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Purpose: Differences in Indigenous worldviews, practices and values highlight the need for Indigenous‐specific health quality indicators, such as patient‐reported outcome measures (PROMs) and patient‐reported experience measures (PREMs). The purpose of this paper is to present our methodology, as part of a larger study that sought to develop a framework for creating Indigenous‐specific PROMs and PREMs. Methods: The research design was informed by Indigenous research methodology and a community‐based participatory approach. It had three core components: (1) a literature exploration of existing Indigenous‐specific PROMs and PREMs; (2) interviews with researchers with expertise in PROMs and PREMs developed for Indigenous populations and community leaders interested in using these Indigenous‐informed evaluation tools; and (3) conversations with Indigenous community members about their experiences with health surveys. Interviews were audio‐recorded and transcribed verbatim; transcripts were analyzed qualitatively using an inductive and deductive approach. Themes and sub‐themes were identified to build a framework that honours Indigenous knowledges and ways of knowing. Results were validated with select research participants and the Project Advisory Committee. Results: Findings demonstrate how relationship building is the necessary starting point for engagement when developing survey instruments with Indigenous peoples. Engagement requires respectful collaboration through all stages of the project from determining what questions are asked to how the information will be collected, interpreted, and managed. A relational stance requires responsibility to Indigenous communities and peoples that goes beyond research carried out using a western scientific lens. It means ensuring that the project is beneficial to the community and framing questions based on Indigenous knowledge, worldviews, and community involvement. Conclusions: This study employed a collaborative, participatory qualitative approach to develop a framework for creating PROMs and PREMs with Indigenous peoples. The methods described offer concrete examples of strategies that can be employed to support relationship‐building and collaboration when developing Indigenous‐specific survey instruments. [ABSTRACT FROM AUTHOR]

Rationale: Patient‐reported outcomes (PROs) are increasingly used in the context of clinical care, but evaluation of patients' perspectives of PRO‐based applications in routine care remains limited. Aims and Objectives: This paper investigates patients' acceptability of a personalized web‐based decision report for total knee or hip replacement and identifies opportunities to refine the report. Method: This qualitative evaluation was embedded in a pragmatic cluster randomized trial of the report. We interviewed 25 patients with knee and hip osteoarthritis about their experiences using the personalized decision report in the context of a surgical consultation. The web‐based report contained current descriptive PRO scores of pain, function and general physical health; tailored predicted postoperative PRO scores (i.e., personalized likely outcomes based on actual knee or hip replacement outcomes of similar patients in a national registry); and information about alternative nonoperative treatments. Two trained researchers analysed the interview data qualitatively using a combination of inductive and deductive coding. Results: We identified three major categories for evaluation: content of report, presentation of data in report and engagement with report. Patients generally liked the report overall but specifically valued different pages of the report based on where they were in the surgical decision‐making process. Patients identified areas of confusion in data presentation related to graph orientation, terminology and interpretation of T‐scores. Patients also highlighted support needs to meaningfully engage with the information in the report. Conclusion: Our findings highlight areas of opportunity to further refine this personalized web‐based decision report and similar patient‐facing PRO applications for routine clinical care. Specific examples include additional tailoring of reports via filterable web‐based dashboards and scalable educational supports to facilitate more independent patient understanding and use. [ABSTRACT FROM AUTHOR]

A significant proportion of somatic symptoms remain, at present, medically unexplained. These symptoms are common, can affect any part of the body, and can result in a wide range of outcomes—from a minor, transient inconvenience to severe, chronic disability—but medical testing reveals no observable pathology. This paper explores two first‐person accounts of so‐called 'medically unexplained' illness: one that is published in a memoir, and the other produced during a semi‐structured interview. Both texts are revelatory for their expression of shame in the context of encountering disrespect from healthcare professionals. The first section of my paper, clinical encounters, explores disrespect which, I argue, takes three interconnecting forms in these texts: disrespect for pain when it is seen as 'medically unexplained', disrespect for the patient's account of her own pain, and disrespect for the patient herself. The second section elucidates the shame that occurs as an affective and embodied consequence of encountering such disrespect. I claim that patients living with so‐called 'medically unexplained' illnesses suffer a double burden. They endure both somatic and social suffering—not only their symptoms, but also disrespectful, traumatic and shame‐inducing experiences of healthcare systems. I conclude with a reflection on the urgent need for changes in clinical training that could improve the quality of life for these patients, even in the absence of an explanation, treatment or cure for their symptoms. [ABSTRACT FROM AUTHOR]

Introduction: Self‐management support for schizophrenia has become expected practice leaving organisations to find ways for feasible implementation. Self‐management support involves a foundational cultural shift for traditional disease‐based services, new ways of clients‐providers working together, coupled with delivering a portfolio of tools and techniques. A new model of self‐management support embedded into traditional case management services, called SET for Health (Self‐management Engaging Together for Health), was designed and tailored to make such services meaningfully accessible to clients of a tertiary care centre. This paper describes the proof of concept demonstration efforts, the successes/challenges, and initial organisational changes. Method: An integrated knowledge translation approach was selected as a means to foster organisational change grounded in users' daily realities. Piloting the model in two community case management programmes, we asked two questions: Can a model of self‐management support be embedded in existing case management and delivered within routine specialised mental health services? What organisational changes support implementation? Results: Fifty‐one clients were enroled. Indicators of feasible delivery included 72.5% completion of self‐management plans in a diverse sample, exceeding the 44% set minimum; and an attrition rate of 21.6%, less than 51% set maximum. Through an iterative evaluation process, the innovation evolved to a targeted hybrid approach revolving around client goals and a core set of co‐created reference tools, supplemental tools and resources. Operationalisation by use of tools was implemented to create spaces for client‐provider collaborations. Monitoring of organisational changes identified realignment of practices. Changes were made to procedures and operations to further spread and sustain the model. Conclusion: This study demonstrated how self‐management support can be implemented, within existing resources, for routine delivery of specialised services for individuals living with schizophrenia. The model holds promise as a hybrid option for supporting clients to manage their own health and wellness. [ABSTRACT FROM AUTHOR]

Rationale Aims and Objectives: Horizontal violence has been defined as aggressive or hostile behaviour directed at an individual or between colleagues from the same working group. Measuring the prevalence of horizontal violence requires valid measures. To date, there has not been a review of the psychometric properties of available measurement tools for horizontal violence. Method: A rapid review of the MEDLINE and BUSINESS EBSCO databases was conducted to identify studies testing the validity of any measure of horizontal violence in any workplace setting. Title and abstract and full‐text screening, data extraction and quality appraisal were completed by two researchers working independently. The COnsensus‐based Standards for the selection of health Measurement Instruments (COSMIN) was used to determine the methodological quality of studies, including details of the psychometric properties of included papers. Results: Fourteen papers reporting 17 studies were included in the review. Seven measures of horizontal violence (Civility Norms Questionnaire Brief; Negative Acts Questionnaire—Revised; Inventory of Violence and Psychological Harassment; Leyman Inventory Psychological Terror Mobbing of Single Cases of Harassment in Employees Relations; Shortened Negative Acts Questionnaire—Revised; Uncivil Workplace Behaviour Questionnaire) were identified. Most included studies were methodologically robust. Six measures had strong psychometric properties except for the Mobbing of Single Cases of Harassment in Employees Relations (MSCH) where key information about psychometric properties was not reported. Conclusions: We identified six measures of horizontal violence that had good psychometric properties. The Negative Acts Questionnaire—Revised has been most extensively tested in different settings but is not necessarily a more precise measure than others. [ABSTRACT FROM AUTHOR]

Rationale: Implementation of strengths model case management is increasing internationally. However, few studies have focused on its implementation process, and none have specifically addressed the implementation experience of direct‐service practitioners. Objective: This paper presents factors that facilitate and impede the successful implementation of the strengths model, with a specific focus on practitioners who deliver the intervention directly to service recipients. Method: To address this objective, a qualitative study of seven mental health agencies that implemented the model was conducted, involving a combination of participant observations and qualitative semistructured interviews with case managers, team supervisors, and senior managers. Qualitative data were analyzed using open coding followed by axial coding. Finally, the findings were aligned with an adapted Consolidated Framework for Implementation Research. Results: Implementation of the strengths model involved a significant change in practice for case management practitioners. The results confirm that at the beginning of implementation, the strengths model was perceived as complex and not always adaptable to on‐the‐ground realities. With time, and with support from management, ongoing training and supervision sessions, and reflection and discussion, practitioners regained feelings of competence and resistance to the model diminished. The use of the model's structured team‐based supervision tools was fundamental to supporting the implementation process by enabling an interactive and concrete training approach. Conclusions: The more an approach leads to changes in daily practice and is perceived as complex, the more concrete support is needed during implementation. This article highlights the importance of attending to a practitioner's sense of personal effectiveness and competence in the adoption of new practices. [ABSTRACT FROM AUTHOR]

Background: Implementation science (IS) should contribute to maintaining high standards of care across healthcare systems and enhancing care practices. However, despite the evident need for greater and more rapid uptake and integration of evidence in practice, IS design and methodology fall short of the needs of effective translation. Aim: In this paper we examine what it is about IS that makes it so appealing for effective uptake of interventions in routine practice, and yet so difficult to achieve. We propose a number of ways that implementation scientists could build mutual relationships with healthcare practitioners and other stakeholders including public members to ensure greater shared care practices, and highlight the value of IS training, collaborative educational events, and co‐designed research. Discussion: More consideration should be given to IS applications in healthcare contexts. Implementation scientists can make a valuable contribution by mobilizing theory and improving practice. However, goals for an evidence‐based system may be more appropriately achieved through greater outreach and collaboration, with methods that are flexible to support rapid implementation in complex adaptive systems. Collective learning and mutual trust can be cultivated by embedding researchers into healthcare services while offering greater opportunities for practitioners to learn about, and engage in, implementation research. Conclusion: To bridge the worlds of healthcare practice and IS, researchers could be more consistent in the relationships they build with professionals and the public, communicating through a shared language and co‐joining practical approaches to effective implementation. This will build capacity for improved collaboration and foster respectful, interdisciplinary relationships. [ABSTRACT FROM AUTHOR]

Rationale, Aims and Objectives: Portenoy and Foley's 1986 landmark case series 'Chronic use of opioid analgesics in non‐malignant pain: report of 38 cases' has been reproached for opening the floodgates of opioid prescribing for chronic non‐cancer pain and the attendant harms. This influential article has been cited over 500 times in the scientific literature over the last four decades. This study seeks to understand the impact of Portenoy and Foley's article on subsequent discussions and research about opioids. Methods: We conducted a multi‐method bibliometric analysis of all citations of this article from 1986 through 2019 using quantitative relational and qualitative content analysis to determine how uses and interpretations of this case series and associated prescribing guidance have changed over time, in relationship to the evolution of the North American opioid crises. Results: Using time series analysis, we identified three periods with distinct interpretations and uses of the index article. In the first 'exploration' period (1986–1996), the index article was well‐received by the scientific community and motivated further study of the effects of opioids. In the second 'implementation' period (1997–2003, coinciding with the release of OxyContin®), this case series was used as evidence to support widespread prescribing of opioid analgesics, even while it was recognized that long‐term effects had not yet been evaluated. The third 'reassessment' period (2004–2019) focused on how opioid‐related harms had been overlooked, and in many cases, these harms were directly attributed to this article. Conclusion: These changes in interpretation demonstrate shifting currents of the use and mobilization of evidence regarding pain and opioids, and how these currents both impact and are impacted by clinical practices and major sociohistorical phenomena such as the opioid crisis. Researchers and clinicians must account for these shifting dynamics when developing and interpreting scientific knowledge, including in the form of clinical practice guidelines. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Despite extensive evidence on the value of patient decision support interventions ( DESIs), there is no consensus on optimal DESI formats. Assessing clinicians' perceptions about DESI formats can help facilitate their adoption. The aim of this study was to assess clinicians' perceptions of DESIs formats and potential use in practice. Methods Semi-structured qualitative interviews were conducted with doctors from diverse practice areas (internal medicine, OB/ GYN, surgery, medical oncology, emergency medicine) and elicited perceptions toward patient DESIs formats (digital vs. paper) and timing of administration. Questions also elicited beliefs underlying attitudes, perceived social norms and self-efficacy for using DESIs and the feasibility of doing so. Data analysis was conducted using a thematic analysis approach. Results Participants identified strengths of both more comprehensive digital and shorter paper-based tools and thought they could complement each other. Participants consistently expressed the advantages of using DESIs outside the consultation to supplement clinical discussions about cancer decisions given the amount of information to discuss during these emotion-laden conversations. Participants felt that patients with older age and lower socio-economic status were more likely to use a paper-based compared with a digital DESI. Participants also noted challenges related to reliable resources such as computers and Internet in the practice setting, which would be necessary for implementing the digital DESIs on site. Conclusions Clinicians' perceptions and opinions about value of DESIs can vary widely across doctor, patient and clinic characteristics. A one-size-fits-all approach to implementation might not be feasible, suggesting that flexible approaches to providing decision support for patients are needed to drive broader adoption. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to identify the factors influencing workarounds to the Hospital Information System (HIS) in Malaysian government hospitals. Methods: Semi‐structured interviews were conducted among 31 medical doctors in three Malaysian government hospitals on the implementation of the Total Hospital Information System (THIS) between March and May 2015. A thematic qualitative analysis was performed on the resultant data to deduce the relevant themes. Results: Five themes emerged as the factors influencing workarounds to the HIS: (a) typing skills, (b) system usability, (c) computer resources, (d) workload, and (e) time. Conclusions: This study provided the key factors as to why doctors were involved in workarounds during the implementation of the HIS. It is important to understand these factors in order to help mitigate work practices that can pose a threat to patient safety. [ABSTRACT FROM AUTHOR]

Rationale A multidisciplinary primary care clinic in Sydney, Australia, was planning to use electronic questionnaires to measure patient-reported outcomes. Methods Semi-structured interviews with 20 patients were undertaken to explore, among other things, practical issues regarding different questionnaire formats. The response rates and costs of email versus postal invitations were also evaluated. Results Compared with postal invitations, email invitations offered a cost-effective and practical alternative, with a greater proportion of patients volunteering for an interview. Assuming the interface is well-designed and user-friendly, many patients were happy to use the Internet to answer questionnaires. Most patients thought alternate formats should also be offered. Patients discussed advantages and disadvantages of the Internet format. Although more younger patients and females had given the clinic an email address; both sexes, and young and old patients, expressed strong preferences for either wanting or not wanting to use the Internet. Conclusion Researchers should consider using email invitations as a cost-effective first-line strategy to recruit patients to participate in health services research. Internet questionnaires are potentially cheaper than paper questionnaires, and the format is acceptable to many patients. However, for the time being, concurrent alternate formats need to be offered to ensure wider acceptability and to maximize response rates. [ABSTRACT FROM AUTHOR]

Rational: The Hawker appropriateness criteria for total knee arthroplasty (TKA) are: osteoarthritis symptoms impacting quality of life, evidence of osteoarthritis, trial of conservative treatments, patient's realistic expectations, patient/surgeon agree benefits outweigh risks, and readiness for surgery. Little is known about the barriers and facilitators of using the Hawker et al. appropriateness criteria for TKA in clinical practice. Aims and Objectives: Explore the barriers and facilitators to using appropriateness criteria for TKA in making decisions for adults with knee osteoarthritis. Methods: Interpretive descriptive qualitative study at an academic hospital. Purposive sampling aimed to recruit: (1) healthcare team members at all levels influencing care delivery, and (2) adults with TKA assessed at the hospital clinic. Semi‐structured interviews asked about the barriers/facilitators to using the Hawker appropriateness criteria. Data analysis consisted of inductive thematic analysis with themes mapped to the Consolidated Framework for Implementation Research domains. Results: Nine healthcare professionals and 14 adults with TKA participated and identified common barriers to using the Hawker appropriateness criteria: (a) intervention characteristics domain: difficulty to assess criteria, patients expecting healthcare professionals to decide, limited accessibility to conservative treatments; (b) individuals characteristics domain: no need to change current TKA process, clinical judgement limited to OA severity/age, implicit assessment of subjective criteria; (c) inner setting domain: TKA information received after decision made; and (d) outer setting domain: no timely access to TKA. A facilitator of use was evidence/buy‐in fosters programme changes. Conclusion: Barriers to using the criteria relevant to clinical practice and the healthcare system were identified while only one facilitator was revealed. Interventions tailored to these barriers are needed to support the use of the Hawker appropriateness criteria in TKA decision‐making. [ABSTRACT FROM AUTHOR]

Rationale: The restrictions to hospital visiting for carers and relatives during the pandemic were unprecedented. To ensure patients could stay in touch with their relatives and carers new liaison roles were introduced. Aims and Objectives: The aim of this study is to report on the evaluation of a Family Liaison Officer (FLO) role to understand the rationale for introducing the role along with the challenges and benefits of its implementation. Methods: A concurrent mixed methods design was used, triangulating both semi structured interviews and online surveys. Data were collected during 2021 from postholders, patients/relatives and key stakeholders. Results: The family liaison officer role occupies a key brokering role between clinical teams and patients/relatives. All participants agreed the importance of the role particularly in relation to communication. Postholders noted issues around clarity of scope of practice. Patients reported the social benefits of the FLOs particularly in relation to technology. There was also key learning in terms of induction, training and line management of this nonprofessional role. Conclusion: There is limited research that evaluates emerging nonprofessional roles that connect clinical teams and patients/relatives. This evaluation study although limited to one organisation provides important insights to the strategic and operational learning to introducing a family liaison officer role during the COVID‐19 pandemic. [ABSTRACT FROM AUTHOR]

Background: Shared decision‐making (SDM) is considered the "final stage" that completes the implementation of evidence‐based medicine. Yet, it is also considered the most neglected stage. SDM shifts the epistemological authority of medical knowledge to one that deliberately includes patients' values and preferences. Although this redefines the work of the clinical encounter, it remains unclear what a shared decision is and how it is practiced. Aim: The aim of this paper is to describe how healthcare professionals manoeuvre the nuances of decision‐making that shape SDM. We identify barriers to SDM and collect strategies to help healthcare professionals think beyond existing solution pathways and overcome barriers to SDM. Methods: Semi‐structured interviews were conducted with 68 healthcare professionals from psychiatry, internal medicine, intensive care medicine, obstetrics and orthopaedics and 15 patients. Results: This study found that healthcare professionals conceptualize SDM in different ways, which indicates a lack of consensus about its meaning. We identified five barriers that limit manoeuvring space for SDM and contest the feasibility of a uniform, normative SDM model. Three identified barriers: (a) "not all patients want new role," (b) "not all patients can adopt new role," and (c) "attitude," were linked to strategies focused on the knowledge, skills and attitudes of individual healthcare professionals. However, systemic barriers: (d) "prioritization of medical issues" and (e) "lack of time" render such individual‐focused strategies insufficient. Conclusion: There is a need for a more nuanced understanding of SDM as a "graded" framework that allows for flexibility in decision‐making styles to accommodate patient's unique preferences and needs and to expand the manoeuvring space for decision‐making. The strategies in this study show how our understanding of SDM as a process of multi‐dyadic interactions that spatially exceed the consulting room offers new avenues to make SDM workable in contemporary medicine. [ABSTRACT FROM AUTHOR]

Rationale: Family caregivers of persons with amyotrophic lateral sclerosis and cognitive and/or behavioural impairments (PALS/CIs) experience various challenges and needs, including emotional and practical support from peers. Various forms of peer‐support have shown different strengths and weaknesses; however, little is known about how family caregivers of PALS/CIs interact with and perceive virtual face‐to‐face peer‐support. Aims and Objectives: The aim of this study was to understand how caregivers of PALS/CIs interact with and perceive virtual face‐to‐face peer‐support in a palliative rehabilitation programme designed to promote targeted palliative rehabilitation initiatives for caregivers of PALS/CIs. Method: A qualitative design using participant observations of 17 recorded virtual group‐facilitated meetings from two rounds of a 4‐month intervention was performed. The Medical Research Council framework, the inductive interpretive description methodology and the theoretical framework of Sense of Coherence guided the study. Nineteen participants, divided into four groups, were included. Results: Three themes emerged: 'Relating my situation to others', 'Making room for forbidden thoughts' and 'Longing for normalcy'. The themes reflected the various ways participants interacted in online group meetings and how the interactions evolved around practical, emotional and forbidden thoughts. Sharing personal and sorrowful concerns and frustrations engendered feelings of trust and a sense of belonging, which empowered the participants to address their genuine wish and longing for normalcy with all the trivialities of which ALS/CIs had robbed them. Conclusion: Virtual face‐to‐face peer‐support can enable caregivers of PALS/CIs to share experiences of everyday life challenges that cannot always be shared elsewhere. Being able to relate to and learn from other's experiences alleviated feelings of loneliness, frustration, and concerns and thereby enhanced comprehensibility, manageability and meaningfulness. Online palliative rehabilitation interventions should provide an opportunity for caregivers to meet regularly in interactive group meetings. Familiarization takes time online and is necessary to improve their sense of feeling safe to share their deepest thoughts. Such group interventions, facilitated by trained healthcare professionals, offer a means to support dynamic group interactions and discussion of sensitive topics. [ABSTRACT FROM AUTHOR]

Rationale: Mobile stroke units (MSUs) are increasingly being implemented to provide acute stroke care in the prehospital environment, but a comprehensive implementation evaluation has not been undertaken. Aim: To identify successes and challenges in the pre‐ and initial operations of the first Australian MSU service from an interdisciplinary perspective. Methods: Process evaluation of the Melbourne MSU with a mixed‐methods design. Purposive sampling targeted key stakeholder groups. Online surveys (administered June–September 2019) and semistructured interviews (October–November 2019) explored experiences. Directed content analysis (raters' agreement 85%) and thematic analysis results are presented using the Interactive Sociotechnical Analysis framework. Results: Participants representing executive/program operations, MSU clinicians and hospital‐based clinicians completed 135 surveys and 38 interviews. Results converged, with major themes addressing successes and challenges: stakeholders, vehicle, knowledge, training/education, communication, work processes and working relationships. Conclusions: Successes and challenges of establishing a new MSU service extend beyond technical, to include operational and social aspects across prehospital and hospital environments. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: There is a general lack of awareness and understanding of dementia within ethnic minority groups in the United Kingdom. There is also a dearth of research involving ethnic minority caregivers about reducing barriers to accessing services and optimizing engagements with religiously tailored interventions. This paper reports findings from a qualitative study that examined the barriers to health care service use in the Bangladeshi community living in the United Kingdom. Methods: The research draws on findings from a doctoral level research study on understanding dementia among the Bangladeshi community in England. The data for the doctoral research were gathered in two ways: (a) focus group discussions and (b) semi‐structured interviews. All data were audio‐recorded and analysed using thematic analysis. NVivo software was used to aid transcribing, coding, and interpretation of emergent themes. Results: The data showed that there were some barriers experienced by participants due to their religious and cultural beliefs and practices with other barriers related to the complexity of the UK health care system. Gender‐based caregiving also appeared to interfere with religious ideologies while religiously appropriate health care services were deemed of great importance for successfully accessing those services. Conclusions: The findings provide an understanding of the experiences of the Bangladeshi community when seeking to access mainstream UK health care services and may help to provide useful directions for future research. [ABSTRACT FROM AUTHOR]

Rationale, Aims and Objectives: Nasogastric feeding is becoming commonly used to support patients with medically compromised eating disorders. Previous research has demonstrated the safety of this approach, however there is limited evidence as to how adult patients and staff perceive this feeding method. This study aimed to describe the acceptability of a nasogastric refeeding protocol with adult patients with medically unstable eating disorders and the staff involved in their treatment. Method: This was a qualitative exploratory study using semi‐structured interviews conducted in acute medical wards of a tertiary hospital where nasogastric nutrition is the sole source of nutrition for the first 7 days of the eating disorder admission. Data were analysed using the Framework method. Results: Eight patients (100% female, median: 22 years old, n = 6 diagnosed with anorexia nervosa) and 12 staff members (medical n = 5, nursing n = 5, dietitians n = 2; median: 8.5 years clinical experience) were interviewed. Patients reported that nasogastric feeding was tolerable, however concerns were raised regarding communication and the desire for concurrent oral feeding. Acceptability from staff was influenced by perceived competence, confidence, tensions around patient‐centred care, and working with stigma and ambivalence. Conclusions: Consideration needs to be given as to whether a 'nil by mouth' status during nasogastric feeding further impacts recommencing an oral diet to progress treatment. Improvements are required within the current service, including improved communication, additional educational resources for patients, and allowing patients to partake in decision‐making as able. [ABSTRACT FROM AUTHOR]

Rationale, Aims, and Objectives: While paediatric clinician‐scientists are ideally positioned to generate clinically relevant research and translate research evidence into practice, they face challenges in this dual role. The authors sought to explore the unique contributions, opportunities, and challenges of paediatric clinician‐scientists, including issues related to training and ongoing support needs to ensure their success. Method: The authors used a qualitative descriptive approach with thematic analysis to explore the experiences of clinician‐scientist stakeholders in child health (n = 39). Semi‐structured interviews (60 min) were conducted virtually and recorded. Thematic analysis was conducted according to the phases outlined by Braun and Clarke (2006). Results: The analysis resulted in the creation of three themes: (1) "Walking on both sides of the fence": unique positioning of clinician‐scientists for advancing clinical practice and research; (2) the clinician‐scientist: a specialized role with significant challenges; and (3) beyond the basics of clinical and research training programmes: essential skill sets and knowledge for future clinician‐scientists. Conclusions: While clinician‐scientists can make unique contributions to the advancement of evidence‐based practice, they face significant barriers straddling their dual roles including divergent institutional cultures in healthcare and academia and a lack of infrastructure to effectively support clinician‐scientist positions. Training programmes can play an important role in mentoring and supporting early‐career clinician‐scientists. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: Decisions about whether to refer or admit a patient to an intensive care unit (ICU) are clinically, organizationally, and ethically challenging. Many explicit and implicit factors influence these decisions, and there is substantial variability in how they are made, leading to concerns about access to appropriate treatment for critically ill patients. There is currently no guidance to support doctors making these decisions. We developed an intervention with the aim of supporting doctors to make more transparent, consistent, patient‐centred, and ethically justified decisions. This paper reports on the implementation of the intervention at three NHS hospitals in England and evaluates its feasibility in terms of usage, acceptability, and perceived impact on decision making. Methods: A mixed method study including quantitative assessment of usage and qualitative interviews. Results: There was moderate uptake of the framework (28.2% of referrals to ICU across all sites during the 3‐month study period). Organizational structure and culture affected implementation. Concerns about increased workload in the context of limited resources were obstacles to its use. Doctors who used it reported a positive impact on decision making, with better articulation and communication of reasons for decisions, and greater attention to patient wishes. The intervention made explicit the uncertainty inherent in these decisions, and this was sometimes challenging. The patient and family information leaflets were not used. Conclusions: While it is feasible to implement an intervention to improve decision making around referral and admission to ICU, embedding the intervention into existing organizational culture and practice would likely increase adoption. The doctor‐facing elements of the intervention were generally acceptable and were perceived as making ICU decision making more transparent and patient‐centred. While there remained difficulties in articulating the clinical reasoning behind some decisions, the intervention offers an important step towards establishing a more clinically and ethically sound approach to ICU admission. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: Although Bangladeshis are three times more likely to be carers than White British, Bangladeshi family carers are the most deprived, neglected, and effectively a hidden group in the United Kingdom.1 There is a paucity of research within the Bangladeshi community that is capable of explaining and predicting the experiences and concerns of Bangladeshi family carers providing care for their relatives with dementia. The purpose of this study is to explore the perspectives of Bangladeshi family carers' knowledge and day‐to‐day experiences living in England. Methods: This is a qualitative study involving semistructured face‐to‐face interviews with six Bangladeshi family carers living in London and Portsmouth. Interviews were recorded with the consent and transcribed verbatim. Data were managed by using NVivo software, and thematic analysis was performed. Results: This paper explores that most carers have a lack of knowledge and awareness of the symptoms of dementia. The results of this study are in contrast to previous studies, where South Asian carers perceived dementia as being possessed by evil spirits or God's punishment for previous life's sins; this study reveals that Bangladeshi family carers believed dementia was a medical condition. Unlike earlier South Asian studies, however, all family carers in this study also believed that there was no stigma attached to dementia. Conclusions: Further research is warranted to investigate the religious beliefs, familism, and interpersonal motives as theoretical perspectives to explain how Bangladeshi family carers negotiate and construct their caregiving roles for their relatives with dementia. [ABSTRACT FROM AUTHOR]

Rationale: Patients recovering from significant COVID‐19 infections benefit from rehabilitation; however, aspects of rehabilitative care can be difficult to implement amidst COVID infection control measures. Aims and Objectives: We used the Consolidated Framework for Implementation Research (CFIR) to evaluate the rapid implementation of a COVID zone in an in‐patient rehabilitation hospital at the onset of the first wave of the pandemic. Methods: Semistructured interviews were conducted with health care providers (n = 12) supporting the COVID zone, as well as with patients (n = 10) who were discharged from the COVID zone and their family caregivers (n = 5). The interviews explored the successes and challenges of working on the unit and the quality of care that was delivered to patients recovering from COVID. Results: Rapid implementation of the COVID zone was supported by champions at the middle‐management level but challenged by a number of factors, including: conflicting expert opinions on best infection control practices (outer setting), limited flow of information from senior leaders to frontline staff (inner setting), lack of rehabilitation equipment and understanding of how to provide high quality rehabilitative care in this context (intervention characteristics), willingness and self‐efficacy of staff working in the COVID zone (individual characteristics) and lack of time to reflect on and assess effectiveness (process). Conclusions: While there was an apparent need for rapid implementation of a COVID rehabilitation zone, senior leadership, middle management and frontline staff faced several challenges. Future evaluations should focus on how to adapt COVID rehabilitation services during fluctuating pandemic restrictions, and to account for rehabilitative needs of people recovering from significant COVID infections. [ABSTRACT FROM AUTHOR]

Background: Clinical practice guidelines (CPGs) have become central to efforts to change clinical practice and improve the quality of health care. Despite growing attention for rigorous development methodologies, it remains unclear what contribution CPGs make to quality improvement. Aim: This mixed methods study examines guideline quality in relation to the availability of certain types of evidence and reflects on the implications of CPGs' promise to improve the quality of care practices. Methods: The quality of 62 CPGs was assessed with the Appraisal of Guidelines, Research, and Evaluation (AGREE) instrument. Findings were discussed in 19 follow‐up interviews to examine how different quality aspects were considered during development. Results: The AGREE assessment showed that while some quality criteria were met, CPGs have limited coverage of domains such as stakeholder involvement and applicability, which generally lack a 'strong' evidence base (e.g., randomized controlled trials [RCT]). Qualitative findings uncovered barriers that impede the consolidation of evidence‐based guideline development and quality improvement including guideline scoping based on the patient‐intervention‐comparison‐outcome (PICO) question format and a lack of clinical experts involved in evidence appraisal. Developers used workarounds to include quality considerations that lack a strong base of RCT evidence, which often ended up in separate documents or appendices. Conclusion: Findings suggest that CPGs mostly fail to integrate different epistemologies needed to inform the quality improvement of clinical practice. To bring CPGs closer to their promise, guideline scoping should maintain a focus on the most pertinent quality issues that point developers toward the most fitting knowledge for the question at hand, stretching beyond the PICO format. To address questions that lack a strong evidence base, developers actually need to appeal to other sources of knowledge, such as quality improvement, expert opinion, and best practices. Further research is needed to develop methods for the robust inclusion of other types of knowledge. [ABSTRACT FROM AUTHOR]

Rationale and Objectives: Education of patients is thought to be key to high‐quality oral anticoagulant (OAC) medication management. Theoretically, improving patients' knowledge should improve their self‐management skills and adherence. The study's objective was to explore the opinions of healthcare providers and patients on the desired content and format of patient education on OACs, in addition to perceived barriers to high‐quality patient education. Methods: We applied qualitative descriptive methods in a focus group study on OAC management. Five focus group discussions were conducted in two health regions in Southwestern Ontario from 2017 to 2018 with 19 patients, 7 caregivers and 16 healthcare providers (physicians, nurses and pharmacists). During the focus groups, participants discussed their experiences with OAC education and made suggestions about the content and format for patient education on OACs. Transcripts were analysed using conventional content analysis. Results: We identified the five themes of patient education on OAC management: content of OAC education (rationale, risk and appropriate drug administration methods), the best times for providing OAC education (time of OACs initiation along with continuing education), preferred education delivery strategies (case management targeted patient information summaries from authoritative sources such as Thrombosis Canada and video education), patient and community pharmacist engagement in OAC education, and perceived barriers to optimal patient education (patients depending too much on their healthcare providers for advice, the limited time patients spend with healthcare providers, gaps in clear communication between providers and the lack of a nationally or provincially coordinated OAC management programme). Conclusion: Our findings suggest that patients, caregivers and healthcare providers support the need for education on OACs, including for patients taking DOACs. Specific important content and proper education format are needed. The optimal combination of content, format, duration, timing and sources for OAC education requires further research. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Open-label extension (OLE) studies following blinded randomized controlled trials (RCTs) of pharmaceuticals are increasingly being carried out but do not conform to regulatory standards and questions surround the validity of their evidence. OLE studies are usually discussed as a homogenous group, yet substantial differences in study design still meet the definition of an OLE. We describe published papers reporting OLE studies focussing on stated objectives, design, conduct and reporting. Method A search of Embase and Medline databases for 1996 to July 2008 revealed 268 papers reporting OLE studies that met our eligibility criteria. A random sample of 50 was selected for detailed review. Results Over 80% of the studies had efficacy stated as an objective. The most common methods of allocation at the start of the OLE were for all RCT participants to switch to one active treatment or for only participants on the new drug to continue, but in three studies all participants were re-randomized at the start of the OLE. Eligibility criteria and other selection factors resulted in on average of 74% of participants in the preceding RCT(s) enrolling in the OLE and only 57% completed it. Conclusions Published OLE studies do not form a homogenous group with respect to design or retention of participants, and thus the validity of evidence from an OLE should be judged on an individual basis. The term 'open label' suggests bias through lack of blinding, but slippage in relation to the sample randomized in the preceding RCT may be the more important threat to validity. [ABSTRACT FROM AUTHOR]

Objective: To explore factors influencing the implementation of patient navigator programs within a hospital for seniors with complex care needs. Methods: A qualitative descriptive design using in‐depth interviews was conducted. Participant interviews were conducted in Toronto, Ontario between September 2020 and February 2021. Data were analysed using thematic analysis. Results: Thirty‐five semi‐structured interviews were conducted with 38 participants from a large urban hospital (n = 21) and community healthcare organizations (n = 17), including organizational leaders, and acute care and rehabilitation providers. Follow‐up interviews occurred with 16 participants (7 from the community and nine from the hospital). This study identified five key factors influencing organizational readiness for successful implementation of a patient navigator program for seniors with complex conditions, which included: (a) vision from senior leadership, (b) technological infrastructure, (c) existing hospital‐community partnerships, (d) well‐established process for referrals, and (e) staff capacity. The overarching theme of communication was also identified. Conclusions: The findings of this study provide a better understanding of hospital and community professionals' needs and challenges when implementing patient navigator programs for seniors with complex care conditions. There are a number of factors that influence an organization's readiness for program uptake and delivery, with the need for clear communication being paramount. Further research to test the effects of readiness on successful implementation outcomes is warranted. [ABSTRACT FROM AUTHOR]

Rationale: Prudent Healthcare is a strategy adopted by the Welsh Government in response to the challenge of improving health care during times of austerity and when needs and demand are rising. Four principles underlie Prudent Healthcare: to achieve health and wellbeing through co production; care for those with the greatest health needs first; do only what is needed; and reduce inappropriate variation. For Prudent Healthcare to be implemented in Wales, it is necessary for health professionals to adopt these principles in practice. Objective: This paper reports a qualitative evaluation of clinicians' awareness, experiences, and views about Prudent Healthcare, identifying barriers and enablers to implementation from the clinician's perspective. Methods: Semi‐structured interviews (n = 28) and five focus groups (with 23 participants) were undertaken with a diverse range of health professionals working in primary and secondary care. Analysis was underpinned by the COM‐B model which provides a framework to understand behaviour change in context using three domains, Capability, Opportunity, and Motivation. Results: Clinicians reported the importance and challenges of accessing and sharing information and evidence to inform practice (Capability). Reduced staffing levels and service availability were highlighted as possible barriers to Prudent Healthcare implementation while multidisciplinary working and reorganization of staff roles and services were considered enablers (Opportunity). Finally, although the principles of Prudent Healthcare were broadly welcomed (Motivation), a lack of awareness of the initiative and the management of patient expectations presented barriers. Conclusion: While there was a positive response and widespread support for the principles of Prudent Healthcare by clinicians, increasing awareness of the initiative and improvement to systems to enable information sharing and the monitoring of patient outcomes could improve the consistency of implementation. [ABSTRACT FROM AUTHOR]

Rationale, aims & objective Tools for the assessment of the quality of research studies tend to be specific to a particular research design (e.g. randomized controlled trials, or qualitative interviews). This makes it difficult to assess the quality of a body of research that addresses the same or a similar research question but using different approaches. The aim of this paper is to describe the development and preliminary evaluation of a quality assessment tool that can be applied to a methodologically diverse set of research articles. Methods The 16-item quality assessment tool (QATSDD) was assessed to determine its reliability and validity when used by health services researchers in the disciplines of psychology, sociology and nursing. Qualitative feedback was also gathered from mixed-methods health researchers regarding the comprehension, content, perceived value and usability of the tool. Results Reference to existing widely used quality assessment tools and experts in systematic review confirmed that the components of the tool represented the construct of 'good research technique' being assessed. Face validity was subsequently established through feedback from a sample of nine health researchers. Inter-rater reliability was established through substantial agreement between three reviewers when applying the tool to a set of three research papers (κ = 71.5%), and good to substantial agreement between their scores at time 1 and after a 6-week interval at time 2 confirmed test-retest reliability. Conclusions The QATSDD shows good reliability and validity for use in the quality assessment of a diversity of studies, and may be an extremely useful tool for reviewers to standardize and increase the rigour of their assessments in reviews of the published papers which include qualitative and quantitative work. [ABSTRACT FROM AUTHOR]

Rationale, Aims and Objectives: Type 2 diabetes (T2D) is an archetypical chronic condition of significant prevalence. Yet the concept of cure in the context of T2D reveals an interplay between the medical imagination and clinical realities that can shift the course of a patient's care. There are two domains in which cure is sociologically constructed: the professional domain occupied by clinicians treating people with T2D, and the lay domain occupied by T2D patients. Lay epistemologies of cure tend to be focused on modifying the experience of having T2D, while professional epistemologies tend to focus on modifying the disease through medical treatment. The objective of this study is to explore the role of the concept of cure in the context of type 2 diabetes, a model for chronic disease. Methods: Through surveys and interviews of T2D patients, providers and researchers at an urban academic medical centre, I explore the perspectives and attitudes each group have towards the concept of cure in T2D. Semi‐structured interviews of T2D professionals and patient surveys consisting of free response questions and Likert scale items were thematically analysed for perspectives on cure in T2D. Results: Sixteen T2D patients met inclusion criteria and consented to the survey and ten T2D professionals were interviewed. Cure is conceived of heterogeneously both within and between epistemologies. Patients carry hopes of cure predicated on eliminating the unpleasant experiences of T2D and its treatments, while T2D professionals tend to avoid invoking the concept of cure, at least to patients, on grounds of clinical uncertainty. However, the concept of cure is a significant motivator of treatment in both lay and professional epistemologies. Conclusion: Different viewpoints on cure in T2D present an opportunity for shared meaning and decision making between patients and their providers that can frame the best possible outcome for patient care. [ABSTRACT FROM AUTHOR]

Rationale, Aims, and Objectives: It is generally believed that evidence from low quality of evidence generate inaccurate estimates about treatment effects more often than evidence from high (certainty) quality evidence (CoE). As a result, we would expect that (a) estimates of effects of health interventions initially based on high CoE change less frequently than the effects estimated by lower CoE (b) the estimates of magnitude of effect size differ between high and low CoE. Empirical assessment of these foundational principles of evidence‐based medicine has been lacking. Methods: We reviewed the Cochrane Database of Systematic Reviews from January 2016 through May 2021 for pairs of original and updated reviews for change in CoE assessments based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method. We assessed the difference in effect sizes between the original versus updated reviews as a function of change in CoE, which we report as a ratio of odds ratio (ROR). We compared ROR generated in the studies in which CoE changed from very low/low (VL/L) to moderate/high (M/H) versus M/H to VL/L. Heterogeneity and inconsistency were assessed using the tau and I2 statistic. We also assessed the change in precision of effect estimates (by calculating the ratio of standard errors) (seR), and the absolute deviation in estimates of treatment effects (aROR). Results: Four hundred and nineteen pairs of reviews were included of which 414 (207 × 2) informed the CoE appraisal and 384 (192 × 2) the assessment of effect size. We found that CoE originally appraised as VL/L had 2.1 [95% confidence interval (CI): 1.19–4.12; p = 0.0091] times higher odds to be changed in the future studies than M/H CoE. However, the effect size was not different (p = 1) when CoE changed from VL/L → M/H [ROR = 1.02 (95% CI: 0.74–1.39)] compared with M/H → VL/L (ROR = 1.02 [95% CI: 0.44–2.37]). Similar overlap in aROR between the VL/L → M/H versus M/H → VL/L subgroups was observed [median (IQR): 1.12 (1.07–1.57) vs. 1.21 (1.12–2.43)]. We observed large inconsistency across ROR estimates (I2 = 99%). There was larger imprecision in treatment effects when CoE changed from VL/L → M/H (seR = 1.46) than when it changed from M/H → VL/L (seR = 0.72). Conclusions: We found that low‐quality evidence changes more often than high CoE. However, the effect size did not systematically differ between the studies with low versus high CoE. The finding that the effect size did not differ between low and high CoE indicate urgent need to refine current EBM critical appraisal methods. [ABSTRACT FROM AUTHOR]

Objective: To describe the perspectives of healthcare professionals regarding the implementation of Shared decision‐making (SDM) in primary healthcare centres (PHCCs) in Saudi Arabia. Methods: Qualitative semi‐structured interviews were conducted with a purposive and snowball sample of healthcare professionals in PHCCs. Interviews have been recorded, transcribed, translated and thematically analysed. Themes were mapped to the COM‐B model. Results: Sixteen healthcare professionals were interviewed. The data analysis identified six themes and 14 sub‐themes. The six themes are patient related factors, health professional related factors, environmental context and resources, patient–physician communication, patient–physician preferences toward SDM and physicians' perceived value and benefits of SDM. Physicians are unlikely to practice SDM in the context of time pressures, shortage of physicians, lack of treatment options, and decision‐making aids. The findings also underscored the importance of building a trustworthy physician‐patient relationship through the use of effective conversation techniques. Conclusions: There are multiple barriers to SDM in primary care. Unless these barriers are addressed, it is unlikely that physicians will effectively or fully engage in SDM with patients. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: Consistent data demonstrates negative psychological effects of caregiving on front‐line health professionals. Evidence that psychological resilience factors can help minimize distress and the potential for low‐cost interventions have created interest in resilience‐based development programmes; yet evidence of perceived value amongst health professionals is lacking. This study explored health professionals' experiences and perceptions of a novel, resilience‐based intervention designed to pro‐actively prepare staff for coping with error; to investigate their perceptions of what resilience meant to them, the relevance of the intervention, and impact of participation on ability to cope with error. Methods: Semi‐structured interviews 4‐6 weeks post intervention with 23 randomly selected participants from seven cohorts (midwives, paediatricians, obstetricians/gynaecologists, paramedics) and trainees (physician associates, mammographers, sonographers). Thematic analysis of interview data. Findings: Participants reported various interpretations of, and a shift in perception regarding what the concept of psychological resilience meant to them and their practice. These included for example, resilience as a positive or negative concept and their awareness and response to a range of personal, organizational and system factors influencing personal resilience. They valued the prophylactic, clinically relevant, interactive and applied nature of the intervention; having developed and applied valuable skills beyond the context of involvement in error, noting that individuals needed to be willing to explore their own coping mechanisms and human fallibility to gain maximum benefit. There was also consensus that whilst proactively developing individual level psychological resilience is important, so too is addressing the organizational and system factors that affect staff resilience which are outside individual staff control. Conclusion: Enhancing resilience appears to be considered useful in supporting staff to prepare for coping with error and the wider emotional burden of clinical work, but such interventions require integration into wider system approaches to reduce the burden of clinical work for health professionals. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The basic single-group interrupted time series analysis (ITSA) design has been shown to be susceptible to the most common threat to validity--history --the possibility that some other event caused the observed effect in the time series. A single-group ITSA with a crossover design (in which the intervention is introduced and withdrawn 1 or more times) should be more robust. In this paper, we describe and empirically assess the susceptibility of this design to bias from history. Method Time series data from 2 natural experiments (the effect of multiple repeals and reinstatements of Louisiana's motorcycle helmet law on motorcycle fatalities and the association between the implementation and withdrawal of Gorbachev's antialcohol campaign with Russia's mortality crisis) are used to illustrate that history remains a threat to ITSA validity, even in a crossover design. Results Both empirical examples reveal that the single-group ITSA with a crossover design may be biased because of history. In the case of motorcycle fatalities, helmet laws appeared effective in reducing mortality (while repealing the law increased mortality), but when a control group was added, it was shown that this trend was similar in both groups. In the case of Gorbachev's antialcohol campaign, only when contrasting the results against those of a control group was the withdrawal of the campaign found to be the more likely culprit in explaining the Russian mortality crisis than the collapse of the Soviet Union. Conclusions Even with a robust crossover design, single-group ITSA models remain susceptible to bias from history. Therefore, a comparable control group design should be included, whenever possible. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Randomized controlled trials ( RCTs) are powerful tools; it is essential that these trials are not only conducted rigorously, but reported accurately. The aim of this paper was to describe the reporting quality among a set of RCTs published in 2011 on methodological details essential to judging the adequacy of allocation concealment methods employed. Methods Medline was searched using the Ovid platform to identify all those RCTs published in January 2011 in core clinical journals. Methodological details in relation to allocation concealment were extracted from the identified RCTs to allow the reporting quality to be assessed. If the information was not available in the paper the corresponding author was contacted. Results Eighty-five papers were identified, 74% ( n = 63) endorsed the CONSORT statement. 73% ( n = 62) required the author to be contacted for further information. Sequence generation methods were ascertained in 74% of trials, allocation concealment method in 41%, details of who recruited participants and who generated the randomization sequence in 38%. Conclusions There is evidence to suggest that in 2011 key methodological information relating to allocation concealment is still not reported well in RCTs. Authors and journal editors need to ensure explicit and clear methods are reported in RCTs published. [ABSTRACT FROM AUTHOR]

In recent years there has been growing attention to the epistemology of clinical decision-making, but most studies have taken the individual physicians as the central object of analysis. In this paper we argue that knowing in current medical practice has an inherently social character and that imaging plays a mediating role in these practices. We have analyzed clinical decision-making within a medical expert team involved in diagnosis and treatment of patients with pulmonary hypertension (PH), a rare disease requiring multidisciplinary team involvement in diagnosis and management. Within our field study, we conducted observations, interviews, video tasks, and a panel discussion. Decision-making in the PH clinic involves combining evidence from heterogeneous sources into a cohesive framing of a patient, in which interpretations of the different sources can be made consistent with each other. Because pieces of evidence are generated by people with different expertise and interpretation and adjustments take place in interaction between different experts, we argue that this process is socially distributed. Multidisciplinary team meetings are an important place where information is shared, discussed, interpreted, and adjusted, allowing for a collective way of seeing and a shared language to be developed. We demonstrate this with an example of image processing in the PH service, an instance in which knowledge is distributed over multiple people who play a crucial role in generating an evaluation of right heart function. Finally, we argue that images fulfill a mediating role in distributed knowing in 3 ways: first, as enablers or tools in acquiring information; second, as communication facilitators; and third, as pervasively framing the epistemic domain. With this study of clinical decision-making in diagnosis and treatment of PH, we have shown that clinical decision-making is highly social and mediated by technologies. The epistemology of clinical decision-making needs to take social and technological mediation into account. [ABSTRACT FROM AUTHOR]

Background: At the start of the COVID‐19 pandemic, guidance was needed more than ever to direct frontline healthcare and national containment strategies. Rigorous guidance based on robust research was compromised by the emergence of the pandemic and the urgency of need for guidance. Rather than aiming to "get guidance right", guidance developers needed to "get guidance right now". Aim: To examine how guidance developers have responded to the need for credible guidance at the start of the COVID‐19 pandemic. Methods: An exploratory mixed‐methods study was conducted among guidance developers. A web‐based survey and follow‐up interviews were used to examine the most pertinent challenges in developing COVID‐19 guidance, strategies used to address these, and perspectives on the implications of the COVID‐19 pandemic on future guidance development. Results: The survey was completed by 46 guidance developers. Survey findings showed that conventional methods of guidance development were largely unsuited for COVID‐19 guidance, with 80% (n = 37) of respondents resorting to other methods. From the survey and five follow‐up interviews, two themes were identified to bolster the credibility of guidance in a setting of extreme uncertainty: (1) strengthening end‐user involvement and (2) conjoining evidence review and recommendation formulation. 70% (n = 32) of survey respondents foresaw possible changes in future guidance production, most notably shortening development time, by reconsidering how to balance between rigour and speed for different types of questions. Conclusion: "Getting guidance right" and "getting guidance right now" are not opposites, rather uncertainties are always part of guidance development and require guidance developers to balance scientific robustness with usability, acceptability, adequacy and contingency. This crisis points to the need to acknowledge uncertainties of scientific evidence more explicitly and points to mechanisms to live with such uncertainty, thus extending guidance development methods and processes more widely. [ABSTRACT FROM AUTHOR]

Study Rationale: Amyotrophic lateral sclerosis is a progressive neurodegenerative disease which causes impairment of the motor functions in the upper and lower limbs and bulbar muscles with a median survival time is three years from the first appearance of symptoms. There is massive psychological impact on health professionals to persons with amyotrophic lateral sclerosis, hence the work leads to multiple challenges and stressful and demanding situations with high risk of experiencing diminished personal well‐being including burnout, moral distress, and compassion fatigue. Aim: To investigate reflections and perspectives from health professionals working within palliative rehabilitation for elements of importance in relation to job satisfaction. Methods and Materials: The design was qualitative and based on the phenomenological‐hermeneutical methodology by Paul Ricoeur's interpretation theory. Data consisted of two semi‐structured focus group interviews with a total of 12 specialized health professionals: Nurses, Psychologists, Physicians, Occupational Therapists, Physiotherapists, and Social workers, working within a hospital setting of specialized palliative rehabilitation for people with amyotrophic lateral sclerosis and their families. Results: The analysis revealed insight into four themes: fundamental drive, working conditions, value of collegiality and work‐life balance. Fundamental drive was deeply rooted in the professionals' sense of having a meaningful job. Working conditions such as self‐management were important for job satisfaction as were good collegial relations. Finally, a good balance between working life and private life was considered important for job satisfaction. Conclusion: Our study indicates that work within the field of palliative rehabilitation is experienced as enriching and beneficial under the right circumstances and in an appreciatory working environment. We found elements like autonomy, mastery, purpose, collegiality, and work‐life balance to be of great importance. Our findings can help guide managements and health professionals in other palliative rehabilitation contexts to ensure satisfied employees and to optimize the quality of care. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The aim of this research note is to reflect on the effectiveness of the QATSDD tool for its intended use in critical appraisals of synthesis work such as integrative reviews. Methods A seven-member research team undertook a critical appraisal of qualitative and quantitative studies using the QATSDD. Results and Conclusion We believe that the tool can spur useful dialogue among researchers and increase in-depth understanding of reviewed papers, including the strengths and limitations of the literature. To increase the clarity of the process, we suggest further definition of the language in each indicator and inclusion of explicit examples for each criterion. We would also like to see the authors outline clear parameters around the use of the tool, essentially stating that the tool should be used in synthesis work for studies of mixed methods or work that includes qualitative and quantitative research informed by a positivist paradigm. In the context of an appropriate team composition, the tool can be a useful mechanism for guiding people who are coming together to discuss the merits of studies across multiple methodologies and disciplines. [ABSTRACT FROM AUTHOR]

Background: Unplanned hospital readmissions are common adverse events. The LACE+ score has been used to identify patients at the highest risk of unplanned readmission or death, yet the external validity of this score remains uncertain. Methods: We constructed a cohort of patients admitted to hospital between 1 October 2014 and 31 January 2017 using population‐based data from British Columbia (Canada). The primary outcome was a composite of urgent hospital readmission or death within 30 days of index discharge. The primary analysis sought to optimize clinical utility and international generalizability by focusing on the modified LACE+ (mLACE+) score, a variation of the LACE+ score which excludes the Case Mix Group score. Predictive performance was assessed using model calibration and discrimination. Results: Among 368,154 hospitalized individuals, 31,961 (8.7%) were urgently readmitted and 5428 (1.5%) died within 30 days of index discharge (crude composite risk of readmission or death, 9.95%). The mLACE+ score exhibited excellent calibration (calibration‐in‐the‐large and calibration slope no different than ideal) and adequate discrimination (c‐statistic, 0.681; 95%CI, 0.678 to 0.684). Higher risk dichotomized mLACE+ scores were only modestly associated with the primary outcome (positive likelihood ratio 1.95, 95%CI 1.93 to 1.97). Predictive performance of the mLACE+ score was similar to that of the LACE+ and LACE scores. Conclusion: The mLACE+, LACE+ and LACE scores predict hospital readmission with excellent calibration and adequate discrimination. These scores can be used to target interventions designed to prevent unplanned hospital readmission. [ABSTRACT FROM AUTHOR]

Rationale, Aims and Objectives: Sharing aspects of the traditional medical record with patients has been successful in primary and antenatal care, but has not been investigated in the UK inpatient setting. Our aim was to evaluate the impact on patient and clinician experience of providing patients with a written lay summary of their care‐plan in the acute care setting. Method: We carried out a qualitative interview study on two acute medicine wards in an NHS University Teaching Hospital for a 4‐week period in 2019. A summary record, designed in response to suggestions from doctors and patients from a previous study, was distributed to patients on the first ward round after admission. Eligible participants included all doctors and nurses working on and all patients and their families attending the acute medical units; patients were excluded if they lacked capacity to consent or were under 18. We interviewed 20 patients, 10 relatives, 10 doctors and 7 nurses. Results: Patients felt that the summary improved their ability to remember details about their care so they could more accurately and easily update their relatives. They did not feel that the summary induced anxiety. Patient‐doctor communication was improved: patients felt empowered to ask more questions and doctors felt that it solidified their plan and encouraged them to avoid medical jargon. Most patients felt the summary included the 'right' amount of information. Healthcare professionals were more concerned about the risk of breaching confidentiality than patients. Doctors felt that providing summaries was time‐consuming; there were differing opinions about whether this was a worthwhile investment of time. Clinicians recognized that the traditional medical record has many roles. Conclusions: A summary record could empower patients and improve patient‐doctor communication but would require additional clinician and administrative time. [ABSTRACT FROM AUTHOR]

Rationale: Postpartum depression is a worldwide public health issue that can have long‐term impact on the family. It is crucial to evaluate intervention program to help new parents cope with the stress of parenthood to reduce the risk of postpartum depression. The aim of this study was to explore the perceived benefits of the couple‐based psychoeducation to first‐time Hong Kong Chinese parents, and the crucial factors influencing the effectiveness of this program underpinned by the concept of process evaluation. Method: Using an exploratory qualitative design, a purposeful sample of 27 couples who had participated in the program were interviewed at 1‐3 months postpartum. Data were collected using semi‐structured interviews and analysed by thematic analysis. Findings: The findings showed that the parents perceived the program to be useful in enhancing their parenting skills and emotional control, and increasing their sense of support. The effectiveness of the program was facilitated by (a) the predisposing factors such as couple‐based approach to enhance mutual expectation and shared decision making when experiencing and managing challenges, and telephone follow‐up calls to sustain the continuity of care from hospital to the community, (b) the enabling factor for instance, the time of intervention arranged in non‐working hour, and (c) reinforcing factor namely involvement of midwives during program implementation and telephone follow‐up consultation. Conclusions: The results of this study suggest the potential of the couple‐based psychoeducation to support first‐time parents in taking care of their children and controlling their emotions in this critical transition. The program could be integrated into maternal and child care services on a regular basis, and thus accessible to all first‐time parents. [ABSTRACT FROM AUTHOR]

Introduction: The management of chronic pain is challenging. Biopsychosocial models recommend interprofessional approaches to treatment, but there is sparse information about participants' experiences of these programs, especially in medically underserved populations coping with the intersectionality of racial bias, low socioeconomic status, and psychosocial stressors. This study explored the perspectives and experiences of black participants with low socioeconomic status and concomitant psychosocial stressors in an outpatient interprofessional pain management program, Power over Pain. The program incorporates cognitive‐behavioural techniques, creative arts therapies, pain education, and psychoeducation about stress management, self‐care, exercise, and medication. Method: This study employed thematic analysis as the qualitative research method. We conducted semi‐structured interviews with nine program participants. Interview questions focused on the impact of the program on participants' overall health and wellbeing and ability to manage chronic pain. Results: Thematic analysis revealed the following treatment benefits as perceived by the participants: (a) moving from feeling stuck to feeling empowered, (b) enhanced understanding of chronic pain resulting in cognitive reframing and debunking certain myths and stigmas, (c) learning new pain management strategies, and (d) social support. Conclusion: The findings suggest that the Power over Pain program may be an effective way to improve self‐management and empower medically underserved people who have chronic pain. [ABSTRACT FROM AUTHOR]

Rationale, Aims, and Objectives: Caregivers of people living with dementia play an essential role in managing medications across transitions of care. Adequate caregiver medication management guidance at hospital discharge is important to ensure optimal outcomes from medication use. This qualitative study explores the experiences and perspectives of caregivers about the medication management guidance provided at hospital discharge. Methods: A qualitative approach using semi‐structured, telephone interviews was conducted with 31 caregivers of people with dementia across Australia. Purposive sampling was used to ensure maximum variation of diverse experiences and perspectives. Results: Caregivers' experiences of medication guidance for people with dementia at discharge were described in three themes including: (a) inadequate information about medication management at discharge; (b) limited caregiver engagement in medication management decisions; and (c) difficulties ensuring medication supply post discharge. Most participants indicated they would like to be included in discussions at discharge. However, participation was influenced by caregivers being overwhelmed by discharge processes; proactively seeking information on medication‐related harm; and belief in advocacy as part of their caregiver role. Caregivers reported they would like to receive a tailored medication list for people with dementia which included information on medications that may impact on the patient's cognition, and for hospital staff to communicate with both the community pharmacist and primary care physician, to improve co‐ordination post transition. Discussion: In our study of caregivers of people with dementia, we identified key recommendations to facilitate regular participation of people living with dementia and their caregiver around medication guidance at discharge. [ABSTRACT FROM AUTHOR]

Rationale: The end of life (EOL) experience in the intensive care unit (ICU) can be psychologically distressing for patients, families, and clinicians. The 3 Wishes Project (3WP) personalizes the EOL experience by carrying out wishes for dying patients and their families. While the 3WP has been integrated in academic, tertiary care ICUs, implementing this project in a community ICU has yet to be described. Objectives: To examine facilitators of, and barriers to, implementing the 3WP in a community ICU from the clinician and implementation team perspective. Methods: This qualitative descriptive study evaluated the implementation of the 3WP in a 20‐bed community ICU in Southern Ontario, Canada. Patients were considered for the 3WP if they had a high likelihood of imminent death or planned withdrawal of life‐sustaining therapy. Following the qualitative descriptive approach, semi‐structured interviews were conducted with purposively sampled clinicians and implementation team. Data from transcribed interviews were analyzed in triplicate through qualitative content analysis. Results: Interviews with 12 participants indicated that the 3WP personalized and enriched the EOL experience. Interviewees indicated higher intensity education strategies were needed to enable spread as the project grew. Clinicians described many physical resources for the project but suggested more non‐clinical project support for orientation, continuing education, and data collection. A majority of wishes focused on physical resources including keepsakes, which helped facilitate project spread when clinician capacity was attenuated by competing duties. Conclusions: In this community hospital, ICU clinicians and implementation team members report perceived improved EOL care for patients, families, and clinicians following 3WP initiation and integration. Implementing individualized and meaningful wishes at EOL for dying patients in a community ICU requires adequate planning and time dedicated to optimizing clinician education. Adapting key features of an intervention to local expertise and capacity may facilitate spread during project initiation and integration. [ABSTRACT FROM AUTHOR]

Rationale: Evidence‐based practice (EBP) can improve health care in underprivileged countries. Bolivia's EBP movement is nascent and the factors contributing to better implementation in nursing are unknown. Aim: To explore Bolivian nurses' readiness to engage in EBP while highlighting the facilitators and barriers for pursuing EBP. Method: The study used a sequential explanatory mixed methods study. First, general trends were disclosed via a survey of 170 nurses in La Paz, Bolivia, holding at least a baccalaureate regarding their perceived beliefs about EBP. The survey identified facilitators and barriers for implementing EBP in acute and ambulatory settings. Second, qualitative data was gathered via a focus group of nine nurses with the purpose of enhancing the survey results. Results: The survey results showed that nurses believe that engaging in EBP can improve their clinical practice. However, the nurses' research behaviors were found to be infrequent. Lack of support from the nurses' clinics and hospitals and from non‐nursing professionals were identified as barriers for engaging in EBP. The qualitative results revealed underlying limitations to nurses' clinical practice, including "feeling undervalued". Conclusions: There is a dearth of EBP knowledge among Bolivian nurses stemming from a lack of preparation in EBP environments, including EBP training opportunities. This situation affects nurses' professional dimensions of relational work, power, and collaboration. Collaborative research among educators, professional nursing societies, and local and international organizations could provide initiatives for implementing EBP, based on local health profiles. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Checklists have been adopted by various institutions to improve patient outcomes. In particular, readmission prevention checklists may be of potential value to improve patient care and reduce medical costs. As a result, a prior quality improvement study was conducted to create an intensive care unit readmission prevention checklist. The previous pilot demonstrated zero readmissions when the readmission prevention checklist was utilized but yielded low compliance (30%). Thus, a subsequent quality initiative was undertaken to refine the readmission prevention checklist with the primary aim of improved compliance while maintaining a reduced readmission rate that was observed with the original quality improvement study. Method A single-centre, cross-sectional study for assessing baseline data and a prospective observational study to assess the effectiveness of a refined readmission prevention checklist tool in a 20-bed tertiary medical-surgical intensive care unit at an academic medical centre in Rochester, MN was conducted. Medical patients admitted through the emergency department, upon direct transfer from outside facility, and post-operative surgical patients at our institution were included. A refined readmission prevention checklist tool was administered during an 8-week pilot period for medical and post-operative surgical patients. Results The refined readmission prevention checklist resulted in an even lower compliance (10.5%) from the initial phase likely resulting from utilization of a paper readmission prevention checklist in an electronic medical environment. Moreover, the refined readmission prevention checklist demonstrated a 22% unplanned readmission rate for patients in which the tool was utilized. Conclusions In conclusion, the findings of the current quality improvement study may serve to rethink the process of health care delivery that applies paper tools in an electronic medical environment. [ABSTRACT FROM AUTHOR]

Aim and objective To evaluate the validity of study outcomes of published papers that report the effects of clinical pathways (CP). Method Systematic review based on two search strategies, including searching Medline, CINAHL, Embase, Psychinfo and Picarta from 1995 till 2005 and ISI Web of KnowledgeSM. We included randomized controlled or quasi-experimental studies evaluating the efficacy of clinical pathway application. Assessment of the methodological quality of the studies included randomization, power analysis, selection bias, validity of outcome indicators, appropriateness of statistical tests, direct (matching) and indirect (statistical) control for confounders. Outcomes included length of stay, costs, readmission rate and complications. Two reviewers independently assessed the methodological quality of the selected papers and recorded the findings with an evaluation tool developed from a set of items for quality assessment derived from the Cochrane Library and other publications. Results The study sample comprised of 115 publications. A total of 91.3% of the studies comprised of retrospective studies and 8.7% were randomized controlled studies. Using a quality-scoring assessment tool, 33% of the papers were classified as of good quality, whereas 67% were classified as of low quality. Of the studies, 10.4% controlled for confounding by matching and 59.1% adopted parametric statistical tests without testing variables on normal distribution. Differences in outcomes were not always statistically tested. Conclusion Readers should be cautious when interpreting the results of clinical pathway evaluation studies because of the confounding factors and sources of contamination affecting the evidence-based validity of the outcomes. [ABSTRACT FROM AUTHOR]

Background Open and honest discussion between healthcare providers and patients and families affected by error is considered to be a central feature of high quality and safer patient care, evidenced by the implementation of open disclosure policies and guidance internationally. This paper discusses the perceived enablers that UK doctors and nurses report as facilitating the enactment of open disclosure. Methods Semistructured interviews with 13 doctors and 22 nurses from a range of levels and specialities from 5 national health service hospitals and primary care trusts in the UK were conducted and analysed using a framework approach. Results Five themes were identified which appear to capture the factors that are critical in supporting open disclosure: open disclosure as a moral and professional duty, positive past experiences, perceptions of reduced litigation, role models and guidance, and clarity. Conclusion Greater openness in relation to adverse events requires health professionals to recognise candour as a professional and moral duty, exemplified in the behaviour of senior clinicians and that seems more likely to occur in a nonpunitive, learning environment. Recognising incident disclosure as part of ongoing respectful and open communication with patients throughout their care is critical. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: Strong health systems are said to be paramount to achieving effective and equitable health care. The World Health Organization has been advocating for using system-wide approaches such as 'systems thinking' to guide intervention design and evaluation. In this paper we report the system-wide effects of a complex health system intervention in Zambia known as Better Health Outcome through Mentorship and Assessment (BHOMA) that aimed to improve service quality. Methods: We conducted a qualitative study in three target districts. We used a systems thinking conceptual framework to guide the analysis focusing on intended and unintended consequences of the intervention. NVivo version 10 was used for data analysis. Results: The addressed community responded positively to the BHOMA intervention. The indications were that in the short term there was increased demand for services but the health worker capacity was not severely affected. This means that the prediction that service demand would increase with implementation of BHOMA was correct and the workload also increased, but the help of clinic lay supporters meant that some of the work of clinicians was transferred to these lay workers. However, from a systems perspective, unintended consequences also occurred during the implementation of the BHOMA. Conclusions: We applied an innovative approach to evaluate a complex intervention in low-income settings, exploring empirically how systems thinking can be applied in the context of health system strengthening. Although the intervention had some positive outcomes by employing system-wide approaches, we also noted unintended consequences. [ABSTRACT FROM AUTHOR]

Rationale aims and objectives Problems exist with Do Not Attempt Cardiopulmonary Resuscitation ( DNACPR) orders: they are often misinterpreted by clinicians to mean that other treatments should be withheld; resuscitation decision discussions are difficult; patients remain inappropriately for resuscitation. We developed an alternative approach. Methods An adapted Delphi method was used. Senior clinicians were interviewed about the strengths and weakness of current practice. Teams who had initiated alternative approaches internationally were contacted. Focus groups were conducted with doctors, nurses and patients to further understand problems with DNACPR orders and establish essential aspects of a new approach. A behavioral economist and management consultant contributed advice. The resulting form was recirculated and further refined. It was: snowballed out to others with specialist expertise (palliative care physicians, intensivists, etc) for further feedback; assessed in simulated clinical encounters before being piloted; further adjusted once in clinical practice. In parallel, a patient information leaflet was developed along with education materials. Results Consensus was achieved that the new approach should: be universal; have discussions and clinical conditions documented first; clarify goals of overall treatment (active treatment or optimal supportive care); contextualize the resuscitation decision among other treatment decisions; have a free text box for 'opting out' of invasive treatments, rather than tick boxes; be green; be limited to one page. Conclusions The Universal Form of Treatment Options was developed iteratively with patients, doctors and nurses as an alternative approach to resuscitation decisions. This paper illustrates a cross-disciplinary approach to developing practical alternatives in health care. [ABSTRACT FROM AUTHOR]