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Background Interorganisational collaboration is currently being promoted to improve the performance of NHS providers. However, up to now, there has, to the best of our knowledge, been no systematic attempt to assess the effect of different approaches to collaboration or to understand the mechanisms through which interorganisational collaborations can work in particular contexts. Objectives Our objectives were to (1) explore the main strands of the literature about interorganisational collaboration and to identify the main theoretical and conceptual frameworks, (2) assess the empirical evidence with regard to how different interorganisational collaborations may (or may not) lead to improved performance and outcomes, (3) understand and learn from NHS evidence users and other stakeholders about how and where interorganisational collaborations can best be used to support turnaround processes, (4) develop a typology of interorganisational collaboration that considers different types and scales of collaboration appropriate to NHS provider contexts and (5) generate evidence-informed practical guidance for NHS providers, policy-makers and others with responsibility for implementing and assessing interorganisational collaboration arrangements. Design A realist synthesis was carried out to develop, test and refine theories about how interorganisational collaborations work, for whom and in what circumstances. Data sources Data sources were gathered from peer-reviewed and grey literature, realist interviews with 34 stakeholders and a focus group with patient and public representatives. Review methods Initial theories and ideas were gathered from scoping reviews that were gleaned and refined through a realist review of the literature. A range of stakeholder interviews and a focus group sought to further refine understandings of what works, for whom and in what circumstances with regard to high-performing interorganisational collaborations. Results A realist review and synthesis identified key mechanisms, such as trust, faith, confidence and risk tolerance, within the functioning of effective interorganisational collaborations. A stakeholder analysis refined this understanding and, in addition, developed a new programme theory of collaborative performance, with mechanisms related to cultural efficacy, organisational efficiency and technological effectiveness. A series of translatable tools, including a diagnostic survey and a collaboration maturity index, were also developed. Limitations The breadth of interorganisational collaboration arrangements included made it difficult to make specific recommendations for individual interorganisational collaboration types. The stakeholder analysis focused exclusively on England, UK, where the COVID-19 pandemic posed challenges for fieldwork. Conclusions Implementing successful interorganisational collaborations is a difficult, complex task that requires significant time, resource and energy to achieve the collaborative functioning that generates performance improvements. A delicate balance of building trust, instilling faith and maintaining confidence is required for high-performing interorganisational collaborations to flourish. Future work Future research should further refine our theory by incorporating other workforce and user perspectives. Research into digital platforms for interorganisational collaborations and outcome measurement are advocated, along with place-based and cross-sectoral partnerships, as well as regulatory models for overseeing interorganisational collaborations. Study registration The study is registered as PROSPERO CRD42019149009. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 6. See the NIHR Journals Library website for further project information. Plain language summary What was the question? How can the collaboration between health-care providers be improved? What did we do? There are continuing concerns about poor patient care across the NHS. One of the ways in which governments have tried to solve these issues is by getting services to work together, rather than separately, to solve any problems. The aim of our review is to learn about how, why and when different approaches to working together – which we call interorganisational collaboration – can be used to improve the performance of NHS providers. We reviewed published evidence and carried out interviews with NHS staff. We also carried out interviews and a focus group with patient and public representatives. What did we find? Our review finds that interorganisational collaborations can work well when a series of elements are in place, which includes the need to build trust between everyone involved. Having a belief in the collaboration is also needed to help inspire others to get involved. To try and reduce possible problems, setting priorities and having clear methods to show how improvements can be achieved are important, as well as having an agreed contract in place to ensure that any conflicts are resolved. If done well, collaboration can improve resource allocation, coordination, communication and shared learning about best practice. What does this mean? Our review provides valuable evidence of how different approaches to interorganisational collaboration can be used by NHS providers to work together to improve services in different situations. Our review provides different options for organisations to reflect on how well they are collaborating, which includes the involvement of key stakeholders, such as patients, the public and communities. Scientific summary Background Improving the collaboration and integration of services has become a mantra for health-care systems. Interorganisational collaborations (IOCs), such as alliances, groups, associations, networks and mergers, have been closely linked to policy contexts where governments have promoted collaboration as a solution for meeting the innovation, coordination, efficiency and quality challenges currently being faced. A variety of factors have been attributed to achieving success within such initiatives, including the importance of organisational capacity, having a shared vision, building trust and collaborative leadership. However, realising the advantages of collaboration is far from straightforward, with notable barriers including the influence of historical events, competitive behaviour, the regulatory environment and a lack of organisational resources. Despite the burgeoning evidence base and increased policy emphasis on collaborative working, notable gaps in knowledge persist. As a result, our understanding of the mechanisms and processes for spreading and sustaining evidence about how IOC relationships work in practice is limited. Many questions remain about how interorganisational arrangements work, for whom and in what circumstances. Given the complexities of collaborative arrangements, contributions identify how ‘theories of change’ approaches provide a way to assess how collaboration synergies are shaped by contexts, behaviours and structures. Realist approaches to the study of IOCs are advocated; however, applications within health-care settings have, hitherto, remained an underdeveloped area. Objectives The research has the following inter-related objectives: •To explore the main strands of the literature about IOC and to identify the main theoretical and conceptual frameworks that can be used to shed light on the conditions and antecedents for effective partnering across sectors and stakeholders •To assess the empirical evidence with regard to how different interorganisational practices may (or may not) lead to improved performance and outcomes •To understand and learn from NHS evidence users and other stakeholders about how and where IOC can best be used as a mechanism to support turnaround processes •To develop a typology of IOC that considers different types and scales of collaborative ventures that are appropriate for particular NHS provider contexts •To generate evidence-informed practical guidance for NHS providers, policy-makers and others with responsibility for implementing and assessing IOC arrangements in the NHS. Methods A realist methodology is employed to provide useful intelligence regarding how, why and in what circumstances different approaches to IOC can improve the performance of NHS provider organisations. Data sources Given the large, multifaceted and complex nature of IOCs, an ‘initial rough theory’ was developed by combining a review of grey and narrative literature, along with systematic reviews of evidence, to capture key definitions, typologies, ingredients and outcomes. Subsequent systematic searches were conducted to gather evidence about how IOC works and the contextual factors shaping a range of entities, such as alliances, buddying, mergers, acquisitions and hospital groups. Searches were run between 7 October 2020 and 4 March 2021 on databases, including the Healthcare Management Information Consortium, MEDLINE, Social Policy and Practice and PsycINFO, and on Google Scholar (Google Inc., Mountain View, CA, USA). Reference-scanning and citation-tracking were also employed. We conducted a realist evaluation to further test our refined programme theory by exploring the experiences of a range of stakeholders, comprising the leaders or architects of IOCs, regulators, policy-makers, professional bodies, front-line staff and patient representatives. Inclusion criteria The realist review used the following inclusion criteria for the title and abstract stage: ‘the paper clearly relates to collaborations between one or more public sector organisations on either a structural or individual level’ and ‘the paper is a case study, evaluation, opinion, or review’. Full-text screening also included ‘propositions about the success or failure of collaboration in the public sector, mechanisms underlying how collaboration works or include information about “entry points” (i.e. drivers of collaboration)’. For the refinement stage, we included papers that (1) were case studies or evaluations (defined as reporting results of arrangements using descriptive methods), (2) report on an IOC between health care-providing organisations and (3) were in English (because of resource limitations of the study). A purposive sampling strategy identified participants through contacts via our Study Advisory Group and from direct contact with potential individuals and organisations identified through scoping work. Participants were chosen based on their likelihood of being able to provide rich information about various aspects of IOCs from being engaged in formulating, influencing, implementing or experiencing such arrangements. The final sample comprised 37 interviews and one focus group with 8 patient and public representatives. Data extraction Selected studies were subject to rigour and relevance checks in accordance with realist synthesis methodology. The screening for rigour was ongoing and primarily involved including context–mechanism–outcome configurations (CMOCs) only when supported by (1) clear data in included studies and (2) multiple sources. For theoretical sources of evidence, only theories that had seen significant use in the literature since publication were used in the building of our middle-range theory (MRT) and CMOCs. No studies or extracts were excluded on the basis of trustworthiness. Analysis of the realist evaluation interview data was performed in NVivo 12 software (QSR International, Warrington, UK) by one coder (JAA), with the coding logic independently verified by a second coder (RM). Coding was performed retroductively, combining inductive and deductive logic. Data synthesis Theory gleaning synthesised document evidence according to whether or not the evidence shed light on entry points into collaboration, contextual factors, mechanisms or other elements relating to collaborations that helped elucidate the underlying ideas and assumptions regarding how collaboration was intended to work. Theory refinement aimed to test the identified CMOCs against case studies, and improve our programme theory. The realist interviews and focus group provided further refinement to the CMOCs relating to collaborative functioning, as well as to glean novel CMOCs relating to collaborative performance. Interview data were retroductively analysed in NVivo 12. Results The realist synthesis incorporated reviews, MRTs, case studies and organisational evaluation literature. A total of 86 papers produced a refined realist theory that surfaced the inter-related roles of trust and risk tolerance, faith, task complexity, interpersonal communication, cultural integration, perception of progress, etc., and how these roles causally interact to drive collaborative behaviour. The results demonstrate that in mandated or highly integrative collaborations the locus may be shifted from trust towards contractual obligation and a sense of confidence that the partner will act collaboratively. These chains of CMOCs were situated within a ‘causal web’ to depict how distant contextual items and their mechanisms work to affect the outcomes underpinning organisational performance. Stakeholder interviews supported the CMOCs identified within the review. In doing so, stakeholders further articulated how building and sustaining trust was connected to the leadership skills and behaviours of authenticity, empathy, visibility and generosity. A commitment to place-based approaches also featured, along with the importance of stakeholder engagement, data analysis and project management. The findings also show how a delicate balance is required for building faith, where energising leadership is tempered by the stark capacity issues facing current NHS contexts. The importance of priority-setting and data analytics features in building faith; however, increasing task complexity can reduce faith, particularly when working across boundaries. Interviews also stress the need for confidence and memoranda of understanding in particular types of IOC. The results present the first comprehensive realist evaluation of how well-functioning IOCs can drive performance improvements. Drawing on the domains of collaborative performance, the interviews and focus group identify how cultural efficacy mechanisms prove to be particularly important in driving improved communication, better coordination, shared improvement strategies and reputation management. Organisational efficiency mechanisms highlight the causal links between collaboration and improving financial and workforce resource allocation, as well as better coordination to increase responsiveness and reduce duplication. Technological effectiveness sheds light on the benefits collaboration can bring for research and development and working across clinical pathways. Conclusions Through analysis of theoretical, empirical and stakeholder evidence, the research presents a synthesis of MRTs and CMOCs to better understand how, why and in what circumstances IOCs are effective for NHS providers. Our study finds that the core mechanisms of collaborative functioning comprise the development of trust, faith and confidence. The extent to which task success or failure is achieved is mediated by supporting mechanisms related to capacity, legitimacy, complexity, conflict and risk tolerance. Performance improvement from collaboration can be achieved when mechanisms underlying organisational efficiency (e.g. reduced duplication of effort), cultural efficacy (e.g. enhanced coordination in local health system) and technological effectiveness (e.g. sharing clinical expertise) are activated. The findings conclude that performance improvements occur in a context of collaborative functioning, which, in turn, drive improvements in long-term outcomes, including care quality, safety, efficiency and experience. The findings provide a range of practical steps that organisations can take in the development of IOCs, including the development of diagnostic surveys for assessing collaboration to help organisations assess their readiness for collaboration, as well as for diagnosing collaborations that are already progressing. A pilot of a survey with a mental health provider collaborative shows promising signs for its utility in providing a valuable means for stimulating discussion with regard to the perceived readiness for collaboration. A maturity index for collaboration was also presented to assess levels of collaboration and encourage critical discussion and reflection. A range of theoretical, empirical and policy implications arise from this research. Specific issues that warrant further consideration and investigation are as follows: •Where much of the analysis of IOCs has captured the experiences, processes and outcomes from the perspective of those leading programmes and initiatives, further research is needed to gather workforce perspectives regarding how new processes are understood and operationalised, and how IOCs shape patient and user interactions. •Research is required to better grasp how IOCs can engage and improve population health by further involving patients and communities through drawing on principles of co-design and co-production. •The COVID-19 pandemic has been a driver for activity using digital platforms for communication, yet further research is needed to better understand and nurture ‘interpersonal communication’ across digital platforms and to better understand the role of digital technology in facilitating collaboration. •Further research is needed to investigate the applicability and adaptability of a number of the elements raised by this project, such as the roles of faith, trust and other mechanisms within the formation and maintenance of place-based partnerships. Learning from other national contexts could facilitate such efforts, with further comparative studies of IOCs from across the United Kingdom and beyond. •A review of regulatory models and perspectives for overseeing collaborative ventures is required, learning from other sectors and health-care contexts, where appropriate. •Building on our realist theory of collaborative performance, further research is needed to disentangle the motivators and drivers from the ‘outcomes’ associated with IOCs. Such analysis can support the current policy landscape, placing greater emphasis on measuring the outcomes and social value generated from collaborative working. •Further research is required to articulate the cross-sectoral relationships within the current IOC policy agenda. The place and positioning of social care and third sector requires further development. Furthermore, greater attention to the role of public/private partnerships, and the private sector more specifically, within collaboration and integration agendas is needed. Study registration The study is registered as PROSPERO CRD42019149009. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 6. See the NIHR Journals Library website for further project information.

Aims Design Methods Results Conclusions Implications for the Profession Impact Reporting Method Patient or Public Contribution To identify the contributing factors behind the second victim phenomenon, describe the emotional responses of nurses after medication errors, assess the support received by them after errors and recognize the need for a suitable support program for second victims.Qualitative descriptive design.Eleven in‐depth semi‐structured interviews were conducted among registered nurses studying advanced degrees at a University in Finland during November 2021–April 2022. Data were analysed using thematic analysis.The study results revealed four themes with various sub‐themes which included: contributing factors behind the second victim phenomenon; emotional responses of nurses after error; support received by nurses; and the desired need for a support program for second victims. The severity of the error and the negative work environment acted as catalysts for the second victim phenomenon among nurses. A “bitter aftermath” of emotions and a sense of insufficient support added further risk to already stressed and anxious nurses.This study identifies the early exploratory and enduring impact of memories associated with medication errors, some of them haunting nurses for long periods of time. Further, the need for support at different levels is highlighted to reduce the impact of negative emotions generated among nurses after medication errors.Through the lens of this study, it has been possible to identify contributing factors behind the second‐victim phenomenon and enduring symptoms that make nurses vulnerable to becoming second victims of medication incidents.This study addresses the aftermath effect of medication errors from the perspective of nurses involved with such incidents. It provides valuable insights for healthcare managers and nurse leaders to establish a just and blame‐free culture in healthcare organizations and help emotionally traumatized nurses cope effectively after error.The research adheres to Consolidated criteria for reporting qualitative research (COREQ) guidelines.No patient or public contribution. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the impact of usual care plus a fundamental nursing care guideline compared to usual care only for patients in hospital with COVID‐19 on patient experience, care quality, functional ability, treatment outcomes, nurses' moral distress, patient health‐related quality of life and cost‐effectiveness. Design: Parallel two‐arm, cluster‐level randomized controlled trial. Methods: Between 18th January and 20th December 2021, we recruited (i) adults aged 18 years and over with COVID‐19, excluding those invasively ventilated, admitted for at least three days or nights in UK Hospital Trusts; (ii) nurses caring for them. We randomly assigned hospitals to use a fundamental nursing care guideline and usual care or usual care only. Our patient‐reported co‐primary outcomes were the Relational Aspects of Care Questionnaire and four scales from the Quality from the Patient Perspective Questionnaire. We undertook intention‐to‐treat analyses. Results: We randomized 15 clusters and recruited 581 patient and 418 nurse participants. Primary outcome data were available for 570–572 (98.1%–98.5%) patient participants in 14 clusters. We found no evidence of between‐group differences on any patient, nurse or economic outcomes. We found between‐group differences over time, in favour of the intervention, for three of our five co‐primary outcomes, and a significant interaction on one primary patient outcome for ethnicity (white British vs. other) and allocated group in favour of the intervention for the 'other' ethnicity subgroup. Conclusion: We did not detect an overall difference in patient experience for a fundamental nursing care guideline compared to usual care. We have indications the guideline may have aided sustaining good practice over time and had a more positive impact on non‐white British patients' experience of care. Implications for the Profession and/or Patient Care: We cannot recommend the wholescale implementation of our guideline into routine nursing practice. Further intervention development, feasibility, pilot and evaluation studies are required. Impact: Fundamental nursing care drives patient experience but is severely impacted in pandemics. Our guideline was not superior to usual care, albeit it may sustain good practice and have a positive impact on non‐white British patients' experience of care. Reporting Method: CONSORT and CONSERVE. Patient or Public Contribution: Patients with experience of hospitalization with COVID‐19 were involved in guideline development and writing, trial management and interpretation of findings. [ABSTRACT FROM AUTHOR]

Background: Simulation‐based education (SBE) is crucial to prepare nursing students prior to their clinical learning experience. Theory‐based simulation learning is increasingly important for analysing how students learn. This study describes and analyses how nursing students learn through simulation in the context of palliative care communication under a socio‐material approach and explores the transfer of their knowledge and skills from simulation to clinical practice. Methods: Twenty‐seven final‐year nursing students in six groups participated in two simulated scenarios, followed by a debriefing and post‐clinical focus groups to capture their reflections and learning. Fourteen of them joined the post‐clinical focus groups after completing their clinical placements. Video recordings of the simulation, and the audio recordings from the debriefing, and post‐clinical focus groups were transcribed and coded based on the human and non‐human elements that were observed. These were triangulated with data collected through team participant observations, an analysis of the existing syllabi and curriculum, and a participant mapping exercise after the simulation. These various data sources illustrate how student learning and reflections took place. Results: The three themes of student learning derived from the results and analysis were (1) students' expanded learning of health care communication through a socio‐material approach in the context of palliative care; 2) students' discovery of the diverse and complex relations and interactions between humans and materials and (3) students' new perspectives on health care communication and the transfer of knowledge and skills through a socio‐material approach in clinical practice. Conclusions: This study highlights how SBE can be further expanded using a socio‐material approach to prepare students to learn beyond standardised and cognitively driven approaches and procedures. Student learning demonstrates that SBE may develop beyond high fidelity and standardisation to leave room for emergent learning and increased awareness in learning for students and teachers to optimise learning outcomes and competence. This study uses sociomateriality to advance understanding of complex human‐material interactions and explain how simulation can evolve beyond standardization to yield better learning. [ABSTRACT FROM AUTHOR]

Background: During the COVID-19 pandemic, concern has been raised about suicide risk among healthcare workers (HCWs). We investigated the incidence risk and prevalence of suicidal thoughts and behaviour (STB), and their relationship with occupational risk factors, among National Health Service HCWs in England between April 2020 and August 2021. Methods: In this longitudinal study, we analysed online survey data completed by 22,501 HCWs from 17 NHS Trusts at baseline (Time 1) and six months (Time 2). The primary outcome measures were suicidal ideation, suicide attempts, and non-suicidal self-injury. We used logistic regression to investigate the relationship between these outcomes and demographic characteristics and occupational factors. Results were stratified by occupational role (clinical/non-clinical). Results: Time 1 and Time 2 surveys were completed by 12,514 and 7,160 HCWs, respectively. At baseline, 10.8% (95% CI = 10.1%, 11.6%) of participants reported having experienced suicidal thoughts in the previous two months, whilst 2.1% (95% CI = 1.8%, 2.5%) of participants reported having attempted suicide over the same period. Among HCWs who had not experienced suicidal thoughts at baseline (and who completed the Time 2 survey), 11.3% (95%CI = 10.4%, 12.3%) reported such thoughts six months later. Six months after baseline, 3.9% (95% CI = 3.4%, 4.4%) of HCWs reported attempting suicide for the first time. Exposure to potentially morally injurious events, lack of confidence about raising safety concerns and these concerns being addressed, feeling unsupported by managers, and providing a reduced standard of care were all associated with increased suicidal ideation among HCWs during the COVID-19 pandemic. At six months, among clinicians, a lack of confidence about safety concerns being addressed, independently predicted suicidal ideation. Conclusion: Suicidal thoughts and behaviour among healthcare workers could be reduced by improving managerial support and enhancing the ability of staff to raise safety concerns. [ABSTRACT FROM AUTHOR]

Objective To examine the impact of nursing team size and composition on inpatient hospital mortality. Design A retrospective longitudinal study using linked nursing staff rostering and patient data. Multilevel conditional logistic regression models with adjustment for patient characteristics, day and time-invariant ward differences estimated the association between inpatient mortality and staffing at the ward-day level. Two staffing measures were constructed: the fraction of target hours worked (fill-rate) and the absolute difference from target hours. Setting Three hospitals within a single National Health Service Trust in England. Participants 19 287 ward-day observations with information on 4498 nurses and 66 923 hospital admissions in 53 inpatient hospital wards for acutely ill adult patients for calendar year 2017. Main outcome measure In-hospital deaths. Results A statistically significant association between the fill-rate for registered nurses (RNs) and inpatient mortality (OR 0.9883, 95% CI 0.9773 to 0.9996, p=0.0416) was found only for RNs hospital employees. There was no association for healthcare support workers (HCSWs) or agency workers. On average, an extra 12- hour shift by an RN was associated with a reduction in the odds of a patient death of 9.6% (OR 0.9044, 95% CI 0.8219 to 0.9966, p=0.0416). An additional senior RN (in NHS pay band 7 or 8) had 2.2 times the impact of an additional band 5 RN (fill-rate for bands 7 and 8: OR 0.9760, 95% CI 0.9551 to 0.9973, p=0.0275; band 5: OR 0.9893, 95% CI 0.9771 to 1.0017, p=0.0907). Conclusions RN staffing and seniority levels were associated with patient mortality. The lack of association for HCSWs and agency nurses indicates they are not effective substitutes for RNs who regularly work on the ward. [ABSTRACT FROM AUTHOR]

Aims: To identify strategies used by registered nurses and non‐registered nursing care staff in overcoming barriers when providing fundamental nursing care for non‐invasively ventilated inpatients with COVID‐19. Design: Online survey with open‐ended questions to collect qualitative data. Methods: In August 2020, we asked UK‐based nursing staff to describe any strategies they employed to overcome barriers to delivering care in 15 fundamental nursing care categories when providing care to non‐invasively ventilated patients with COVID‐19. We analysed data using Framework Analysis. Results: A total of 1062 nurses consented to participate in our survey. We derived four themes. 1) Communication behaviours included adapting verbal and non‐verbal communication with patients, using information technology to enable patients' significant others to communicate with staff and patients, and establishing clear information‐sharing methods with other staff. 2) Organizing care required clustering interventions, carefully managing supplies, encouraging patient self‐care and using 'runners' and interdisciplinary input. 3) Addressing patients' well‐being and values required spending time with patients, acting in loco familiae, providing access to psychological and spiritual support, obtaining information about patients' wishes early on and providing privacy and comforting/meaningful items. 4) Management and leadership behaviours included training, timely provision of pandemic information, psychological support, team huddles and facilitating regular breaks. Conclusions: Our respondents identified multiple strategies in four main areas of clinical practice. Management and leadership are crucial to both fundamental care delivery and the well‐being of nurses during pandemics. Grouping strategies into these areas of action may assist nurses and leaders to prepare for pandemic nursing. Impact As these strategies are unlikely to be exclusive to the COVID‐19 pandemic, their global dissemination may improve patient experience and help nurses deliver fundamental care when planning pandemic nursing. However, their effectiveness is unknown. Therefore, we are currently evaluating these strategies in a cluster randomized controlled trial. [ABSTRACT FROM AUTHOR]