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Investigations of institutional failure in healthcare typically use staff narratives to identify the cultural factors contributing to the incident. But, to what extent can staff, who are embedded in the culture and who were part of the failing, reflect on and report on the culture? We investigate this by comparing 40 witness statements from staff and 53 witness statements from patients and relatives collected by a public inquiry into a major UK healthcare failure (Clostridium difficile outbreak). Through quantitative text analysis, we found that, while staff and external stakeholders both recognised problems in care, they diverged on the factors considered paramount. Staff emphasised underlying factors such as under‐resourcing and training (causal culture), while patients and relatives emphasised corrective behaviours such as communication for identifying and taking precautions against the spread of C. difficile (corrective culture). The results indicate that patients and relatives may be able to report on cultural factors that staff do not report or are unaware of, thus allowing a more complete analysis. Even in light of an institutional failure, staff may have incomplete accounts of the contributing cultural factors, with implications for learning and postincident improvement. [ABSTRACT FROM AUTHOR]

Background Antibiotics are extensively prescribed in intensive care units (ICUs), yet little is known about how antibiotic-related decisions are made in this setting. We explored how beliefs, perceptions and contextual factors influenced ICU clinicians' antibiotic prescribing. Methods We conducted 4 focus groups and 34 semistructured interviews with clinicians involved in antibiotic prescribing in four English ICUs. Focus groups explored factors influencing prescribing, whereas interviews examined decision-making processes using two clinical vignettes. Data were analysed using thematic analysis, applying the Necessity Concerns Framework. Results Clinicians' antibiotic decisions were influenced by their judgement of the necessity for prescribing/not prescribing, relative to their concerns about potential adverse consequences. Antibiotic necessity perceptions were strongly influenced by beliefs that antibiotics would protect patients from deterioration and themselves from the ethical and legal consequences of undertreatment. Clinicians also reported concerns about prescribing antibiotics. These generally centred on antimicrobial resistance; however, protecting the individual patient was prioritised over these societal concerns. Few participants identified antibiotic toxicity concerns as a key influencer. Clinical uncertainty often complicated balancing antibiotic necessity against concerns. Decisions to start or continue antibiotics often represented 'erring on the side of caution' as a protective response in uncertainty. This approach was reinforced by previous experiences of negative consequences ('being burnt') which motivated prescribing 'just in case' of an infection. Prescribing decisions were also context-dependent, exemplified by a lower perceived threshold to prescribe antibiotics out-of-hours, input from external team members and local prescribing norms. Conclusion Efforts to improve antibiotic stewardship should consider clinicians' desire to protect with a prescription. Rapid molecular microbiology, with appropriate communication, may diminish clinicians' fears of not prescribing or of using narrower-spectrum antibiotics. [ABSTRACT FROM AUTHOR]

Background: Rapid molecular diagnostic tests to investigate the microbial aetiology of pneumonias may improve treatment and antimicrobial stewardship in intensive care units (ICUs). Clinicians' endorsement and uptake of these tests is crucial to maximise engagement; however, adoption may be impeded if users harbour unaddressed concerns or if device usage is incompatible with local practice. Accordingly, we strove to identify ICU clinicians' beliefs about molecular diagnostic tests for pneumonias before implementation at the point-of-care. Methods: We conducted semi-structured interviews with 35 critical care doctors working in four ICUs in the United Kingdom. A clinical vignette depicting a fictitious patient with signs of pneumonia was used to explore clinicians' beliefs about the importance of molecular diagnostics and their concerns. Data were analysed thematically. Results: Clinicians' beliefs about molecular tests could be grouped into two categories: perceived potential of molecular diagnostics to improve antibiotic prescribing (Molecular Diagnostic Necessity) and concerns about how the test results could be implemented into practice (Molecular Diagnostic Concerns). Molecular Diagnostic Necessity stemmed from beliefs that positive results would facilitate targeted antimicrobial therapy; that negative results would signal the absence of a pathogen, and consequently that having the molecular diagnostic results would bolster clinicians' prescribing confidence. Molecular Diagnostic Concerns included unfamiliarity with the device's capabilities, worry that it would detect non-pathogenic bacteria, uncertainty whether it would fail to detect pathogens, and discomfort with withholding antibiotics until receiving molecular test results. Conclusions: Clinicians believed rapid molecular diagnostics for pneumonias were potentially important and were open to using them; however, they harboured concerns about the tests' capabilities and integration into clinical practice. Implementation strategies should bolster users' necessity beliefs while reducing their concerns; this can be accomplished by publicising the tests' purpose and benefits, identifying and addressing clinicians' misconceptions, establishing a trial period for first-hand familiarisation, and emphasising that, with a swift (e.g., 60–90 min) test, antibiotics can be started and refined after molecular diagnostic results become available. [ABSTRACT FROM AUTHOR]

Ancient, veteran and notable trees are ecologically important keystone organisms and have tangible connections to folklore, history and sociocultural practices. Although found worldwide, few countries have such a rich history of recording and treasuring these trees as the UK, with its extensive Royal and aristocratic land ownership, unique land management methods and long-standing interest in natural history and species record collecting. As a result, the UK has collated an extensive database of ancient, veteran and notable trees called the Ancient Tree Inventory (ATI). The ATI is the result of a successful, long-term citizen science recording project and is the most comprehensive database of ancient and other noteworthy trees to date. We present here the first review of the ATI in its entirety since its initiation in 2004, including summaries of the UK ancient, veteran and notable tree distributions, the status and condition of the trees, and key information about the recording process and maintenance of the database. Statistical analysis of components of the dataset, comprising 169,967 tree records, suggest there are significant differences in the threats, size, form and location of different types of trees, especially in relation to taxonomic identity and tree age. Our goal is to highlight the value of the ATI in the UK, to encourage the development of similar ancient tree recording projects in other countries, and to emphasise the importance to conservation of continued efforts to maintain and expand databases of this kind. [ABSTRACT FROM AUTHOR]

Background: The ability of medical teams to develop and maintain team situation awareness (team SA) is crucial for patient safety. Limited research has investigated team SA within clinical environments. This study reports the development of a method for investigating team SA during the intensive care unit (ICU) round and describes the results., Methods: In one ICU, a sample of doctors and nurses (n = 44, who combined to form 37 different teams) were observed during 34 morning ward rounds. Following the clinical review of each patient (n = 105), team members individually recorded their anticipations for expected patient developments over 48 h. Patient-outcome data were collected to determine the accuracy of anticipations. Anticipations were compared among ICU team members, and the degree of consensus was used as a proxy measure of team SA. Self-report and observational data measured team-member involvement and communication during patient reviews., Results: For over half of 105 patients, ICU team members formed conflicting anticipations as to whether patients would deteriorate within 48 h. Senior doctors were most accurate in their predictions. Exploratory analysis found that team processes did not predict team SA. However, the involvement of junior and senior trainee doctors in the patient decision-making process predicted the extent to which those team members formed team SA with senior doctors., Conclusions: A new method for measuring team SA during the ICU round was successfully employed. A number of areas for future research were identified, including refinement of the situation awareness and teamwork measures.