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Introduction: The adoption of remote healthcare methods has been accelerated by the COVID‐19 pandemic, but evidence suggests that some patients need additional support to engage remotely, potentially increasing health disparities if needs are not met. This study of COVID‐19 remote home monitoring services across England explores experiences of and engagement with the service across different patient groups. Methods: This was a mixed‐methods study with survey and interview data collected from 28 services across England between February and June 2021. Surveys were conducted with staff and patients and carers receiving the service. Interviews with staff service leads, patients and carers were conducted in 17 sites. Quantitative data were analysed using univariate and multivariate methods, and qualitative data were analysed using thematic analysis. Findings: Survey responses were received from 292 staff and 1069 patients and carers. Twenty‐three staff service leads, 59 patients and 3 carers were interviewed. Many service leads reported that they had considered inclusivity when adapting the service for their local population; strategies included widening the eligibility criteria, prioritising vulnerable groups and creating referral pathways. However, disparities were reported across patient groups in their experiences and engagement. Older patients reported the service to be less helpful (p = 0.004), were more likely to report a problem (p < 0.001) and had more difficulty in understanding information (p = 0.005). Health status (p = 0.004), ethnicity (p < 0.001), gender (p < 0.001) and employment (p = 0.007) were associated with differential engagement with monitoring, and minority ethnic groups reported more difficulty understanding service information (p = 0.001). Qualitative data found illness severity to be an important factor in the support required, and patients' living situation and social network affected whether they found the service reassuring. Conclusion: Addressing health disparities must be a key focus in the design and delivery of remote care. Services should be tailored to match the needs of their local population, encourage access through collaboration and referral pathways with other services and monitor their inclusiveness. Involving patients and staff in service design can illuminate the diversity of patients' needs and experiences of care. Patient or Public Contribution: The study team met with service user and public members of the BRACE PPI group and patient representatives from RSET in a series of workshops. Workshops informed study design, data collection tools, data interpretation and dissemination activities. Study documents (such as consent forms, topic guides, surveys and information sheets) were reviewed by PPI members; patient surveys and interview guides were piloted, and members also commented on the manuscript. [ABSTRACT FROM AUTHOR]

Based on a three-year ethnographic study of four UK National Health Service (NHS) organizations, we explore the everyday cultural experience of managing clinical and administrative workforces. Although NHS organizations claim to function as enlightened HRM employers, we argue that the inflexible application of metrics-based target systems to clinical and administrative tasks, including HRM operations, can result in dysfunctional outcomes for patient care and workforce morale. Reminiscent of the recent Mid Staffordshire health care scandal, the priorities attached to NHS personnel meeting the demands of performance management systems can prove incompatible with them also meeting the fundamental 'human' needs of patients. The everyday experience of health care organization becomes one of employees reconciling competing logics of business efficiency and integrity of care. Trapped metaphorically between shrinking resources and expanding targets, the inclination-on the frontline and at mid-management level-is to extend the integrity of care, although this is sometimes impossible and can prove problematic in terms of system accountability. In response to such organizational tensions the behavior of many frontline and mid-management staffs ultimately reflects a form of 'street-level bureaucracy'-a situation in which traditional professional norms are reasserted informally in ways that often transgress prescribed performance systems. © 2015 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Background: Sustaining high‐quality, critical care practice is challenging because of current limits to financial, environmental, and social resources. The National Health Service in England intends to be more sustainable, although there is minimal research into what sustainability means to people working in critical care, and a theoretical framework is lacking that explains the social processes influencing sustainability in critical care. Aims and objectives: This study aimed to explain the concept of sustainability from the perspective of practitioners caring for critically ill patients. Design The qualitative research followed a Charmazian constructivist grounded theory approach, including concurrent data collection and interpretation through constant comparison analysis. Methods: In‐depth interviews were conducted online or by telephone with 11 health care professionals working in critical care in the South of England (8 nurses, 2 physiotherapists, and 1 technician). Schatzman's dimensional analysis and Straussian grounded theory techniques supplemented the data analysis. Results: Sustainability was defined as maintaining financial, environmental, and social resources throughout the micro, meso, and macro systems of critical care practice. The most pertinent social process enabling sustainability of critical care was satisficing (satisfaction of achieving a goal of quality care while sufficing within the limits of available resources). Increased satisficing enabled practitioners to fulfil their sense of normative, responsible, sustainable, and flourishing practice. Satisficing was bounded by the cognitive and environmental influences on decisions and an ethical imperative to ensure resources were used wisely through stewarding. Conclusions: An explanation of the concept of sustainability and significant social processes, in relation to critical care, are presented in a theoretical framework, with implications for how financial, environmental, and social resources for critical care practice can be maintained. Relevance to clinical practice: This theory offers clinicians, managers, educators, and researchers a definition of sustainability in critical care practice and provides a structured approach to addressing critical care sustainability issues. [ABSTRACT FROM AUTHOR]

Background: It is widely acknowledged that inadequate handovers are associated with putting patients at risk in clinical settings; however, handover practices have received little attention in other 24‐hr settings such as long‐stay residential care facilities. Aim: This study aimed to explore the perceived purpose and organisational processes involved in the handover of information between shifts of staff caring for older residents in five care homes in England. Methods: The study took an ethnographic approach to fieldwork, undertaken between February and June 2016. It consisted of observations of handovers (n = 12) and interviews with managers, Registered Nurses (RNs) and care assistants (n = 27) working day and night shifts. Interview transcripts and observation notes were analysed within NVivo using a matrix approach. Results: Handovers were highly variable in all five care homes in relation to their timings, locations, content and participants. Managers and RNs highlighted handovers as an opportunity for risk assurance, supervision, team building, staff education and monitoring of residents' clinical status. In comparison, care assistants considered the purpose of handovers to be prepared for the responsibilities of working a shift. The discussion addresses implications of these findings, particularly consideration of how best use can be made of RN skills and knowledge in handovers. Conclusion: Research is needed to identify whether care home resident safety can be linked to handover practices and how the presence of RNs in handovers in care homes affects this. Implications for practice: Care home managers, RNs and care workers may find this research useful in practice when considering how best to organise handovers and deploy staff in care homes for older people. [ABSTRACT FROM AUTHOR]

Abstract: This article examines the articulation and enactment of racialised classifications in clinical practice guidelines and in accounts of clinical practice. It contributes to debates about racialisation in medicine and its consequences. The research centred on the case study of prescribing guidelines for hypertension in England and Wales, drawing on documentary sources and semi‐structured expert interviews. We found that conceptual and socio‐political uncertainties existed about how to interpret the designation ‘Black patients’ and about the practices for identifying patients’ race/ethnicity. To ‘close’ uncertainties, and thus produce the guidelines and treat patients, respondents drew authority from disparate elements of the ‘topologies of race’. This has implications for understanding processes of racialisation and for the future use of racialised clinical practice guidelines. We argue that clinical practice guidelines play a ‘nodal’ role in racialisation by forming an authoritative material connection that creates a path for translating racialised research into racialised healthcare practice, and that they carry with them implicit conceptual and socio‐political uncertainties that are liable to create inconsistencies in healthcare practice. [ABSTRACT FROM AUTHOR]

Context: The long-term sustainability of whole-system change programs is rarely studied, and when it is, it is inevitably undertaken in a shifting context, thereby raising epistemological and methodological questions. This article describes a transferable methodology that was developed to guide the evaluation of a three-year follow-up of a large health care change program in London, which took place during a period of economic turbulence and rapid policy change. Method: Using a mixed-method organizational case study design, we studied three services (stroke, kidney, and sexual health) across primary and secondary care. Each had received £5 million (US$7.8 million) in modernization funding in 2004. In 2010/2011, we gathered data on the services and compared them with data from 2004 to 2008. The new data set contained quantitative statistics (access, process, and outcome metrics), qualitative interviews with staff and patients, documents, and field notes. Our data analysis was informed by two complementary models of sustainability: intervention-focused (guided by the question, What, if anything, of the original program has been sustained?) and system-dynamic (guided by the question, How and why did change unfold as it did in this complex system?). Findings: Some but not all services introduced in the original transformation effort of 2004-2008 were still running; others had ceased or been altered substantially to accommodate contextual changes (e.g., in case mix, commissioning priorities, or national policies). Key cultural changes (e.g., quality improvement, patient centeredness) largely persisted, and innovative ideas and practices had spread elsewhere. To draw causal links between the original program and current activities and outcomes, it was necessary to weave a narrative thread with multiple intervening influences. In particular, against a background of continuous change in the local health system, the sustainability of the original vision and capacity for quality improvement was strongly influenced by (1) stakeholders' conflicting and changing interpretations of the targeted health need; (2) changes in how the quality cycle was implemented and monitored; and (3) conflicts in stakeholders' values and what each stood to gain or lose. Conclusions: The sustainability of whole-system change embodies a tension between the persistence of past practice and the adaptation to a changing context. Although the intervention-focused question, What has persisted from the original program? (addressed via a conventional logic model), may be appropriate, evaluators should qualify their findings by also considering the system-dynamic question, What has changed, and why? (addressed by producing a meaningful narrative). [ABSTRACT FROM AUTHOR]

Background Despite the policy rhetoric, patient involvement in health service decisions remains limited. Highlighted barriers include a concern that most patients are unable to see beyond personal aspects of their care in order to contribute meaningfully to health service development, and a perception that professionals do not welcome patient involvement. Objectives We aimed to explore respiratory patients' awareness of changes in local health service provision and provide insight into health professionals' attitudes to engaging patients. Methods Nested within an ethnographic study of health service reconfiguration, we recruited 31 patients with a range of respiratory diseases from four case study areas in England and Wales. Data from telephone interviews, illness diaries and focus groups with patients, and interviews with health professionals and managers were transcribed and analysed using the Framework approach. Results Participants were not only aware of trends in health service provision (e.g. emergence of new professional roles, shift from secondary to primary care) but interpreted changes in the light of local and national events. Despite this awareness, none of the patients was formally involved in service development, though some contributed to local voluntary groups. Professionals generally welcomed the need for patients' views to be heard. Discussion and conclusions Our data give grounds for optimism. Patients are aware of and interested in a broad range of health-related issues. Professionals' motivation to involve patients in service development may be underestimated. Although practical obstacles remain, our findings should encourage the ongoing search for effective models of promoting patient engagement in health-care services. [ABSTRACT FROM AUTHOR]