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Background: There is a growing international policy focus on involving those affected by healthcare safety incidents, in subsequent investigations. Nonetheless, there remains little UK-based evidence exploring how this relates to the experiences of those affected over time, including the factors influencing decisions to litigate. Aims: We aimed to explore the experiences of patients, families, staff and legal representatives affected by safety incidents over time, and the factors influencing decisions to litigate. Methods: Participants were purposively recruited via (i) communication from four NHS hospital Trusts or an independent national investigator in England, (ii) relevant charitable organizations, (iii) social media, and (iv) word of mouth to take part in a qualitative semi-structured interview study. Data were analyzed using an inductive reflexive thematic approach. Findings: 42 people with personal or professional experience of safety incident investigations participated, comprising patients and families (n = 18), healthcare staff (n = 7), legal staff (n = 1), and investigators (n = 16). Patients and families started investigation processes with cautious hope, but over time, came to realize that they lacked power, knowledge, and support to navigate the system, made clear in awaited investigation reports. Systemic fear of litigation not only failed to meet the needs of those affected, but also inadvertently led to some pursuing litigation. Staff had parallel experiences of exclusion, lacking support and feeling left with an incomplete narrative. Importantly, investigating was often perceived as a lonely, invisible and undervalued role involving skilled "work" with limited training, resources, and infrastructure. Ultimately, elusive "organizational agendas" were prioritized above the needs of all affected. Conclusions: Incident investigations fail to acknowledge and address emotional distress experienced by all affected, resulting in compounded harm. To address this, we propose five key recommendations, to: (1) prioritize the needs of those affected by incidents, (2) overcome culturally engrained fears of litigation to re-humanize processes and reduce rates of unnecessary litigation, (3) recognize and value the emotionally laborious and skilled work of investigators (4) inform and support those affected, (5) proceed in ways that recognize and seek to reduce social inequities. [ABSTRACT FROM AUTHOR]

Background: Healthcare organisations risk harming patients and their families twofold. First, through the physical, emotional and/or financial harm caused by safety incidents themselves, and second, through the organisational response to incidents. The former is well-researched and targeted by interventions. However, the latter, termed 'compounded harm' is rarely acknowledged. Aims: We aimed to explore the ways compounded harm is experienced by patients and their families as a result of organisational responses to safety incidents and propose how this may be reduced in practice. Methods: We used framework analysis to qualitatively explore data derived from interviews with 42 people with lived or professional experience of safety incident responses. This comprised 18 patients/relatives, 16 investigators, seven healthcare staff and one legal staff. People with lived and professional experience also helped to shape the design, conduct and findings of this study. Findings: We identified six ways that patients and their families experienced compounded harm because of incident responses. These were feeling: (1) powerless, (2) inconsequential, (3) manipulated, (4) abandoned, (5) de-humanised and (6) disoriented. Discussion: It is imperative to reduce compounded harm experienced by patients and families. We propose three recommendations for policy and practice: (1) the healthcare system to recognise and address epistemic injustice and equitably support people to be equal partners throughout investigations and subsequent learning to reduce the likelihood of patients and families feeling powerless and inconsequential; (2) honest and transparent regulatory and organisational cultures to be fostered and enacted to reduce the likelihood of patients and families feeling manipulated; and (3) the healthcare system to reorient towards providing restorative responses to harm which are human centred, relational and underpinned by dignity, safety and voluntariness to reduce the likelihood of patients and families feeling abandoned, de-humanised and disoriented. [ABSTRACT FROM AUTHOR]

This opinion paper investigates how healthcare organizations identify and act upon different types of risk signals. These signals may generally be acknowledged, but we also often see with hindsight that they might not be because they have become a part of normal practice. Here, we detail how risk signals from patients and families should be acknowledged as system-level safety critical information and as a way of understanding and changing safety culture in healthcare. We discuss how healthcare organizations could work more proactively with patient experience data in identifying risks and improving system safety. [ABSTRACT FROM AUTHOR]

Introduction: Complex intervention development has been described as the 'Cinderella' black box in health services research. Greater transparency in the intervention development process is urgently needed to help reduce research waste. Methods: We applied a new consensus‐based framework for complex intervention development to our programme of research, in which we developed an intervention to improve the safety and experience of care transitions for older people. Through this process, we aimed to reflect on the framework's utility for intervention development and identify any important gaps within it to support its continued development. Findings: The framework was a useful tool for transparent reporting of the process of complex intervention development. We identified potential 'action' gaps in the framework including 'consolidation of evidence' and 'development of principles' that could bracket and steer decision‐making in the process. Conclusions: We consider that the level of transparency demonstrated in this report, aided through use of the framework, is essential in the quest for reducing research waste. Patient or Public Contribution: We have involved our dedicated patient and public involvement group in all work packages of this programme of research. Specifically, they attended and contributed to co‐design workshops and contributed to finalizing the intervention for the pilot evaluation. Staff also participated by attending co‐design workshops, helping us to prioritize content ideas for the intervention and supporting the development of intervention components outside of the workshops. [ABSTRACT FROM AUTHOR]

Introduction: Healthcare system resilience is a conceptual approach that seeks to explore how health services adapt and respond to variability in demand and resources. As has been witnessed since the beginning of the COVID‐19 pandemic, healthcare services have undergone many reconfigurations. One understudied aspect of how the 'system' is able to adapt and respond is the contribution of key stakeholders—patients and families, and in the context of the pandemic, the general public as a whole. This study aimed to understand what people were doing during the first wave of the pandemic to protect the safety of their health, and the health of others from COVID‐19, and the resilience of the healthcare system. Methods: Social media (Twitter) was used as a method of recruitment due to its ability for social reach. Twenty‐one participants took part in 57 semistructured interviews over three time points from June to September 2020. The included an initial interview and invitation to two follow‐up interviews after 3 and 6 weeks. Interviews were conducted virtually using Zoom—an encrypted secure video conferencing software. A reflexive thematic analysis approach to analysis was used. Results: Three themes, each with its own subthemes were identified in the analysis: (1) A 'new safety normal'; (2) Existing vulnerabilities and heightened safety and (3) Are we all in this together? Conclusion: This study found that the public had a role in supporting the resilience of healthcare services and systems during the first wave of the pandemic by adapting their behaviour to protect themselves and others, and to avoid overwhelming the National Health Service. People who had existing vulnerabilities were more likely to experience safety gaps in their care, and be required to step in to support their safety, despite it being more difficult for them to do so. It may be that the most vulnerable were previously required to do this extra work to support the safety of their care and that the pandemic has just illuminated this issue. Future research should explore existing vulnerabilities and inequalities, and the heightened safety consequences created by the pandemic. Patient and Public Contribution: The National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC), Patient and Public Involvement and Engagement Research Fellow and NIHR Yorkshire and Humber PSTRC Patient Involvement in Patient Safety theme lay leader are involved in the preparation of a lay version of the findings within this manuscript. [ABSTRACT FROM AUTHOR]

Introduction: Care Opinion is an online feedback platform supporting patients to author stories about their care. It is not known whether authors would be willing to be involved in improving care through research. The aims of this study were to explore the views and preferences of Care Opinion authors about joining an online research community and to pilot new research community functionality. Methods: Five hundred and nine Care Opinion authors were invited to take part in an online survey in June 2019. Survey items included questions about participants' willingness to take part in research and their preferences for supporting processes. Data were analysed descriptively. Authors were invited to consent to join a research community and were asked to participate in three pilot studies. Results: One hundred and sixty‐three people consented to take part in the survey (32%). Participants indicated they would like to know the time commitment to the project (146, 90%), details about the organization carrying out the research (124, 76%) and safeguarding information (124, 76%). Over half indicated that they did not know how to get involved in healthcare research (87, 53%). Subsequently, 667 authors were invited to join the research community, 183 (27%) accepted, and three studies were matched to their expressed preferences for project attributes or organization type. Conclusion: Many people who leave online feedback about their experiences of healthcare are also willing to join a research community via that platform. They have strong preferences for supporting University and NHS research. Eligibility and acceptance rates to join pilot research studies varied. Further work is needed to grow the research community, increase its diversity, and create relevant and varied opportunities to support research. Patient or Public Contribution: Four members of the Safety In Numbers patient and public involvement and engagement (PPIE) group advised about survey development. [ABSTRACT FROM AUTHOR]

Healthcare staff are encouraged to use feedback from their patients to inform service and quality improvement. Receiving patient feedback via online channels is a relatively new phenomenon that has rarely been conceptualised. Further, the implications of a wide, varied and unknown(able) audience being able to view and interact with online patient feedback are yet to be understood. We applied a theoretical lens of dramaturgy to a large ethnographic dataset, collected across three NHS Trusts during 2019/2020. We found that organisations demonstrated varying levels of 'preparedness to perform' online, from invisibility through to engaging in public conversation with patients within a wider mission for transparency. Restrictive 'cast lists' of staff able to respond to patients was the hallmark of one organisation, whereas another devolved responding responsibility amongst a wide array of multidisciplinary staff. The visibility of patient‐staff interactions had the potential to be culturally disruptive, dichotomously invoking either apprehensions of reputational threat or providing windows of opportunity. We surmise that a transparent and conversational feedback response frontstage aligns with the ability to better prioritise backstage improvement. Legitimising the autonomous frontstage activity of diverse staff groups may help shift organisational culture, and gradually ripple outwards a shared responsibility for transparent improvement. [ABSTRACT FROM AUTHOR]

Background: The Partners at Care Transitions (PACTs) intervention was developed to support older people's involvement in hospital to improve outcomes at home. A booklet, question card, record sheet, induction leaflet, and patient‐friendly discharge letter support patients to be more involved in their health and wellbeing, medications, activities of daily living and post‐discharge care. We aimed to assess intervention acceptability, identify implementation tools, and further develop the intervention. Methods: This was a qualitative formative evaluation involving three wards from one hospital. We recruited 25 patients aged 75 years and older. Ward staff supported intervention delivery. Data were collected in wards and patients' homes, through semi‐structured interviews, observation, and documentary analysis. Data were analysed inductively and iteratively with findings sorted according to the research aims. Results: Patients and staff felt there was a need for, and understood the purpose of, the PACT intervention. Most patients read the booklet but other components were variably used. Implementation challenges included time, awareness, and balancing intervention benefits against risks. Changes to the intervention and implementation included clarifying the booklet's messages, simplifying the discharge letter to reduce staff burden, and using prompts and handouts to promote awareness. Conclusion: The PACT intervention offers a promising new way to improve care transitions for older people by supporting patient involvement in their care. After further development of the intervention and implementation package, it will undergo further testing. Patient or Public Contribution: This study regularly consulted a panel representing the local patient community, who supported the development of this intervention and its implementation. [ABSTRACT FROM AUTHOR]

Background: Healthcare is not without risk. Despite two decades of policy focus and improvement efforts, the global incidence of harm remains stubbornly persistent, with estimates suggesting that 10% of hospital patients are affected by adverse events. Methods: We explore how current investigative responses can compound the harm for all those affected—patients, families, health professionals and organizations—by neglecting to appreciate and respond to the human impacts. We suggest that the risk of compounded harm may be reduced when investigations respond to the need for healing alongside system learning, with the former having been consistently neglected. Discussion: We argue that incident responses must be conceived within a relational as well as a regulatory framework, and that this—a restorative approach—has the potential to radically shift the focus, conduct and outcomes of investigative processes. Conclusion: The identification of the preconditions and mechanisms that enable the success of restorative approaches in global health systems and legal contexts is required if their demonstrated potential is to be realized on a larger scale. The policy must be co‐created by all those who will be affected by reforms and be guided by restorative principles. Patient or Public Contribution: This viewpoint represents an international collaboration between a clinician academic, safety scientist and harmed patient and family members. The paper incorporates key findings and definitions from New Zealand's restorative response to surgical mesh harm, which was co‐designed with patient advocates, academics and clinicians. [ABSTRACT FROM AUTHOR]

Background: The nonlinear nature of contagious diseases and the potential for exponential growth can be difficult to grasp for the general public. This has strong implications for public health communication, which needs to be both easily accessible and efficient. A pandemic is an extreme situation, and the accompanying strict societal measures are generally easier to accept if one understands the underlying reasoning behind them. Bringing about informed attitude change and achieving compliance to strict restrictions requires explanations of scientific concepts and terminologies that laypersons can understand. Objective: The aim of the project is to develop effective, evidence-based modes of video communication for translating complex, but important, health messages about pandemics to both the general population and decision makers. The study uses COVID-19 as a case to learn and prepare society for handling the ongoing and future pandemics, as well as to provide evidence-based tools for the science communication toolbox. Methods: The project applies a mixed methods design, combining qualitative methods (eg, interviews, observational studies, literature reviews) and quantitative methods (eg, randomized controlled trials [RCTs]). The project brings together researchers from a wide range of academic fields, as well as communication industry professionals. Results: This study has received funding from the Trond Mohn Foundation through the Research Council of Norway’s “COVID-19 Emergency Call for Proposals” March 2020. Recruitment and data collection for the exploratory first phase of the project ran from February 2021 to March 2021. Creative communication work started in May 2021, and the production of videos for use in the RCTs in the final phase of the project started in September 2021. Conclusions: The COVCOM project will take on several grand challenges within the field of communicating science and provide evidence-based tools to the science communication toolbox. A long-term goal of the project is to contribute to the creation of a more resilient health care system by developing communication responses tailormade for different audiences, preparing society for any future pandemic. [ABSTRACT FROM AUTHOR]

Medical education has an important role in developing attitudes, behaviors and cultures that support safe care. Increasingly, however, research has argued for a more interprofessional approach to be taken. This scoping review examines the design and impact of interprofessional education interventions involving medical students that focus on patient safety. We systematically searched PubMed, EMBASE, PsycINFO and CINAHL between January 2000 and November 2019. Studies were eligible if they included medical students and at least one other profession, interactive learning, a strong emphasis on patient safety in the learning objectives, and an empirical method of evaluation. Forty-three studies met these criteria and the diverse range of approaches to intervention design and method of evaluation are detailed in this review. We found that interprofessional patient safety education interventions are generally well received by students with knowledge and skill gain documented; several also reported changes in student behaviour. However, the lack of empirically driven study designs, combined with the lack of rigour when reporting, makes it difficult to draw clear comparisons. Future research should address this, and in particular, report how and why the intervention has been designed to be delivered interprofessionally. [ABSTRACT FROM AUTHOR]

Logic models feature prominently in intervention research yet there is increasing debate about their ability to express how interventions work in the real-world. 'Real-world' logic models are a new proposition which express complex interventions in context. They are designed to help researchers strike a balance between context-sensitivity and scalability. This article explores the utility of real-world logic models in a trial involving a complex intervention called 'Your Care Needs You', designed to improve hospital-home transitions for UK older patients. The approach is found to usefully capture, refine and express important learning about intervention-implementation-context dynamics. The findings imply the need for intervention researchers to think creatively about how to implement interventions in diverse and sometimes challenging environments and to develop understanding of how complex interventions adapt on implementation to produce outcomes. The possibility of assessing the wider social and policy context within intervention research is also posed. [ABSTRACT FROM AUTHOR]

Background: Resilient and responsive healthcare systems is on the agenda as ever before. COVID-19, specialization of services, resource demands, and technology development are all examples of aspects leading to adaptations among stakeholders at different system levels whilst also attempting to maintain high service quality and safety. This commentary sets the scene for a journal collection on Resilient and responsive health systems in a changing world. The commentary aims to outline main challenges and opportunities in resilient healthcare theory and practice globally, as a backdrop for contributions to the collection.Main Text: Some of the main challenges in this field relate to a myriad of definitions and approaches to resilience in healthcare, and a lack of studies having multilevel perspectives. Also, the role of patients, families, and the public in resilient and responsive healthcare systems is under researched. By flipping the coin, this illustrates opportunities for research and practice and raise key issues that future resilience research should pay attention to. The potential of combining theoretical lenses from different resilience traditions, involvement of multiple stakeholders in co-creating research and practice improvement, and modelling and visualizing resilient performance are all opportunities to learn more about how healthcare succeeds under stress and normal operations.Conclusion: A wide understanding of resilience and responsiveness is needed to support planning and preparation for future disasters and for handling the routine small-scale adaptation. This collection welcomes systematic reviews, quantitative, qualitative, and mixed-methods research on the topic of resilience and responsiveness in all areas of the health system. [ABSTRACT FROM AUTHOR]

Background Teamwork and communication are recognised as key contributors to safe and high-quality patient care. Interventions targeting process and relational aspects of care may therefore provide patient safety solutions that reflect the complex nature of healthcare. Team reflexivity is one such approach with the potential to support improvements in communication and teamwork, where reflexivity is defined as the ability to pay critical attention to individual and team practices with reference to social and contextual information. Objective To systematically review articles that describe the use of team reflexivity in interprofessional hospital-based healthcare teams. Methods Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, six electronic databases were searched to identify literature investigating the use of team reflexivity in interprofessional hospital-based healthcare teams. The review includes articles investigating the use of team reflexivity to improve teamwork and communication in any naturally occurring hospital-based healthcare teams. Articles' eligibility was validated by two second reviewers (5%). Results Fifteen empirical articles were included in the review. Simulation training and video-reflexive ethnography (VRE) were the most commonly used forms of team reflexivity. Included articles focused on the use of reflexive interventions to improve teamwork and communication within interprofessional healthcare teams. Communication during interprofessional teamworking was the most prominent focus of improvement methods. The nature of this review only allows assessment of team reflexivity as an activity embedded within specific methods. Poorly defined methodological information relating to reflexivity in the reviewed studies made it difficult to draw conclusive evidence about the impact of reflexivity alone. Conclusion The reviewed literature suggests that VRE is well placed to provide more locally appropriate solutions to contributory patient safety factors, ranging from individual and social learning to improvements in practices and systems. Trial registration number CRD42017055602. [ABSTRACT FROM AUTHOR]

Background: The number of physician associates (PAs) training and working in the UK has increased over the last few years following the proliferation of postgraduate courses. Understanding early experiences and what impacts on engagement is important if we are to appropriately support this relatively new professional group. Methods: This paper reports on a cross-sectional analysis of the first year of data from a prospective 10-year longitudinal cohort study. First year PA students (n = 89) were enrolled from five universities in one UK region where the training programmes were less than 2 years old. Data collected were: demographic information, wellbeing, burnout and engagement, expectations, placement experience, performance and caring responsibilities. Pearson's correlations were used to examine relationships between variables and to select variables for a hierarchical regression analysis to understand which factors were associated with engagement. Descriptive statistics were calculated for questions relating to experience. Results: The experiences of PA students during their first 3–6 months were mixed. For example, 78.7% of students felt that there were staff on placement they could go to for support, however, 44.8% reported that staff did not know about the role and 61.3% reported that staff did not know what clinical work they should undertake. Regression analysis found that their level of engagement was associated with their perceived career satisfaction, overall well-being, and caring responsibilities. Conclusions: The support systems required for PAs may need to be examined as results showed that the PA student demographic is different to that of medical students and caring responsibilities are highly associated with engagement. A lack of understanding around the PA role in clinical settings may also need to be addressed in order to better support and develop this workforce. [ABSTRACT FROM AUTHOR]

Background: Understanding the resilience of healthcare is critically important. A resilient healthcare system might be expected to consistently deliver high quality care, withstand disruptive events and continually adapt, learn and improve. However, there are many different theories, models and definitions of resilience and most are contested and debated in the literature. Clear and unambiguous conceptual definitions are important for both theoretical and practical considerations of any phenomenon, and resilience is no exception. A large international research programme on Resilience in Healthcare (RiH) is seeking to address these issues in a 5-year study across Norway, England, the Netherlands, Australia, Japan, and Switzerland (2018-2023). The aims of this debate paper are: 1) to identify and select core operational concepts of resilience from the literature in order to consider their contributions, implications, and boundaries for researching resilience in healthcare; and 2) to propose a working definition of healthcare resilience that underpins the international RiH research programme.Main Text: To fulfil these aims, first an overview of three core perspectives or metaphors that underpin theories of resilience are introduced from ecology, engineering and psychology. Second, we present a brief overview of key definitions and approaches to resilience applicable in healthcare. We position our research program with collaborative learning and user involvement as vital prerequisite pillars in our conceptualisation and operationalisation of resilience for maintaining quality of healthcare services. Third, our analysis addresses four core questions that studies of resilience in healthcare need to consider when defining and operationalising resilience. These are: resilience 'for what', 'to what', 'of what', and 'through what'? Finally, we present our operational definition of resilience.Conclusion: The RiH research program is exploring resilience as a multi-level phenomenon and considers adaptive capacity to change as a foundation for high quality care. We, therefore, define healthcare resilience as: the capacity to adapt to challenges and changes at different system levels, to maintain high quality care. This working definition of resilience is intended to be comprehensible and applicable regardless of the level of analysis or type of system component under investigation. [ABSTRACT FROM AUTHOR]

Background: Measures exist to improve early recognition of, and response to deteriorating patients in hospital. Despite these, 7% of the deaths reported to the National Reporting and Learning System from acute hospitals in 2015 related to a failure to recognise or respond to deterioration. Interventions have been developed that allow patients and relatives to escalate patient deterioration to a critical care outreach team. However, there is not a strong evidence base for the clinical effectiveness of these interventions, or patients' ability to recognise deterioration. Aims: The aims of this study were as follows. (a) To identify methods of involving patients in recognising deterioration in hospital, generated by health professionals. (b) To develop and evaluate an identified method of patient involvement in practice, and explore its feasibility and acceptability from the perspectives of patients. Methods: The study used a mixed-methods design. A measure to capture patient-reported wellness during observation was developed (Patient Wellness Questionnaire) through focus group discussion with health professionals and patients, and piloted on inpatient wards. Results: There was limited uptake where patients were asked to record ratings of their wellness using the Patient Wellness Questionnaire themselves. However, where the researcher asked patients about their wellness using the Patient Wellness Questionnaire and recorded their responses during observation, this was acceptable to most patients. Conclusions: This study has developed a measure that can be used to routinely collect patient-reported wellness during observation in hospital and may potentially improve early detection of deterioration. [ABSTRACT FROM AUTHOR]

• Patients and families should be involved as co-creators of evidence in RHC studies. • Patients and family activity should also be modelled as co-creators of resilience. • Our tool supports decisions about how patient and families should be involved. Whilst interest in resilient healthcare (RHC) research has increased over the past five years, our understanding of the role of patients, families and carers in supporting system resilience remains limited (Berg et al., 2018; Laugaland and Aase, 2015). The extant empirical evidence for RHC has almost exclusively been undertaken from the perspective of staff. However, evidence is emerging suggesting that patients, families and carers impact on variability and outcomes within complex health systems, and as such could be regarded as co-creators of resilience (Schubert et al., 2015 ; O'Hara et al., 2019). Within health services research and improvement, engagement of patients and the public is widespread, with an ever building evidence base examining how, and in what ways such engagement should be done (Kirwan et al., 2017). Thus, as it grows as a discipline, there is no doubt that this 'moral' argument for the involvement of patients and families in RHC research will increase. However, in this paper we argue that whilst involving patients and families in RHC research clearly remains a moral imperative, it is also – and perhaps as importantly – driven by the logic of doing so. We view the integration of patient and family perspectives in RHC studies, as comprising two discrete, but not mutually exclusive approaches: (i) Patient and family 'involvement' in RHC studies, as co-creators of evidence ; and, (ii) exploring and modeling patient and family 'functional activity' within systems, recognising their role as co-creators of resilience. We will discuss six case studies of RHC research: two that explore the role of patient and family activity within systems, and four that do not view patient and family activity as part of the system. Our aim is to demonstrate how without these perspectives, our understanding of work-as-done may be limited, and not account for variability introduced by these key actors within the system, that both supports, and compromises, the resilience of that system. In short, without understanding this variability we risk misunderstanding the resilience of our healthcare systems. Drawing on the case study examples, we present a planning support tool for the involvement of patient and family perspectives in RHC studies, which will provide practical guidance to support decisions about when, and how, to explore and document patient and family activity within systems. As key stakeholders in healthcare systems, patients and families should always be involved as co-creators of evidence in RHC studies. However, here we argue that for most healthcare systems, they are likely to additionally be co-creators of resilience. [ABSTRACT FROM AUTHOR]

Background: Current models of patient‐enacted involvement do not capture the nuanced dynamic and interactional nature of involvement in care. This is important for the development of flexible interventions that can support patients to 'reach‐in' to complex health‐care systems. Objective: To develop a dynamic and interactional model of patient‐enacted involvement in care. Search strategy: Electronic search strategy run in five databases and adapted to run in an Internet search engine supplemented with searching of reference lists and forward citations. Inclusion criteria: Qualitative empirical published reports of older people's experiences of care transitions from hospital to home. Data extraction and synthesis: Reported findings meeting our definition of involvement in care initially coded into an existing framework. Progression from deductive to inductive coding leads to the development of a new framework and thereafter a model representing changing states of involvement. Main results: Patients and caregivers occupy and move through multiple states of involvement in response to perceived interactions with health‐care professionals as they attempt to resolve health‐ and well‐being‐related goals. 'Non‐involvement', 'information‐acting', 'challenging and chasing' and 'autonomous‐acting' were the main states of involvement. Feeling uninvolved as a consequence of perceived exclusion leads patients to act autonomously, creating the potential to cause harm. Discussion and conclusion: The model suggests that involvement is highly challenging for older people during care transitions. Going forward, interventions which seek to support patient involvement should attempt to address the dynamic states of involvement and their mediating factors. [ABSTRACT FROM AUTHOR]

Background: The PRASE (Patient Reporting and Action for a Safe Environment) intervention provides a way to systematically collect patient feedback to support service improvement. To provide a sustainable mechanism for the PRASE intervention, a 2‐year improvement project explored the potential for hospital volunteers to facilitate the collection of PRASE feedback. Objective: To explore the implementation of the PRASE intervention delivered in collaboration with hospital volunteers from the perspectives of key stakeholders. Design: A qualitative case study design was utilized across three acute NHS trusts in the United Kingdom between March 2016 and October 2016. Ward level data (staff interviews; action planning meeting recordings; implementation fidelity information) were analysed taking a pen portrait approach. We also carried out focus groups with hospital volunteers and interviews with voluntary services/patient experience staff, which were analysed thematically. Results: Whilst most ward staff reported feeling engaged with the intervention, there were discordant views on its use and usefulness. The hospital volunteers were positive about their involvement, and on some wards, worked with staff to produce actions to improve services. The voluntary services/patient experience staff participants emphasised the need for PRASE to sit within an organisations' wider governance structure. Conclusion: From the perspective of key stakeholders, hospital volunteers facilitating the collection of PRASE feedback is a feasible means of implementing the PRASE intervention. However, the variability around ward staff being able to use the feedback to make changes to services demonstrates that it is this latter part of the PRASE intervention cycle that is more problematic. [ABSTRACT FROM AUTHOR]