also be sought in each country involved in the study according to their respective regulatory procedures. Country-specific reports of study outcomes will be produced for dissemination online. A collection of case study summaries will be made freely available, translated into multiple languages. Brief policy communications will be produced to inform policymakers and regulators about the study results and to facilitate translation into practice. Academic dissemination will occur through publication in journals specialising in health services research. Findings will be presented at academic, policy and practitioner conferences, including the annual RHC Network meeting and other healthcare quality and safety conferences. Presentations at practitioner and academic conferences will include workshops to translate the findings into practice and influence quality and safety programmes internationally.
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http://dx.doi.org/10.1136/bmjopen-2020-039158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722365PMC
December 2020

Resilience in Healthcare (RiH): a longitudinal research programme protocol.

BMJ Open 2020 10 26;10(10):e038779. Epub 2020 Oct 26.

SHARE - Centre for Resilience in Healthcare, University of Stavanger, Stavanger, Norway.

Introduction: Over the past three decades, extensive research has been undertaken to understand the elements of what constitutes high quality in healthcare. Yet, much of this research has been conducted on individual elements and their specific challenges. Hence, goals other than understanding the complex of factors and elements that comprises quality in healthcare have been privileged. This lack of progress has led to the conclusion that existing approaches to research are not able to address the inherent complexity of healthcare systems as characterised by a significant degree of performance variability within and across system levels, and what makes them resilient. A shift is, therefore, necessary in such approaches. Resilience in Healthcare (RiH) adopts an approach comprising a comprehensive research programme that models the capacity of healthcare systems and stakeholders to adapt to changes, variations and/or disruptions: that is, resilience. As such, RiH offers a fresh approach capable of capturing and illuminating the complexity of healthcare and how high-quality care can be understood and advanced.

Methods And Analysis: Methodologically, to illuminate what constitutes quality in healthcare, it is necessary to go beyond single-site, case-based studies. Instead, there is a need to engage in multi-site, cross-national studies and engage in long-term multidisciplinary collaboration between national and international researchers interacting with multiple healthcare stakeholders. By adopting such processes, multiple partners and a multidisciplinary orientation, the 5-year RiH research programme aims to confront these challenges and accelerate current understandings about and approaches to researching healthcare quality.The RiH research programme adopts a longitudinal collaborative interactive design to capture and illuminate resilience as part of healthcare quality in different healthcare settings in Norway and in five other countries. It combines a meta-analysis of detailed empirical research in Norway with cross-country comparison from Australia, Japan, Netherlands, Switzerland and the UK. Through establishing an RiH framework, the programme will identify processes with outcomes that aim to capture how high-quality healthcare provisions are achieved. A collaborative learning framework centred on engagement aims to systematically translate research findings into practice through co-construction processes with partners and stakeholders.

Ethics And Dissemination: The RiH research programme is approved by the Norwegian Centre for Research Data (No. 864334). The empirical projects selected for inclusion in this longitudinal research programme have been approved by the Norwegian Centre for Research Data or the Regional Committees for Medical and Health Research Ethics. The RiH research programme has an embedded publication and dissemination strategy focusing on the progressive sharing of scientific knowledge, information and results, and on engaging with the public, including relevant patient and stakeholder representatives. The findings will be disseminated through scientific articles, PhD dissertations, presentations at national and international conferences, and through social media, newsletters and the popular media.
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http://dx.doi.org/10.1136/bmjopen-2020-038779DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592282PMC
October 2020

Experience of mobile nursing workforce from Portugal to the NHS in UK: influence of institutions and actors at the system, organization and individual levels.

Eur J Public Health 2020 09;30(Suppl_4):iv18-iv21

Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.

In UK, since 2010 shortages of nurses and policy changes led many health service providers to become more active in recruiting nurses from the European Union Member States. This article analyses the experience of Portuguese nurses working in the English NHS considering the individual and organizational factors that affect the quality and duration of nurses' migration experience, future career plans and expectations. Twenty-seven semi-structured interviews were conducted at the individual, organizational and policy levels in UK with Portuguese nurses and NHS healthcare staff in 2015-16. The results demonstrate that organizational settings, conditions, actors' attitudes and level of support influence nurses' level of commitment to their employer and their overall mobility experience. Professional achievements, professional and personal sources of support made these nurses evaluate their overall mobility experience as positive, even overcoming personal challenges such as homesickness. The results reveal that migration is accomplished through constant interaction between institutions and individual actors at different levels. Understanding the influencing factors as well as the complex and dynamic nature of a professional's decision-making can design more effective retention responses.
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http://dx.doi.org/10.1093/eurpub/ckaa129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526771PMC
September 2020

From hospital to post-acute care organizations: the relationship between patient experience and health recovery.

Int J Qual Health Care 2020 Nov;32(9):585-590

Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, UK.

Objective: To determine to what extent patient health status and recovery in post-acute care organizations (PACO) is related to patient experience of the discharge process from hospital and to patient experience while staying in these facilities.

Design: Longitudinal study of patients discharged from hospitals to PACO.

Setting: 12 hospitals and 14 PACO Portuguese organizations.

Participants: 181 patients participated in the both stages of data gathering.

Main Outcome Measures: Patients' physical and mental health status was measured through the 36-item short form health survey scale. The experience of transition from hospital to PACO was measured with the Care Transition Measure. The Picker Adult In-Patient Questionnaire was used to measure patients' experience in these organizations.

Results: Patients reporting better physical condition in PACO had a better experience on discharge [b = 0.21, 95% confidence interval, CI (0.10, 0.31)] and perceive fewer problems inside facilities [b = - 0.19, 95% CI (-0.31, 0.08)]. The experience in PACO is significantly related to patients' mental health status [b = - 0.47, 95% CI (-0.59, - 0.36)]. Patients showing higher levels of physical recovery had a better experience on discharge [b = - 0.18, 95% CI (0.08, 0.28)], while those registering better mental recovery experienced fewer problems during their stay [b = - 0.41, 95% CI (-0.52, - 0.30)].

Conclusions: PACO play a key role in maintaining and promoting patients' health, and this goal is influenced by their experience both in the transition from hospitals to PACO and while staying in these facilities.
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http://dx.doi.org/10.1093/intqhc/mzaa095DOI Listing
November 2020

A Board Level Intervention to Develop OrganisationWide Quality Improvement Strategies: Cost-Consequences Analysis in 15 Healthcare Organisations.

Int J Health Policy Manag 2020 Jun 28. Epub 2020 Jun 28.

Department of Applied Health Research, University College London, London, UK.

Background: Hospital boards have statutory responsibility for upholding the quality of care in their organisations. International research on quality in hospitals resulted in a research-based guide to help senior hospital leaders develop and implement quality improvement (QI) strategies, the QUASER Guide. Previous research has established a link between board practices and quality of care; however, to our knowledge, no board-level intervention has been evaluated in relation to its costs and consequences. The aim of this research was to evaluate these impacts when the QUASER Guide was implemented in an organisational development intervention (iQUASER).

Methods: We conducted a 'before and after' cost-consequences analysis (CCA), as part of a mixed methods evaluation. The analysis combined qualitative data collected from 66 interviews, 60 hours of board meeting observations and documents from 15 healthcare organisations, of which 6 took part on iQUASER, and included direct and opportunity costs associated with the intervention. The consequences focused on the development of an organisation-wide QI strategy, progress on addressing 8 dimensions of QI (the QUASER challenges), how organisations compared to benchmarks, engagement with the intervention and progress in the implementation of a QI project.

Results: We found that participating organisations made greater progress in developing an organisation-wide QI strategy and became more similar to the high-performing benchmark than the comparators. However, progress in addressing all 8 QUASER challenges was only observed in one organisation. Stronger engagement with the intervention was associated with the implementation of a QI project. On average, iQUASER costed £23 496 per participating organisation, of which approximately 44% were staff time costs. Organisations that engaged less with the intervention had lower than average costs (£21 267 per organisation), but also failed to implement an organisation-wide QI project.

Conclusion: We found a positive association between level of engagement with the intervention, development of an organisation-wide QI strategy and the implementation of an organisation-wide QI project. Support from the board, particularly the chair and chief executive, for participation in the intervention, is important for organisations to accrue most benefit. A board-level intervention for QI, such as iQUASER, is relatively inexpensive as a proportion of an organisation's budget.
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http://dx.doi.org/10.34172/ijhpm.2020.91DOI Listing
June 2020

Defining the boundaries and operational concepts of resilience in the resilience in healthcare research program.

BMC Health Serv Res 2020 Apr 19;20(1):330. Epub 2020 Apr 19.

SHARE - Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, N-4036, Stavanger, Norway.

Background: Understanding the resilience of healthcare is critically important. A resilient healthcare system might be expected to consistently deliver high quality care, withstand disruptive events and continually adapt, learn and improve. However, there are many different theories, models and definitions of resilience and most are contested and debated in the literature. Clear and unambiguous conceptual definitions are important for both theoretical and practical considerations of any phenomenon, and resilience is no exception. A large international research programme on Resilience in Healthcare (RiH) is seeking to address these issues in a 5-year study across Norway, England, the Netherlands, Australia, Japan, and Switzerland (2018-2023). The aims of this debate paper are: 1) to identify and select core operational concepts of resilience from the literature in order to consider their contributions, implications, and boundaries for researching resilience in healthcare; and 2) to propose a working definition of healthcare resilience that underpins the international RiH research programme.

Main Text: To fulfil these aims, first an overview of three core perspectives or metaphors that underpin theories of resilience are introduced from ecology, engineering and psychology. Second, we present a brief overview of key definitions and approaches to resilience applicable in healthcare. We position our research program with collaborative learning and user involvement as vital prerequisite pillars in our conceptualisation and operationalisation of resilience for maintaining quality of healthcare services. Third, our analysis addresses four core questions that studies of resilience in healthcare need to consider when defining and operationalising resilience. These are: resilience 'for what', 'to what', 'of what', and 'through what'? Finally, we present our operational definition of resilience.

Conclusion: The RiH research program is exploring resilience as a multi-level phenomenon and considers adaptive capacity to change as a foundation for high quality care. We, therefore, define healthcare resilience as: the capacity to adapt to challenges and changes at different system levels, to maintain high quality care. This working definition of resilience is intended to be comprehensible and applicable regardless of the level of analysis or type of system component under investigation.
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http://dx.doi.org/10.1186/s12913-020-05224-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7168985PMC
April 2020

Erratum to "Knowledge management infrastructure to support quality improvement: A qualitative study of maternity services in four European hospitals" [Health Policy 124 (2020) 205-215].

Health Policy 2020 May 6;124(5):575. Epub 2020 Apr 6.

Jönköping Academy for Improvement of Health and Welfare, Jönköping, Sweden; Futurum, Region Jönköping County, Jönköping, Sweden. Electronic address:

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http://dx.doi.org/10.1016/j.healthpol.2020.03.007DOI Listing
May 2020

Using Safety-II and resilient healthcare principles to learn from Never Events.

Int J Qual Health Care 2020 May;32(3):196-203

Human Factors and Complex Systems, Loughborough Design School, Loughborough University, Leicestershire LE11 3TU, UK.

Objectives: Conduct a secondary analysis of root cause analysis (RCA) reports of Never Events to determine whether and how Safety-II/resilient healthcare principles could contribute to improving the quality of investigation reports and therefore preventing future Never Events.

Design: Qualitative and quantitative retrospective analysis of RCA reports.

Setting: A large acute healthcare Trust in London.

Participants: None.

Interventions: None.

Main Outcome Measure: Quality of RCA reports, robustness of actions proposed.

Results: RCA reports had low-to-moderate effectiveness ratings and low resilience ratings. Reports identified many system vulnerabilities that were not addressed in the actions proposed. Using a Safety-II/resilient healthcare lens to examine work-as-done and misalignments between demand and capacity would strengthen analysis of Never Events.

Conclusion: Safety-II/Resilient Healthcare concepts can increase the quality of RCA reports and focus attention on prospectively strengthening systems. Recommendations for incorporating Safety-II concepts into RCA processes are provided.
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http://dx.doi.org/10.1093/intqhc/mzaa009DOI Listing
May 2020

Knowledge management infrastructure to support quality improvement: A qualitative study of maternity services in four European hospitals.

Health Policy 2020 02 22;124(2):205-215. Epub 2019 Nov 22.

Jönköping Academy for Improvement of Health and Welfare, Jönköping, Sweden; Futurum, Region Jönköping County, Jönköping, Sweden. Electronic address:

The influence of multilevel healthcare system interactions on clinical quality improvement (QI) is still largely unexplored. Through the lens of knowledge management (KM) theory, this study explores how hospital managers can enhance the conditions for clinical QI given the specific multilevel and professional interactions in various healthcare systems. The research used an in-depth multilevel analysis in maternity departments in four purposively sampled European hospitals (Portugal, England, Norway and Sweden). The study combines analysis of macro-level policy documents and regulations with semi-structured interviews (96) and non-participant observations (193 hours) of hospital and clinical managers and clinical staff in maternity departments. There are four main conclusions: First, the unique multilevel configuration of national healthcare policy, hospital management and clinical professionals influence the development of clinical QI efforts. Second, these different configurations provide various and often insufficient support and guidance which affect professionals' action strategies in QI efforts. Third, hospital managers' opportunities and capabilities for developing a consistent KM infrastructure with reinforcing enabling conditions which merge national policies and guidelines with clinical reality is crucial for clinical QI. Fourth, understanding these interrelationships provides an opportunity for improvement of the KM infrastructure for hospital managers through tailored interventions.
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http://dx.doi.org/10.1016/j.healthpol.2019.11.005DOI Listing
February 2020

Empowering Better End-of-Life Dementia Care (EMBED-Care): A mixed methods protocol to achieve integrated person-centred care across settings.

Int J Geriatr Psychiatry 2020 08 15;35(8):820-832. Epub 2020 Jan 15.

Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.

Objectives: Globally, the number of people with dementia who have palliative care needs will increase fourfold over the next 40 years. The Empowering Better End-of-Life Dementia Care (EMBED-Care) Programme aims to deliver a step change in care through a large sequential study, spanning multiple work streams.

Methods: We will use mixed methods across settings where people with dementia live and die: their own homes, care homes, and hospitals. Beginning with policy syntheses and reviews of interventions, we will develop a conceptual framework and underpinning theory of change. We will use linked data sets to explore current service use, care transitions, and inequalities and predict future need for end-of-life dementia care. Longitudinal cohort studies of people with dementia (including young onset and prion dementias) and their carers will describe care transitions, quality of life, symptoms, formal and informal care provision, and costs. Data will be synthesised, underpinned by the Knowledge-to-Action Implementation Framework, to design a novel complex intervention to support assessment, decision making, and communication between patients, carers, and inter-professional teams. This will be feasibility and pilot tested in UK settings. Patient and public involvement and engagement, innovative work with artists, policymakers, and third sector organisations are embedded to drive impact. We will build research capacity and develop an international network for excellence in dementia palliative care.

Conclusions: EMBED-Care will help us understand current and future need, develop novel cost-effective care innovations, build research capacity, and promote international collaborations in research and practice to ensure people live and die well with dementia.
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http://dx.doi.org/10.1002/gps.5251DOI Listing
August 2020

Next-of-Kin Involvement in Regulatory Investigations of Adverse Events That Caused Patient Death: A Process Evaluation (Part II: The Inspectors' Perspective).

J Patient Saf 2019 Oct 22. Epub 2019 Oct 22.

From the SHARE-Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger.

Objective: The aim of the study was to explore regulatory inspectors' experiences with a new method for next-of-kin involvement in investigation of adverse events causing patient death. A resilient healthcare perspective is used as the theoretical foundation.

Methods: The study design was a qualitative process evaluation of the new involvement method in 2 Norwegian counties. Next of kin, who had lost a close family member in an adverse event, were invited to a 2-hour face-to-face meeting with the inspectors. Data collection involved 3 focus group interviews with regulatory inspectors and observation (20 hours) of the meetings (2017-2018). Data were analyzed by a thematic content analysis.

Results: Next-of-kin involvement informed the investigations by additional and new information about the adverse events and by different versions of the investigators' earlier obtained information, such as time sequences, what happened and how, and who were involved. Inspectors considered next of kin as a key source of information that contributed to improve the quality of the investigation. The downside was that the involvement method increased work load and could challenge the principle of equal treatment in regulatory practice.

Conclusions: Involvement of next of kin in regulatory investigation of adverse events causing patient death contributes to a better understanding of work as done in clinical practice and contributes to strengthen the learning potential in resilience.
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http://dx.doi.org/10.1097/PTS.0000000000000634DOI Listing
October 2019

An evidence based framework for the Temporal Observational Analysis of Teamwork in healthcare settings.

Appl Ergon 2020 Jan 15;82:102915. Epub 2019 Aug 15.

The Florence Nightingale Faculty of Nursing, Midwifery and PalliativeCare, King's College London, London, UK.

Objective: Effective teamwork is critical to patient safety across multiple healthcare settings. However, current observational tools assessing teamwork performance tend to be developed for specific settings or tasks and do not capture temporal features of interaction. This study aimed to develop a valid and reliable observational teamwork behaviour framework, which is based on healthcare practice, applicable across a variety of healthcare contexts and can be used to capture temporal team dynamics.

Methods: Team interactions were audio-visually recorded during routine simulation training at two large clinical education centres specialising in physical and mental healthcare. The framework was based on theoretical models of teamwork and was developed in three steps: 1-micro analysis of verbal and nonverbal behaviour during recorded scenarios (n = 20); 2-iterative test and refine cycles; 3-final behavioural framework applied to a cohort of acute emergency scenarios (n = 9) by two raters to assess inter-rater agreement.

Results: The framework contains twenty-three specific verbal and nonverbal behaviours that can be identified during observations. Behaviours are grouped conceptually based on their function resulting in thirteen behavioural functions, which cluster into five overarching teamwork domains. Inter-rater agreement was excellent (Cohen's Kappa = .84, SE = 0.03).

Conclusion: We present a valid and reliable behavioural framework, grounded in teamwork theory and empirical observations of clinical team behaviour. This framework enables analysis of the nuances and temporal features of clinical practice in depth and across a wide range of clinical contexts and settings. Use of this framework will advance our understanding of teamworking in healthcare.
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http://dx.doi.org/10.1016/j.apergo.2019.102915DOI Listing
January 2020

Beyond the clinical team: evaluating the human factors-oriented training of non-clinical professionals working in healthcare contexts.

Adv Simul (Lond) 2019 13;4:11. Epub 2019 Jun 13.

2Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.

Background: As clinical simulation has evolved, it is increasingly used to educate staff who work in healthcare contexts (e.g. hospital administrators) or frequently encounter clinical populations as part of their work (e.g. police officers) but are not healthcare professionals. This is in recognition of the important role such individuals play in the patients' experience of healthcare, frequently being a patients' first point of contact with health services. The aim of the training is to improve the ability of the team to communicate and co-ordinate their actions, but there is no validated instrument to evaluate the human factors learning of non-clinical staff. Our aim was to develop, pilot and evaluate an adapted version of the Human Factors Skills for Healthcare Instrument, for non-clinical professionals.

Method: The 18-item instrument was developed reflecting the human factors skills of situation awareness, decision making, communication, teamwork, leadership, care and compassion and stress and fatigue management. The instrument was piloted pre- and post-training with non-healthcare professionals ( = 188) attending mental health simulation training within an 11-month period (June 2017-April 2018). Trainees were hospital/primary care administrators ( = 53, 28%), police officers ( = 112, 59%), probation officers ( = 13, 7%) and social workers ( = 10, 5%). Most participants were female ( = 110, 59%) and from White ethnic backgrounds ( = 144, 77%).

Results: Six items were removed, five were not sufficiently sensitive to change ( < .3) and one showed poor reliability. The remaining 12 items revealed a Cronbach's alpha of .93. An exploratory factor analysis revealed a one-factor solution, which explained 58.3% of the variance. The final 12-item instrument was sensitive to change post-training ( < .0001) with large effect sizes ( .7). Cluster analysis revealed that participants with lower pre-training scores showed the greatest improvement.

Discussion: The Human Factors Skills for Healthcare Instrument-Auxiliary version (HuFSHI-A) provides a reliable and valid instrument for the evaluation of human factors skills learning following training of non-clinical populations working in healthcare contexts. Although this instrument has been developed and evaluated with training courses specifically focusing on mental health topics, HuFSHI-A is applicable for any training where teamwork and co-ordination between clinical and non-clinical professionals is considered.
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http://dx.doi.org/10.1186/s41077-019-0101-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6567904PMC
June 2019

Translating research on quality improvement in five European countries into a reflective guide for hospital leaders: the 'QUASER Hospital Guide'.

Int J Qual Health Care 2019 Oct;31(8):G87-G96

Department of Applied Health Research, University College London, UK.

Objective: The aim was to translate the findings of the QUASER study into a reflective, dialogic guide to help senior hospital leaders develop an organization wide QI strategy.

Design: The QUASER study involved in depth ethnographic research into QI work and practices in two hospitals in each of five European countries. Three translational stakeholder workshops were held to review research findings and advise on the design of the Guide. An extended iterative process involving researchers from each participant country was then used to populate the Guide.

Setting: The research was carried out in two hospitals in each of five European countries.

Participants: In total, 389 interviews with healthcare practitioners and 803 hours of observations.

Intervention: None.

Main Outcome Measure: None.

Results: The QUASER Hospital Guide was designed for leadership teams to diagnose their organization's strengths and weaknesses in the eight QI challenges. The Guide supports organizational dialogue about QI challenges, enables leaders to share perspectives, and helps teams to develop solutions to their situated problems. The Guide includes extensive examples of QI strategies drawn from the data and is published online and on paper.

Conclusions: The QUASER Hospital Guide is empirically based, draws on a dialogical approach to Organizational Development and complexity science and can facilitate hospital leadership teams to identify the best solutions for their organization.
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http://dx.doi.org/10.1093/intqhc/mzz055DOI Listing
October 2019

Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service.

BMJ Qual Saf 2019 03 31;28(3):198-204. Epub 2018 Oct 31.

Department of Applied Health Research, University College London, London, UK.

Background: Healthcare systems worldwide are concerned with strengthening board-level governance of quality. We applied Lozeau, Langley and Denis' typology (transformation, customisation, loose coupling and corruption) to describe and explain the organisational response to an improvement intervention in six hospital boards in England.

Methods: We conducted fieldwork over a 30-month period as part of an evaluation in six healthcare provider organisations in England. Our data comprised board member interviews (n=54), board meeting observations (24 hours) and relevant documents.

Results: Two organisations transformed their processes in a way that was consistent with the objectives of the intervention, and one customised the intervention with positive effects. In two further organisations, the intervention was only loosely coupled with organisational processes, and participation in the intervention stopped when it competed with other initiatives. In the final case, the intervention was corrupted to reinforce existing organisational processes (a focus on external regulatory requirements). The organisational response was contingent on the availability of 'slack'-expressed by participants as the 'space to think' and 'someone to do the doing'-and the presence of a functioning board.

Conclusions: Underperforming organisations, under pressure to improve, have little time or resources to devote to organisation-wide quality improvement initiatives. Our research highlights the need for policy-makers and regulators to extend their focus beyond the choice of intervention, to consider how the chosen intervention will be implemented in public sector hospitals, how this will vary between contexts and with what effects. We provide useful information on the necessary conditions for a board-level quality improvement intervention to have positive effects.
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http://dx.doi.org/10.1136/bmjqs-2018-008291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6560458PMC
March 2019

Development of the Human Factors Skills for Healthcare Instrument: a valid and reliable tool for assessing interprofessional learning across healthcare practice settings.

BMJ Simul Technol Enhanc Learn 2017 Oct 21;3(4):135-141. Epub 2017 Jun 21.

The Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK.

Background: A central feature of clinical simulation training is human factors skills, providing staff with the social and cognitive skills to cope with demanding clinical situations. Although these skills are critical to safe patient care, assessing their learning is challenging. This study aimed to develop, pilot and evaluate a valid and reliable structured instrument to assess human factors skills, which can be used pre- and post-simulation training, and is relevant across a range of healthcare professions.

Method: Through consultation with a multi-professional expert group, we developed and piloted a 39-item survey with 272 healthcare professionals attending training courses across two large simulation centres in London, one specialising in acute care and one in mental health, both serving healthcare professionals working across acute and community settings. Following psychometric evaluation, the final 12-item instrument was evaluated with a second sample of 711 trainees.

Results: Exploratory factor analysis revealed a 12-item, one-factor solution with good internal consistency (α=0.92). The instrument had discriminant validity, with newly qualified trainees scoring significantly lower than experienced trainees ((98)=4.88, p<0.001) and was sensitive to change following training in acute and mental health settings, across professional groups (p<0.001). Confirmatory factor analysis revealed an adequate model fit (RMSEA=0.066).

Conclusion: The Human Factors Skills for Healthcare Instrument provides a reliable and valid method of assessing trainees' human factors skills self-efficacy across acute and mental health settings. This instrument has the potential to improve the assessment and evaluation of human factors skills learning in both uniprofessional and interprofessional clinical simulation training.
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http://dx.doi.org/10.1136/bmjstel-2016-000159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5765849PMC
October 2017

How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England.

BMJ Qual Saf 2017 Dec 8;26(12):978-986. Epub 2017 Jul 8.

Department of Applied Health Research, University College London, London, UK.

Background: Health systems worldwide are increasingly holding boards of healthcare organisations accountable for the quality of care that they provide. Previous empirical research has found associations between certain board practices and higher quality patient care; however, little is known about how boards govern for quality improvement (QI).

Methods: We conducted fieldwork over a 30-month period in 15 healthcare provider organisations in England as part of a wider evaluation of a board-level organisational development intervention. Our data comprised board member interviews (n=65), board meeting observations (60 hours) and documents (30 sets of board meeting papers, 15 board minutes and 15 Quality Accounts). We analysed the data using a framework developed from existing evidence of links between board practices and quality of care. We mapped the variation in how boards enacted governance of QI and constructed a measure of QI governance maturity. We then compared organisations to identify the characteristics of those with mature QI governance.

Results: We found that boards with higher levels of maturity in relation to governing for QI had the following characteristics: explicitly prioritising QI; balancing short-term (external) priorities with long-term (internal) investment in QI; using data for QI, not just quality assurance; engaging staff and patients in QI; and encouraging a culture of continuous improvement. These characteristics appeared to be particularly enabled and facilitated by board-level clinical leaders.

Conclusions: This study contributes to a deeper understanding of how boards govern for QI. The identified characteristics of organisations with mature QI governance seemed to be enabled by active clinical leadership. Future research should explore the biographies, identities and work practices of board-level clinical leaders and their role in organisation-wide QI.
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http://dx.doi.org/10.1136/bmjqs-2016-006433DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750431PMC
December 2017

Emergency Department Escalation in Theory and Practice: A Mixed-Methods Study Using a Model of Organizational Resilience.

Ann Emerg Med 2017 Nov 26;70(5):659-671. Epub 2017 Jun 26.

Kings College London, UK.

Study Objective: Escalation policies are used by emergency departments (EDs) when responding to an increase in demand (eg, a sudden inflow of patients) or a reduction in capacity (eg, a lack of beds to admit patients). The policies aim to maintain the ability to deliver patient care, without compromising safety, by modifying "normal" processes. The study objective is to examine escalation policies in theory and practice.

Methods: This was a mixed-method study involving a conceptual analysis of National Health Service escalation policies (n=12) and associated escalation actions (n=92), as well as a detailed ethnographic study of escalation in situ during a 16-month period in a large UK ED (n=30 observations).

Results: The conceptual analysis of National Health Service escalation policies found that their use requires the ability to dynamically reconfigure resources (staff and equipment), change work flow, and relocate patients. In practice, it was discovered that when the ED is under pressure, these prerequisites cannot always be attained. Instead, escalation processes were adapted to manage pressures informally. This adaptive need ("work as done") was found to be incompletely specified in policies ("work as imagined").

Conclusion: Formal escalation actions and their implementation in practice differed and varied in their effectiveness. Monitoring how escalation works in practice is essential in understanding whether and how escalation policies help to manage workload.
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http://dx.doi.org/10.1016/j.annemergmed.2017.04.032DOI Listing
November 2017

Work environment issues and intention-to-leave in Portuguese nurses: A cross-sectional study.

Health Policy 2015 Dec 28;119(12):1584-92. Epub 2015 Sep 28.

Florence Nightingale Faculty of Nursing & Midwifery, King's College London, London, UK.

This study extends the Registered Nurses Forecasting (RN4CAST) study evidence base with newly collected data from Portuguese nurses working in acute care hospitals, in which the measurement of the quality of work environment, workload and its association with intention-to-leave emerge as of key importance. Data included surveys of 2235 nurses in 144 nursing units in 31 hospitals via stratified random sampling. Multilevel multivariate regression analysis shows that intention-to-leave is higher among nurses with a specialty degree, nurses aged 35-39, and in nursing units where nurses are less satisfied with opportunities for career advancement, staffing levels and participation in hospital affairs. Analysis with moderation effects showed the observed effect of age and of having a specialty degree on intention-to-leave during the regression analysis is reduced in nursing units where nurses are more satisfied with opportunities for career advancement. The most important finding from the study suggests that promoting retention strategies that increase satisfaction with opportunities for career advancement among Portuguese nurses has the potential to override individual characteristics associated with increased turnover intentions.
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http://dx.doi.org/10.1016/j.healthpol.2015.09.006DOI Listing
December 2015

One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs.

BMJ Qual Saf 2016 Apr 25;25(4):241-56. Epub 2015 Sep 25.

Business School, Imperial College, London, UK.

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.
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http://dx.doi.org/10.1136/bmjqs-2015-004265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4819646PMC
April 2016

Work Domain Analysis for understanding medication safety in care homes in England: an exploratory study.

Ergonomics 2016 28;59(1):15-26. Epub 2015 Jul 28.

c Royal College of Art , London , UK.

Unlabelled: Medication safety and errors are a major concern in care homes. In addition to the identification of incidents, there is a need for a comprehensive system description to avoid the danger of introducing interventions that have unintended consequences and are therefore unsustainable. The aim of this study was to explore the impact and uniqueness of Work Domain Analysis (WDA) to facilitate an in-depth understanding of medication safety problems within the care home system and identify the potential benefits of WDA to design safety interventions to improve medication safety. A comprehensive, systematic and contextual overview of the care home medication system was developed for the first time. The novel use of the abstraction hierarchy (AH) to analyse medication errors revealed the value of the AH to guide a comprehensive analysis of errors and generate system improvement recommendations that took into account the contextual information of the wider system.

Practitioner Summary: It is widely acknowledged that a systems approach is necessary to improve medication safety. This study used a cognitive engineering method, Work Domain Analysis, to map the care home medication system and analyse medication errors. A macro-level view of the system was developed and this has provided a knowledge base for future interventions.
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http://dx.doi.org/10.1080/00140139.2015.1057542DOI Listing
January 2017

Complex interventions and their implications for systematic reviews: Commentary on Petticrew et al. (2015).

Authors:
Janet E Anderson

Int J Nurs Stud 2015 Jul 9;52(7):1209-10. Epub 2015 Jan 9.

King's College London, Florence Nightingale Faculty of Nursing and Midwifery, United Kingdom.

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http://dx.doi.org/10.1016/j.ijnurstu.2015.01.003DOI Listing
July 2015

Patient reactions to community pharmacies' roles: evidence from the Portuguese market.

Health Expect 2015 Dec 17;18(6):2853-64. Epub 2014 Sep 17.

Department of Human Resources Management and Organizational Behavior, ISCTE-IUL, Lisbon, Portugal.

Background: There is little knowledge about how patients perceive and react to the extended role of community pharmacies.

Aim: To develop a model describing the expanded role of Portuguese community pharmacies as comprising three roles - medicines supplier, advice provider and community health promoter - and two important patient reactions: satisfaction and loyalty.

Design: In 2010, 1200 face-to-face interviews were conducted with patients of community pharmacies in Portugal. A model comprising the three pharmacy roles and the two patient reactions was developed and tested using structural equation modelling.

Results: The results showed that the model was appropriate and that the roles of medicines supplier, advice provider and community health promoter were positively related to patients' satisfaction and loyalty.

Conclusions: These results show that patients are aware of the different roles played by community pharmacies in Portugal. The data support the idea that the movement of Portuguese pharmacists' extended role, framed within a global context where society sends expectations regarding the role of organizations in the community in which they operate, is producing positive results for both patients and pharmacists.
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http://dx.doi.org/10.1111/hex.12269DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5810721PMC
December 2015

Assessing the validity of prospective hazard analysis methods: a comparison of two techniques.

BMC Health Serv Res 2014 Jan 27;14:41. Epub 2014 Jan 27.

Centre for Health Informatics and Multiprofessional Education, Institute of Epidemiology & Health Care, University College London, London, UK.

Background: Prospective Hazard Analysis techniques such as Healthcare Failure Modes and Effects Analysis (HFMEA) and Structured What If Technique (SWIFT) have the potential to increase safety by identifying risks before an adverse event occurs. Published accounts of their application in healthcare have identified benefits, but the reliability of some methods has been found to be low. The aim of this study was to examine the validity of SWIFT and HFMEA by comparing their outputs in the process of risk assessment, and comparing the results with risks identified by retrospective methods.

Methods: The setting was a community-based anticoagulation clinic, in which risk assessment activities had been previously performed and were available. A SWIFT and an HFMEA workshop were conducted consecutively on the same day by experienced experts. Participants were a mixture of pharmacists, administrative staff and software developers. Both methods produced lists of risks scored according to the method's procedure. Participants' views about the value of the workshops were elicited with a questionnaire.

Results: SWIFT identified 61 risks and HFMEA identified 72 risks. For both methods less than half the hazards were identified by the other method. There was also little overlap between the results of the workshops and risks identified by prior root cause analysis, staff interviews or clinical governance board discussions. Participants' feedback indicated that the workshops were viewed as useful.

Conclusions: Although there was limited overlap, both methods raised important hazards. Scoping the problem area had a considerable influence on the outputs. The opportunity for teams to discuss their work from a risk perspective is valuable, but these methods cannot be relied upon in isolation to provide a comprehensive description. Multiple methods for identifying hazards should be used and data from different sources should be integrated to give a comprehensive view of risk in a system.
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http://dx.doi.org/10.1186/1472-6963-14-41DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3906758PMC
January 2014

Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting.

Int J Qual Health Care 2013 Apr 18;25(2):141-50. Epub 2013 Jan 18.

Florence Nightingale School of Nursing and Midwifery, King's College London, London, UK.

Objective: Recent critiques of incident reporting suggest that its role in managing safety has been over emphasized. The objective of this study was to examine the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences.

Design: Qualitative research design using documentary analysis and semi-structured interviews.

Setting: Two large teaching hospitals in London; one providing acute and the other mental healthcare.

Participants: Sixty-two healthcare practitioners with experience of reporting and analysing incidents.

Results: Incident reporting was perceived as having a positive effect on safety, not only by leading to changes in care processes but also by changing staff attitudes and knowledge. Staff discussed examples of both instrumental and conceptual uses of the knowledge generated by incident reports. There are difficulties in using incident reports to improve safety in healthcare at all stages of the incident reporting process. Differences in the risks encountered and the organizational systems developed in the two hospitals to review reported incidents could be linked to the differences we found in attitudes to incident reporting between the two hospitals.

Conclusion: Incident reporting can be a powerful tool for developing and maintaining an awareness of risks in healthcare practice. Using incident reports to improve care is challenging and the study highlighted the complexities involved and the difficulties faced by staff in learning from incident data.
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http://dx.doi.org/10.1093/intqhc/mzs081DOI Listing
April 2013

Prospects for comparing European hospitals in terms of quality and safety: lessons from a comparative study in five countries.

Int J Qual Health Care 2013 Feb 4;25(1):1-7. Epub 2013 Jan 4.

Centre for Patient Safety and Service Quality, Faculty of Medicine, Imperial College London, Room 508 Medical School Building, St Mary's Campus, Norfolk Place, W2 1PG London, UK.

Purpose: Being able to compare hospitals in terms of quality and safety between countries is important for a number of reasons. For example, the 2011 European Union directive on patients' rights to cross-border health care places a requirement on all member states to provide patients with comparable information on health-care quality, so that they can make an informed choice. Here, we report on the feasibility of using common process and outcome indicators to compare hospitals for quality and safety in five countries (England, Portugal, The Netherlands, Sweden and Norway).

Main Challenges Identified: The cross-country comparison identified the following seven challenges with respect to comparing the quality of hospitals across Europe: different indicators are collected in each country; different definitions of the same indicators are used; different mandatory versus voluntary data collection requirements are in place; different types of organizations oversee data collection; different levels of aggregation of data exist (country, region and hospital); different levels of public access to data exist; and finally, hospital accreditation and licensing systems differ in each country.

Conclusion: Our findings indicate that if patients and policymakers are to compare the quality and safety of hospitals across Europe, then further work is urgently needed to agree the way forward. Until then, patients will not be able to make informed choices about where they receive their health care in different countries, and some governments will remain in the dark about the quality and safety of care available to their citizens as compared to that available in neighbouring countries.
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http://dx.doi.org/10.1093/intqhc/mzs079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3557961PMC
February 2013

How do osteoporosis patients perceive their illness and treatment? Implications for clinical practice.

Arch Osteoporos 2012 10;7:115-24. Epub 2012 Jul 10.

NIHR King's Patient Safety and Service Quality Research Centre, King's College London, 2 Basement, 138-142 Strand Bridge House, Strand, London WC2R 1HH, UK.

Unlabelled: Non-adherence inhibits successful treatment of osteoporosis. This study used a theoretical framework to explore osteoporosis patients' cognitive and emotional representations of their illness and medication, using both interviews and drawing. We recorded some misconceptions patients have about their condition and medication which could act as barriers to treatment adherence.

Purpose: Despite the high efficacy of current treatments in reducing fracture risk, poor adherence is still a problem in osteoporosis. This qualitative study aims to inform the development of a psychological intervention to increase adherence through the investigation of osteoporosis patients' perceptions of their illness and medication. The self-regulation model (Leventhal) provided the framework for the study.

Method: Participants were 14 female outpatients from a London teaching hospital who suffer with osteoporosis or osteopenia. Data were collected using both semi-structured interviews and drawings. Drawings were used to elicit participants' visual representations (imagery) of their condition.

Results: We found that patients held illness and medication beliefs that were not in accord with current scientific evidence. Interviews revealed that participants had good knowledge of what osteoporosis is, but they had low understanding of the role of medication in reducing fracture risk, various concerns about the side effects of medication, poor understanding of the causes of osteoporosis and uncertainty about how it can be controlled. Additionally, drawings elicited more information about the perceived effects of osteoporosis and emotional reactions to the condition.

Conclusions: Osteoporosis sufferers need a better understanding of their fracture risk and what they can do to control their condition. Concerns about medication need to be addressed in order to improve adherence, particularly in relation to the management of side effects. Since drawings of osteoporosis were found to arouse emotions, it is concluded that risk communication in osteoporosis could benefit from using visual images.
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http://dx.doi.org/10.1007/s11657-012-0089-9DOI Listing
July 2013
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