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Abstract Background Midwifery continuity of carer (MCoC) is a model of care in which the same midwife or small team of midwives supports women throughout pregnancy, birth and the postnatal period. The model has been prioritised by policy makers in a number of high-income countries, but widespread implementation and sustainability has proved challenging. Methods In this narrative review and synthesis of the global literature on the implementation and sustainability of midwifery continuity of carer, we identify barriers to, and facilitators of, this model of delivering maternity care. By mapping existing research evidence onto the Consolidated Framework for Implementation Research (CFIR), we identify factors for organisations to consider when planning and implementing midwifery continuity of carer as well as gaps in the current research evidence. Results Analysing international evidence using the CFIR shows that evidence around midwifery continuity of carer implementation is patchy and fragmented, and that the impetus for change is not critically examined. Existing literature pays insufficient attention to core aspects of the innovation such as the centrality of on call working arrangements and alignment with the professional values of midwifery. There is also limited attention to the political and structural contexts into which midwifery continuity of carer is introduced. Conclusions By synthesizing international research evidence with the CFIR, we identify factors for organisations to consider when planning and implementing midwifery continuity of carer. We also call for more systematic and contextual evidence to aid understanding of the implementation or non-implementation of midwifery continuity of carer. Existing evidence should be critically evaluated and used more cautiously in support of claims about the model of care and its implementation, especially when implementation is occurring in different settings and contexts to the research being cited.

Background Unprofessional behaviour in healthcare systems can negatively impact staff well-being, patient safety and organisational costs. Unprofessional behaviour encompasses a range of behaviours, including incivility, microaggressions, harassment and bullying. Despite efforts to combat unprofessional behaviour in healthcare settings, it remains prevalent. Interventions to reduce unprofessional behaviour in health care have been conducted – but how and why they may work is unclear. Given the complexity of the issue, a realist review methodology is an ideal approach to examining unprofessional behaviour in healthcare systems. Aim To improve context-specific understanding of how, why and in what circumstances unprofessional behaviours between staff in acute healthcare settings occur and evidence of strategies implemented to mitigate, manage and prevent them. Methods Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards reporting guidelines. Data sources Literature sources for building initial theories were identified from the original proposal and from informal searches of various websites. For theory refinement, we conducted systematic and purposive searches for peer-reviewed literature on databases such as EMBASE, Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases as well as for grey literature. Searches were conducted iteratively from November 2021 to December 2022. Results Initial theory-building drew on 38 sources. Searches resulted in 2878 titles and abstracts. In total, 148 sources were included in the review. Terminology and definitions used for unprofessional behaviours were inconsistent. This may present issues for policy and practice when trying to identify and address unprofessional behaviour. Contributors of unprofessional behaviour can be categorised into four areas: (1) workplace disempowerment, (2) organisational uncertainty, confusion and stress, (3) (lack of) social cohesion and (4) enablement of harmful cultures that tolerate unprofessional behaviours. Those at most risk of experiencing unprofessional behaviour are staff from a minoritised background. We identified 42 interventions in the literature to address unprofessional behaviour. These spanned five types: (1) single session (i.e. one-off), (2) multiple sessions, (3) single or multiple sessions combined with other actions (e.g. training session plus a code of conduct), (4) professional accountability and reporting interventions and (5) structured culture-change interventions. We identified 42 reports of interventions, with none conducted in the United Kingdom. Of these, 29 interventions were evaluated, with the majority (n = 23) reporting some measure of effectiveness. Interventions drew on 13 types of behaviour-change strategy designed to, for example: change social norms, improve awareness of unprofessional behaviour, or redesign the workplace. Interventions were impacted by 12 key dynamics, including focusing on individuals, lack of trust in management and non-existent logic models. Conclusions Workplace disempowerment and organisational barriers are primary contributors to unprofessional behaviour. However, interventions predominantly focus on individual education or training without addressing systemic, organisational issues. Effectiveness of interventions to improve staff well-being or patient safety is uncertain. We provide 12 key dynamics and 15 implementation principles to guide organisations. Future work Interventions need to: (1) be tested in a United Kingdom context, (2) draw on behavioural science principles and (3) target systemic, organisational issues. Limitations This review focuses on interpersonal staff-to-staff unprofessional behaviour, in acute healthcare settings only and does not include non-intervention literature outside the United Kingdom or outside of health care. Study registration This study was prospectively registered on PROSPERO CRD42021255490. The record is available from: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131606) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 25. See the NIHR Funding and Awards website for further award information. Plain language summary For this study, we asked: how, why and in what situations can unprofessional behaviour between healthcare staff working in acute care (usually hospitals) be reduced, managed and prevented? We wanted to research how people understand unprofessional behaviour, explore the circumstances leading to unprofessional behaviour and understand how existing approaches to addressing unprofessional behaviour worked (or did not work) across staff groups and acute healthcare organisations. We used a literature review method called a ‘realist review’, which differs from other review methods. A realist review focuses on understanding not only if interventions work but how and why they work, and for whom. This allowed us to analyse a wider range of relevant international literature – not only academic papers. We found 148 sources, which were relevant either because they described unprofessional behaviour or because they provided information on how to address unprofessional behaviour. Definitions of unprofessional behaviour varied, making it difficult to settle on one description. For example, unprofessional behaviour may involve incivility, bullying, harassment and/or microaggressions. We examined what might contribute to unprofessional behaviour and identified factors including uncertainty in the working environment. We found no United Kingdom-based interventions and only one from the United States of America that sought to reduce unprofessional behaviour towards minority groups. Strategies often tried to encourage staff to speak up, provide ways to report unprofessional behaviour or set social standards of behaviour. We also identified factors that may make it challenging for organisations to successfully select, implement and evaluate an intervention to address unprofessional behaviour. We recommend a system-wide approach to addressing unprofessional behaviour, including assessing the context and then implementing multiple approaches over a long time (rather than just once), because they are likely to have greater impact on changing culture. We are producing an implementation guide to support this process. Interventions need to enhance staff ability to feel safe at work, work effectively and support those more likely to experience unprofessional behaviour. Scientific summary Background Unprofessional behaviour (UB) in healthcare systems can have significant negative impact on staff well-being, patient safety and organisational costs. UB encompasses a range of behaviours – such as incivility, microaggressions, harassment and bullying – that remain prevalent in healthcare systems around the world. In 2022, Workforce Race Equality Standard data indicated that the percentage of staff experiencing UB from colleagues in the National Health Service (NHS) was 22.5% for white respondents and 27.6% for ethnic minority respondents. Unprofessional behaviour can impact negatively on the psychological well-being of both targets and witnesses. This may result in higher rates of staff sick leave and turnover. Conservative estimates suggest that damages from bullying alone cost the NHS approximately £2.28 billion per annum. The negative impacts of UB also extend to patient safety, which can be compromised if staff members who are victims of UB are unable to speak up – leading to medical errors and poor patient outcomes. Managing, mitigating and preventing UB can assist in addressing the increasing workforce crisis in health care and declining rates of patient satisfaction, as well as improve patient outcomes. Extant literature has focused predominantly on bullying. Literature exploring the implementation and effectiveness of interventions designed to reduce UB is often underpinned by the belief that the more people know about UB – including how to recognise and challenge it – the more likely it is to be reduced. However, this is very challenging to do and places the responsibility on individuals. Interventions to reduce UB in health care may need to be tailored to specific contexts and may need to go beyond increasing awareness and assertiveness to address deeper systemic issues. This is a complex, widespread and urgent issue that is heavily reliant on context and has negative impact on staff well-being, patient safety and organisational costs. A realist review methodology may be an ideal method for examining the interacting components of UB between staff in acute healthcare settings. Objectives This review aimed to: Conceptualise and refine terminology, by mapping behaviours defined as unprofessional to understand differences and similarities between terms referring to UB (e.g. incivility, bullying, microaggressions) and how these terms are used by different professional groups in acute healthcare settings. Develop and refine context, mechanism and outcome configurations (CMOCs), to understand the causes and contexts of UB, the mechanisms that trigger different behaviours, and the outcomes on staff, patients and the wider system of health care. Identify strategies designed to mitigate, manage and prevent UB and explore how, why and in what circumstances these work and whom they benefit. Produce recommendations and comprehensive resources that support the tailoring, UB and their impacts. Methods Realist reviews seek to understand why an intervention may work in one context but not another. This involves building an understanding of how various contextual factors affect the activation of mechanisms (i.e. changes in participant reasoning) to produce various outcomes. Often these relationships are not well articulated in the literature, so realist research draws on retroductive reasoning to unpack this information, drawing on ‘hunches’ as well as inductive and deductive reasoning to ask, ‘why do things appear as they do?’. The aim of this is to build CMOCs that underpin programme theories and to build an understanding of how contributors drive UB and how different strategies may be used in different contexts to address UB. Realist reviews also enable grey literature to be drawn upon. Our review had six main stages: Formulating initial programme theories drawing on informal literature searches of NHS England, The King’s Fund, British Medical Association, Health and Care Professions Council and NHS Employers websites, as well as literature already known to the study team and in the study protocol. This comprised 38 studies after screening for relevancy and rigour. Performing systematic and purposive searches for peer-reviewed literature on EMBASE, Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases as well as grey literature on Health Management Information Consortium, National Institute for Health and Care Excellence Evidence Search, Patient Safety Network, Google and Google Scholar databases, and NHS Employers and NHS Health Education England websites. Searches were conducted in November 2021, then expanded to include United States of America (USA) literature in August 2022 and updated in December 2022. Selecting appropriate documents while considering rigour and relevance. The above searches identified 5967 total titles and abstracts across all databases after deduplication. We applied strict conceptual-richness criteria to include the most relevant and useful literature. Searching and screening in November 2022 resulted in 64 included sources. Additional searching in August 2022 resulted in the addition of 36 sources; the December 2022 search added a further 10 sources. This meant that 110 sources were used for theory refinement (step 2 onwards) while 38 were used in step 1 for initial theory generation, with 148 sources included in total. Extracting data using NVivo 12 software (QSR International, Warrington, UK) using a mix of inductive and deductive code creation. Key excerpts were also extracted separately into a Word document so that patterns across literature could be collated and investigated. Characteristics of included sources were extracted into an Excel spreadsheet. Synthesising data with the aid of the data categorised within NVivo, where data were coded according to UB definitions, contributors, interventions, and strategies. This enabled us to compare and contrast, reconcile, adjudicate and consolidate different sources of evidence to build an understanding of which contexts affect how interventions work, and why and how various UB contributors may work. Refining and testing initial programme theories against additional identified literature. At this stage, CMOCs and programme theories were either confirmed, refuted or added to our step 2 analysis. Stakeholder feedback was also incorporated at five points in the project through the following process: (1) record theory presentation to stakeholders for refinement, (2) record suggested alterations, (3) perform purposive searching to sense-check non-aligned suggestions, (4) discuss discrepancies within the team to determine consensus and action taken and (5) represent changes made to stakeholders/group for further sense-checking. Results Terminology We explored the use of UB-related terminology in the literature and found that forms of UB can be placed on a spectrum according to how specific they were, whether they were visible to the organisation or their targets, and whether they required a hierarchical structure to occur. We also found that there is little agreement within the literature about how to define dimensions of UB. This may cause confusion and make it challenging to synthesise the literature on this topic. In practice, the lack of a shared definition or understanding of UB could lead to difficulties in understanding its prevalence, reduce the likelihood of individuals reporting UB and hinder the effectiveness of interventions to address UB. Contributors to unprofessional behaviour We explored how UBs are developed and experienced by staff in acute healthcare settings. We were able to create a comprehensive programme theory that categorised contributors into four aspects: Workplace disempowerment: factors such as hierarchy can lead to people becoming an easier target for instigators, foster a sense of unfairness and cause a reduction in psychological safety, which can all facilitate propagation of UB. Organisational uncertainty, confusion and stress: factors such as organisational change or a lack of resources contribute to increased instances and experiences of UB. When staff are more likely to experience a lack of control in their day-to-day work, this can exacerbate pre-existing stress, create challenges in building relationships and worsen UB. Social cohesion: a lack of social cohesion among colleagues – including reduced ability to communicate effectively (e.g. due to stress and pressure as outlined above) – can lead to the undermining of social relationships between staff that would otherwise enable a greater ability to cope with and collectively address UB. Enablement of harmful cultures that tolerate UB: leadership and organisational culture can enable, model or tacitly permit UB. This can create an environment in which UB becomes part of an organisation’s fabric and the social norm. Our programme theory depicts how these contributors interact and, in so doing, identifies the many overlapping mechanisms across each area and type of UB. Outcomes of unprofessional behaviour on staff, patients and organisations Our review identified that UB is experienced more frequently by people from a minoritised background. More broadly, we also highlighted impacts on staff psychological well-being as a result of UB. Intra-professional forms of UB were found to be more harmful to well-being than interprofessional UB, perhaps due to the differing strengths of social ties within and between groups. We identified that the economic impact of UB to organisations is significant. We were able to create a programme theory regarding how the presence of UB can impact staff and thereby patient safety through various mechanisms, such as inability to communicate and loss of learning. Interventions and strategies to reduce or mitigate unprofessional behaviour We identified 42 interventions that sought to reduce UB between acute healthcare staff. The majority were developed and implemented in the USA (n = 30), with none reported from the United Kingdom (UK). The interventions included single-session or multiple-session designs, combined with other actions such as codes of conduct, professional accountability and reporting interventions and structured culture-change interventions. However, most interventions did not draw on theoretical frameworks to inform their design, report theoretical underpinnings, provide an understanding of why and how the intervention is expected to work or report any comprehensive long-term evaluation. Only one intervention targeted UB impacting minoritised groups (racism). Of the 29 studies that assessed intervention effectiveness, the majority (n = 23) reported positive results – but this depended on the outcome measures these studies chose. Interventions drawing on single-session designs were reported as less effective compared to multiple-session interventions. There was a trend towards more complex interventions reporting greater effectiveness. Interventions can have degrees of flexibility, allowing for variation as to which components or strategies participants are exposed to. However, this makes them more resource-intensive to implement and harder to evaluate. We also found (via information from our stakeholder group) that there are interventions taking place in practice that are not adequately reported in the literature, making it difficult to assess their effectiveness. Finally, we did not include interventions to improve civility or professionalism alone, which may also address some contributors to UB. The review identified 13 categories of strategies to reduce UB. These strategies included direct or indirect approaches to instigators (such as informal or disciplinary actions), improving awareness and knowledge of UB for all staff, improving teamwork, setting social norms through leadership role-modelling and code of conduct, and reporting and escalation systems. Improving leadership competence and empathy, workplace redesign and changing recruitment and dismissal processes were also identified, as were external pressures on organisations and strategies to aid implementation. Overall, the strategies highlighted the importance of addressing UB from multiple angles and levels (individual, team, organisational and societal), involving all staff and management levels, and creating a culture of respect and accountability. When do unprofessional behaviour interventions and strategies work? The study identified 12 key dynamics that can be summarised into four broad categories helping to optimise the effectiveness of interventions aimed at reducing UB in healthcare settings. Firstly, if interventions can focus on systemic issues such as organisational uncertainty, this is likely to be more effective than addressing problematic individuals. Secondly, seeking ways to build trust with management and other senior staff members is crucial. This relies on interventions being seen as authentic and leaders being role models. Thirdly, interventions need to be focused on an identified target audience and ensure they are both inclusive and fair. Lastly, there are trade-offs in intervention design that must be considered – that is, whether to build interventions in a theory-based or practice-first manner or to focus on effectiveness or ability to evaluate. For example, interventions encouraging bystanders to intervene are important for culture change but may lead to moral injury if individuals do not feel capable of intervening. Findings also emphasised the importance of maintaining a focus on why reducing UB is important (to improve patient safety and staff psychological well-being), encouraging triage of messages in systems that enable anonymous reporting and comprehensive evaluation of interventions to better understand what works, where and why. We identified a further 15 key implementation principles that may help the effectiveness, sustainability and perception of UB interventions in healthcare organisations. Examples include: covering a broad section of the organisation, co-creation with staff, dedicated staff to lead the work, skilled facilitation, multiple strategies, ongoing evaluation, maximising visibility, assessing the organisational landscape before implementation, early intervention, maximising existing opportunities such as onboarding processes to establish social norms during induction, manager engagement, cultivating perceptions of justice, avoiding mixing of hierarchies in session-based interventions, and avoiding simply moving the target or instigator of UB. Conclusions Unprofessional behaviour is a pervasive issue currently poorly addressed by existing interventions. We identified many contributors to UB, most of which relate to worker disempowerment and organisational barriers. However, most existing interventions do not address these systemic, organisational contributors to UB, instead relying on education or training workshops to boost individual knowledge or awareness, identify problematic individuals or improve UB targets’ ability to speak up. Such approaches may reduce UB prevalence; however, it is unclear whether this has lasting positive impact or improves staff psychological well-being and patient safety. Future interventions would benefit from being designed and tested in UK settings, drawing on contemporary behavioural science principles to help inform their design, and focusing on systemic issues within organisations. We provide 12 key dynamics and 15 implementation principles to guide organisations. Study registration This study was prospectively registered on PROSPERO CRD42021255490. The record is available from: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131606) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 25. See the NIHR Funding and Awards website for further award information.

IntroductionThere is growing evidence within the healthcare sector that employee investigations can harm individuals involved in the process, an organization’s culture and the delivery of its services.MethodsThis paper details an intervention developed by an NHS Wales organization to reduce the number of its employee investigations through an organization-wide focus that promoted a ‘last resort’ approach and introduced the concept of ‘avoidable employee harm’. A range of associated improvement initiatives were developed to support behavior change among those responsible for determining whether an employee investigation should be initiated.ResultsOver a 13-month period, organizational records showed an annual reduction of 71% in investigation cases post-intervention, resulting in an estimated 3,308 sickness days averted annually and total estimated annual savings of £738,133 (based on direct savings and costs averted). This indicates that the organization has started to embrace the “last resort” approach to using employee investigations to address work place issues. The programme was supported with training for those responsible for commissioning and leading the organization’s employee investigations. Analysis of survey data from those who attended training workshops to support the programme indicated that participants showed an increased awareness of the employee investigation process post-workshop and an understanding of the concept of avoidable employee harm.DiscussionThe programme is congruent with the Healthy Healthcare concept, as the study illustrates how its practices and processes have a beneficial impact on staff, as well as potentially on patients. This study highlights wider issues for consideration, including the: (1) the role of Human Resources (HR), (2) taking a multi-disciplinary approach, (3) culture and practice, (4) the responsibility of the wider HR profession.

Unprofessional behaviours (UBs) between healthcare staff are widespread and have negative impacts on patient safety, staff well-being and organisational efficiency. However, knowledge of how to address UBs is lacking. Our recent realist review analysed 148 sources including 42 reports of interventions drawing on different behaviour change strategies and found that interventions insufficiently explain their rationale for using particular strategies. We also explored the drivers of UBs and how these may interact. In our analysis, we elucidated both common mechanisms underlying both how drivers increase UB and how strategies address UB, enabling the mapping of strategies against drivers they address. For example, social norm-setting strategies work by fostering a more professional social norm, which can help tackle the driver 'reduced social cohesion'. Our novel programme theory, presented here, provides an increased understanding of what strategies might be effective to adddress specific drivers of UB. This can inform logic model design for those seeking to develop interventions addressing UB in healthcare settings.

Abstract Background Unprofessional behaviours (UB) between healthcare staff are rife in global healthcare systems, negatively impacting staff wellbeing, patient safety and care quality. Drivers of UBs include organisational, situational, team, and leadership issues which interact in complex ways. An improved understanding of these factors and their interactions would enable future interventions to better target these drivers of UB. Methods A realist review following RAMESES guidelines was undertaken with stakeholder input. Initial theories were formulated drawing on reports known to the study team and scoping searches. A systematic search of databases including Embase, CINAHL, MEDLINE and HMIC was performed to identify literature for theory refinement. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories. Results We included 81 reports (papers) from 2,977 deduplicated records of grey and academic reports, and 28 via Google, stakeholders, and team members, yielding a total of 109 reports. Five categories of contributor were formulated: (1) workplace disempowerment; (2) harmful workplace processes and cultures; (3) inhibited social cohesion; (4) reduced ability to speak up; and (5) lack of manager awareness and urgency. These resulted in direct increases to UB, reduced ability of staff to cope, and reduced ability to report, challenge or address UB. Twenty-three theories were developed to explain how these contributors work and interact, and how their outcomes differ across diverse staff groups. Staff most at risk of UB include women, new staff, staff with disabilities, and staff from minoritised groups. UB negatively impacted patient safety by impairing concentration, communication, ability to learn, confidence, and interpersonal trust. Conclusion Existing research has focused primarily on individual characteristics, but these are inconsistent, difficult to address, and can be used to deflect organisational responsibility. We present a comprehensive programme theory furthering understanding of contributors to UB, how they work and why, how they interact, whom they affect, and how patient safety is impacted. More research is needed to understand how and why minoritised staff are disproportionately affected by UB. Study registration This study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490 .

Abstract Background Unprofessional behaviour (UB) between staff encompasses various behaviours, including incivility, microaggressions, harassment, and bullying. UB is pervasive in acute healthcare settings and disproportionately impacts minoritised staff. UB has detrimental effects on staff wellbeing, patient safety and organisational resources. While interventions have been implemented to mitigate UB, there is limited understanding of how and why they may work and for whom. Methods This study utilised a realist review methodology with stakeholder input to improve understanding of these complex context-dependent interventions. Initial programme theories were formulated drawing upon scoping searches and reports known to the study team. Purposive systematic searches were conducted to gather grey and published global literature from databases. Documents were selected if relevant to UB in acute care settings while considering rigour and relevance. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories. Results Of 2977 deduplicated records, 148 full text reports were included with 42 reports describing interventions to address UB in acute healthcare settings. Interventions drew on 13 types of behaviour change strategies and were categorised into five types of intervention (1) single session (i.e. one off); (2) multiple session; (3) single or multiple sessions combined with other actions (e.g. training sessions plus a code of conduct); (4) professional accountability and reporting programmes and; (5) structured culture change interventions. We formulated 55 context-mechanism-outcome configurations to explain how, why, and when these interventions work. We identified twelve key dynamics to consider in intervention design, including importance of addressing systemic contributors, rebuilding trust in managers, and promoting a psychologically safe culture; fifteen implementation principles were identified to address these dynamics. Conclusions Interventions to address UB are still at an early stage of development, and their effectiveness to reduce UB and improve patient safety is unclear. Future interventions should incorporate knowledge from behavioural and implementation science to affect behaviour change; draw on multiple concurrent strategies to address systemic contributors to UB; and consider the undue burden of UB on minoritised groups. Study registration This study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490 .

In the present study an effort-sharing approach based on Inertia and Capability principles is proposed to assess European Union (EU27) carbon budget distribution among the Member States. This is done within the context of achieving the Green Deal objective and EU27 carbon neutrality by 2050. An in-depth analysis is carried out about the role of Economic Decoupling embedded in the Capability principle to evaluate the correlation between the expected increase of economic production and the level of carbon intensity in the Member States. The study proposes a simple mathematical model as a policy tool to assess and redistribute Member States’ carbon budgets as frequently as necessary to encourage progress or overcome the difficulties each Member State may face during the decarbonization pathways.

Abstract Background Migrant and ethnic inequalities in maternal and perinatal mortality persist across high‐income countries. Addressing social adversity and inequities across the childbirth trajectory cannot be left to chance and the good intentions of practitioners. Robust, evidence‐based tools designed to address inequity by enhancing both the quality of provision and the experience of care are needed. Methods An inductive modelling approach was used to develop a new evidence‐based conceptual model of woman–midwife relationships, drawing on data from an ethnographic study of relationships between migrant Pakistani women and midwives, conducted between 2013 and 2016 in South Wales, UK. Key analytic themes from early data were translated into social–ecological concepts, and a model was developed to represent how these key themes interacted to influence the woman–midwife relationship. Results Three key concepts influencing the woman–midwife relationship were developed from the three major themes of the underpinning research: (1) Healthcare System; (2) Culture and Religion; and (3) Family Relationships. Two additional weaving concepts appeared to act as a link between these three key concepts: (1) Authoritative Knowledge and (2) Communication of Information. Social and political factors were also considered as contextual factors within the model. A visual representation of this model was developed and presented. Conclusions The model presented in this paper, along with future work to further test and refine it in other contexts, has the potential to impact on inequalities by facilitating future discussion on cultural issues, encouraging collaborative learning and knowledge production and providing a framework for future global midwifery practice, education and research. Patient or Public Contribution At the outset of the underpinning research, a project involvement group was created to contribute to study design and conduct. This group consisted of the three authors, an Advocacy Officer at Race Equality First and an NHS Consultant Midwife. This group met regularly throughout the research process, and members were involved in discussions regarding ethical/cultural/social issues, recruitment methods, the creation of participant information materials, interpretation of data and the dissemination strategy. Ideas for the underpinning research were also discussed with members of the Pakistani community during community events and at meetings with staff from minority ethnic and migrant support charities (BAWSO, Race Equality First, The Mentor Ring). Local midwives contributed to study design through conversations during informal observations of antenatal appointments for asylum seekers and refugees.

Background One in six five 16-year-olds have a probable mental health difficulty. Of these, almost half of older teenagers and a quarter of 11–16-year-olds report having self-harmed or attempted suicide. Currently, there is little research into mental health crisis services for young people, with little understanding of what services exist, who uses them, or what works best. Question ‘How are mental health crisis responses for children and young people up to the age of 25 sustained, experienced and integrated within their local systems of services’? Objectives To describe National Health Service (NHS), local authority, education and third sector approaches to the implementation and organisation of crisis care for children and young people across England and Wales. To identify eight contrasting case studies in which to evaluate how crisis services have developed and are currently organised, sustained, experienced and integrated within the context of their local systems of services. To compare and contrast these services in the context of the available international evidence, drawing out and disseminating clear implications for the design and delivery of future crisis responses for children and young people and their families. Methods A sequential mixed methods approach, underpinned by normalisation process theory will be employed. A survey will create a detailed record of how crisis responses across England and Wales are organised, implemented and used. Subsequently, eight contrasting services in relation to geographic and socioeconomic setting, populations served, and service configuration will be identified as case studies. Interviews will be conducted with children, young people and parents/carers who have used the service, as well as commissioners, managers and practitioners. Operational policies and service usage data will also be examined. Analysis of how each service is provided, experienced, implemented and sustained will be conducted both inductively and deductively, reflecting normalisation process theory constructs.

The European Green Deal comprises various policy initiatives with the goal of reaching carbon neutrality by 2050. The “Fit for 55 packages” include the Social Climate Fund, which aims to help, among others, vulnerable households and transport users meet the costs of the green energy transition. Thus, analyzing households’ expenditures and the associated carbon emissions is crucial to achieving a net-zero society. In the present study, we combine scenarios of households’ expenditures according to the Classification of Individual Consumption According to Purpose with economic decoupling scenarios to assess, for the first time, the European carbon budget allocation on a consumption basis. Expenditure projections based on socioeconomic scenarios were calculated using the Bayesian structural time series, and the associated emissions were estimated through the greenhouse gas intensity of the Gross Domestic Product. The model can be used to report the carbon budget of households and monitor the effectiveness of the measures funded by the Social Climate Fund. However, the emissions burden obtained by means of averaged greenhouse gas intensity of Gross Domestic Product results in a rough approximation of outcomes, and more accurate indicators should be developed across the member states.

Abstract Background Health‐care service users are often being described as ‘co‐producers’ with an active role in their care. However, there are challenges associated with this approach, including how standardization affects personalized care, and the ability of patients to retain high volumes of information. Objective Our study explores patient and nursing perspectives of information provision in the pre‐admission element of an Enhanced Recovery After Surgery programme, an evidence‐based approach implemented to improve the quality of surgical care. Our analysis has been informed by an evidence‐based model developed by Grande et al Patient Educ Couns. 2014;95:281. Design/Setting and participants This was a qualitative study including observations of pre‐admission clinics and semi‐structured interviews across three surgical wards. Patients (n = 21) and registered nurses (n = 21) were purposively selected for interviews. Results Patients welcomed the opportunity for active involvement in their care. However, we also identified informational boundaries and how illness and treatment‐related anxieties were barriers to patient engagement with the information provided. Discussion We recommend that to support a patient‐centred and individualized approach to patient involvement the ‘information (giving) + activation’ element of Grande et al Patient Educ Couns. 2014;95:281 model be reconfigured to allow for ‘information (giving) + exploration +activation’. Conclusion Nurses need to feel empowered to adopt strategies that allow for different informational needs, rather than adopting a one‐size‐fits‐all paternalistic approach. Patient contribution This study focused on patient involvement and we give thanks to all the patients who took part in interviews and those who allowed us to observe their care.

Abstract Background People living with dementia (PLWD) are at significant risk of developing urinary and/or faecal incontinence and are also at risk of functional incontinence or being labelled as being incontinent. Despite the growing population of PLWD and importance of continence care, little is known about the appropriate management, organisation, and interactional strategies for PLWD admitted to acute hospitals. This mixed methods systematic review and thematic synthesis sought to identify successful strategies across all care settings that could then be used to inform innovations in continence care for PLWD in the acute hospital setting. Methods In phase 1, a scoping search of two electronic databases (MEDLINE and PsycINFO) and a consultation with stakeholders was undertaken. Findings were presented to the project steering group and two priority areas for phase 2 were identified which were communication and individualised care plans. In phase 2, eight databases and relevant UK government and other organisational websites were searched for English language citations from inception to August 2020. Critical appraisal was conducted using the Mixed Methods Appraisal Tool (MMAT Version 11). Thematic synthesis was employed and the strength of synthesised findings for the intervention studies was assessed using the GRADE approach and the confidence in synthesised qualitative and survey findings was assessed using the CERQual approach. Results In phase 1, 1348 citations were found and 75 included. In phase 2, 6247 citations were found, 14 research studies and 14 policy and guidance documents were included. The quality of studies varied. Material was synthesised into three overarching syntheses which were: communication this is dignified, person-centred and respectful; communication during outpatients apointments and delivering individualised continence care. Conclusions Recognising that PLWD are not always able to communicate their continence needs verbally is important. Incorporating interpersonal and communication skills into the context of continence care within training for those working with this patient group is crucial for continence to be maintained during an acute admission. Continence care in the acute setting should be tailored to the individual and be developed in partnership with staff and caregivers. Trial registration PROSPERO: CRD42018119495 .

Background: The introduction of ‘Freedom to Speak Up Guardians’ into every NHS trust in England was intended to support workers and trusts to better raise, respond to and learn from speaking-up concerns. However, only broad guidance was provided on how to implement the role. As a result, there is the potential for important local differences to emerge as the role is implemented across England. Objectives: The overall aim of this study was to better understand the implementation of Guardians in acute trusts and mental health trusts. Design: The Freedom to Speak Up Guardian role was conceptualised as a complex intervention consisting of several interacting and interlocking components spanning the macro level (national organisations), the meso level (individual trusts) and the micro level (employees, teams and wards/units). A mixed-methods study was designed, which consisted of three work packages: (1) a systematic narrative review of the international literature regarding interventions promoting ‘speaking up’ by health-care employees; (2) semistructured telephone interviews with Guardians working in acute hospital trusts and mental health trusts; and (3) qualitative case studies of Freedom to Speak Up Guardian implementation, consisting of observations and interviews undertaken in four acute trusts and two mental health trusts. Interviews were also undertaken with national stakeholders. Setting: Acute trusts and mental health NHS trusts in England. Participants: Work package 2: Freedom to Speak Up Guardians (n = 87) were interviewed. Work package 3: 116 interviews with key stakeholders involved in pre-implementation and early implementation decision-making, workers who had spoken up to the Guardian, and national stakeholders. Results: Wide variability was identified in how the Guardian role had been implemented, resourced and deployed by NHS trusts. ‘Freedom to Speak Up Guardian’ is best considered an umbrella term, and multiple versions of the role exist simultaneously across England. Any comparisons of Guardians’ effectiveness are likely to be possible or meaningful only when this variability is properly accounted for. Many Freedom to Speak Up Guardians identified how a lack of available resources, especially time scarcity, negatively and significantly affected their ability to effectively respond to concerns; their opportunities to collect, analyse and learn from speaking-up data; and, more generally, the extent to which they developed their role and speak-up culture. Limitations: It is possible that those whom we interviewed were more receptive of Freedom to Speak Up Guardians or may have been biased by ‘socially desirability’, and their answers may not always have represented respondents’ true perceptions. Conclusions: Optimal implementation of the Guardian role has five components: (1) establishing an early, collaborative and coherent strategy congruent with the values of Freedom to Speak Up fosters the implementation of (2) policies and robust, yet supportive, practices (3) informed by frequent and reflexive monitoring of Freedom to Speak Up implementation that is (4) underpinned by sufficient time and resource allocation that leads to (5) a positive implementation climate that is congruent with Freedom to Speak Up values and is well placed to engender positive and sustainable Freedom to Speak Up culture and the well-being of a Guardian. Future work: The following recommendations for future research are considered to be of equal priority. Studies of the speaking-up experiences of minority communities and ‘seldom-heard’ workforce groups are a priority requirement. There is also value in undertaking a similar study in non-hospital settings and where peripatetic working is commonplace, such as in ambulance services and in primary care settings. The role of human resources and ‘middle managers’ in the management of concerns is an area requiring further research, especially regarding concerns relating to unprofessional and transgressive behaviours. Devolved administrations in Scotland and Wales have adopted different approaches to speaking up; research undertaken in these contexts would offer valuable comparative insights. Researching the Guardian role ≥ 5 years post implementation is recommended to understand the medium-term impact and the longer-term sustainability of the role and well-being of Guardians. Study registration: This study is registered as ISRCTN38163690 and has the study registration CRD42018106311. 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. 10, No. 23. See the NIHR Journals Library website for further project information.

Introduction Unprofessional behaviours encompass many behaviours including bullying, harassment and microaggressions. These behaviours between healthcare staff are problematic; they affect people’s ability to work, to feel psychologically safe at work and speak up and to deliver safe care to patients. Almost a fifth of UK National Health Service staff experience unprofessional behaviours in the workplace, with higher incidence in acute care settings and for staff from minority backgrounds. Existing analyses have investigated the effectiveness of strategies to reduce these behaviours. We seek to go beyond these, to understand the range and causes of such behaviours, their negative effects and how mitigation strategies may work, in which contexts and for whom.Methods and analysis This study uses a realist review methodology with stakeholder input comprising a number of iterative steps: (1) formulating initial programme theories drawing on informal literature searches and literature already known to the study team, (2) performing systematic and purposive searches for grey and peer-reviewed literature on Embase, CINAHL and MEDLINE databases as well as Google and Google Scholar, (3) selecting appropriate documents while considering rigour and relevance, (4) extracting data, (5) and synthesising and (6) refining the programme theories by testing the theories against the newly identified literature.Ethics and dissemination Ethical review is not required as this study is a secondary research. An impact strategy has been developed which includes working closely with key stakeholders throughout the project. Step 7 of our project will develop pragmatic resources for managers and professionals, tailoring contextually-sensitive strategies to reduce unprofessional behaviours, identifying what works for which groups. We will be guided by the ‘Evidence Integration Triangle’ to implement the best strategies to reduce unprofessional behaviours in given contexts. Dissemination will occur through presentation at conferences, innovative methods (cartoons, videos, animations and/or interactive performances) and peer-reviewed journals.PROSPERO registration number CRD42021255490.

Background: The acute hospital setting has become a key site of care for people living with dementia. People living with dementia are one of the largest populations in our hospitals, with the Department of Health and Social Care recognising that 25–50% of all acute hospital admissions are people who are also living with dementia. However, people living with dementia are a highly vulnerable group in the hospital setting and, following an acute admission, their functional abilities can deteriorate quickly and significantly. Detailed research is required to explore what constitutes ‘good care’. Objectives: This study’s focus was a common, but poorly understood, aspect of everyday care for people living with dementia during an acute admission, that is continence care. We asked the following questions: what caring practices are observable when interacting with this patient group? How do ward teams respond to and manage continence needs? What informs these approaches? What are staff doing and why? Design: This ethnography was informed by the symbolic interactionist research tradition, focusing on understanding how action and meaning are constructed within a setting. In-depth evidence-based analysis of everyday care enabled us to examine how ward staff responded to the continence care needs of people living with dementia and to follow the consequences of their actions. We carried out a mixed-methods systematic narrative review to refine our approach to fieldwork and analysis. Setting: This ethnography was carried out for 180 days, across 12 months, in six wards in three hospitals across England and Wales that were purposefully selected to represent a range of hospital types, geographies and socioeconomic catchments. Participants: In addition to general observations, 108 individuals participated directly in this study, contributing to 562 ethnographic interviews. Ten detailed case studies were also undertaken with people living with dementia. Results: This study identified ‘pad cultures’ as an embedded practice on these acute wards. The routine use of continence pads among people living with dementia (regardless of continence and independence) was widespread. The use of continence pads was viewed as a precautionary strategy, the rationale being to provide safeguards, ensure containment and prevent ‘accidents’ or incontinence episodes, with an expectation that patients living with dementia not only will wear pads, but will use them. Conclusions: These ‘pad cultures’ enabled the number of unscheduled interruptions to the institutionally mandated timetabled work of these wards to be reduced, but had significant impacts on people living with dementia and, in turn, wider consequences for these individuals and their identities. Ward staff described feeling abandoned with the responsibility of caring for large numbers of people living with dementia, believing that it was impossible to work in other ways to support their patient’s continence. Limitations: The limitations identified included the potential for the Hawthorne effect to influence data collection. Future work: In collaboration with a specialist dementia care and continence teams, the findings are informing the development of education and training at the interactional and organisational level. Study registration: This study is registered as PROSPERO CRD42018119495. 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. 10, No. 14. See the NIHR Journals Library website for further project information.

Activating epidermal growth factor receptor gene mutations (EGFRm) are relatively common in non-small cell lung cancer (NSCLC) and are predictive of superior outcomes with EGFR tyrosine kinase inhibitors (TKIs). Eventually, acquired genetic or phenotypic resistance overcomes EGFR TKI therapy. Heterogeneity of acquired anti-EGFR resistance mechanisms is increasingly described, presenting a significant challenge in their clinical management. Here, we report a rare case of concurrent acquired EGFRT790M and small cell lung cancer transformation in a patient with EGFR exon 21-L858R mutant lung adenocarcinoma, following treatment with a second-generation EGFR TKI. The case highlights the clinical significance of serial EGFR genotyping with peripheral ctDNA alongside targeted biopsies, for the detection of genetic and phenotypic resistance mechanisms to EGFR TKIs, which can occur concurrently. This case provides further evidence in favour of upfront treatment approaches that target the heterogeneity of acquired anti-EGFR resistance mechanisms, such as experimental combinations of cytotoxic chemotherapy with a third-generation EGFR TKI.

Abstract Background Involving mental health service users in planning and reviewing their care can help personalised care focused on recovery, with the aim of developing goals specific to the individual and designed to maximise achievements and social integration. We aimed to ascertain the views of service users, carers and staff in acute inpatient wards on factors that facilitated or acted as barriers to collaborative, recovery-focused care. Methods A cross-national comparative mixed-methods study involving 19 mental health wards in six service provider sites in England and Wales. This included a survey using established standardised measures of service users (n = 301) and staff (n = 290) and embedded case studies involving interviews with staff, service users and carers (n = 76). Quantitative and qualitative data were analysed within and across sites using descriptive and inferential statistics, and framework method. Results For service users, when recovery-oriented focus was high, the quality of care was rated highly, as was the quality of therapeutic relationships. For staff, there was a moderate correlation between recovery orientation and quality of therapeutic relationships, with considerable variability. Staff members rated the quality of therapeutic relationships higher than service users did. Staff accounts of routine collaboration contrasted with a more mixed picture in service user accounts. Definitions and understandings of recovery varied, as did views of hospital care in promoting recovery. Managing risk was a central issue for staff, and service users were aware of measures taken to keep them safe, although their involvement in discussions was less apparent. Conclusions There is positive practice within acute inpatient wards, with evidence of commitment to safe, respectful, compassionate care. Recovery ideas were evident but there remained ambivalence on their relevance to inpatient care. Service users were aware of efforts taken to keep them safe, but despite measures described by staff, they did not feel routinely involved in care planning or risk management decisions. Research on increasing therapeutic contact time, shared decision making in risk assessment and using recovery focused tools could further promote personalised and recovery-focused care planning. This paper arises from a larger study published by National Institute for Health Research (Simpson A, et al, Health Serv Deliv Res 5(26), 2017).

Objective Management of age-related macular degeneration (AMD) places a high demand on already constrained hospital-based eye services. This study aims to assess the safety and quality of follow-up within the community led by suitably trained non-medical practitioners for the management of quiescent neovascular AMD (QnAMD).Methods/design This is a prospective, multisite, randomised clinical trial. 742 participants with QnAMD will be recruited and randomised to either continue hospital-based secondary care or to receive follow-up within a community setting. Participants in both groups will be monitored for disease reactivation over the course of 12 months and referred for treatment as necessary. Outcomes measures will assess the non-inferiority of primary care follow-up accounting for accuracy of the identification of disease reactivation, patient loss to follow-up and accrued costs and the budget impact to the National Health Service.Ethics and dissemination Research ethics approval was obtained from the London Bloomsbury Ethics Committee. The results of this study will be disseminated through academic peer-reviewed publications, conferences and collaborations with eye charities to insure the findings reach the appropriate patient populations.Trial registration number NCT03893474.

As the impact of climate change increases it is more likely that we will see an increase of extreme weather events leading to significant food production losses. Therefore, understanding the complexities of how production losses impact on policy (through export or import restrictions) and prices (through markets) is important for the governance of the global food system in the future. In this paper our aim is to understand the variability of food prices utilizing a statistical methodology relating to the detection of extreme values and change points in the decomposed time series of food price indices (change-point analysis). These change points are identified using the FAO total food price index and also the indices for meat, oil, cereal, dairy and sugar. The results of the study highlight for the first time specific change points within these food categories when these changes occur and also the duration of these periods before the next change. Keywords: Climate change, Food production, Extreme weather, Food price index

This perspective critically assesses how the Intergovernmental Panel on Climate Change (IPCC) could facilitate a closer alignment of its activities and include lessons drawn from the policy and decision-making communities working on the ground at the regional/local levels. The objective is to facilitate practitioner input into the detailed choice of topics and priorities for IPCC review and in the conclusions drawn (we define practitioners as those engaged in the development and application of practical responses to climate change on the ground). By means of a series of workshops with academics, policy officials and decision-makers in the United Kingdom, the research reported here illuminates how the IPCC’s Working Group II (WGII) has been used in the past to inform decision-making and how practitioner responses to climate change could better inform the IPCC process in the future. In particular, we recommend three key actions. Firstly that IPCC WGII should incorporate more practitioners as authors to improve the awareness and understanding amongst the writing teams of the nature and detail of decisions being made in response to climate change; secondly a practitioner-led IPCC Special Report should be commissioned on good-practice responses to climate change; and thirdly a new body should be created, attached to the IPCC, to synthesise and report on good practice on climate response strategies in a timely manner. By adopting these recommendations, the IPCC could become more directly useful to decision-makers working on adaptation at the national, regional and local levels and enable more actionable decision-making.

Introduction: Care coordination is intended to ensure needs are met and integrated services are provided. Formalised processes for the coordination of mental health care arrived in the UK with the introduction of the care programme approach in the early 1990s. Since then the care coordinator role has become a central one within mental health systems. Theory and methods: This paper contrasts care coordination as work that is imagined with care coordination as work that is done. This is achieved via a critical review of policy followed by a qualitative analysis of interviews, focusing on day-to-day work, conducted with 28 care coordinators employed in four NHS organisations in England and two in Wales. Findings: Care coordination is imagined as a vehicle for the provision of collaborative, recovery-focused, care. Those who practise care coordination are concerned with the quality of their relationships with service users and the tailoring of services, but limits exist to collaboration and open discussion. Care coordinators describe doing necessary work connecting people and the system of care. However, this work also brings significant administrative demands, is subject to performance management which distorts its primary purpose, and in a context of scarce resources promotes generic professional roles. Conclusion: Care coordination must be done. However, it is not consistently being done in the way policymakers imagine, and in the real world of work can be done differently.

ContextIn response to political and social factors over the last sixty years mental health systems internationally have endeavoured to transfer the delivery of care from hospitals into community settings. As a result, there has been increased emphasis on the need for better quality care planning and care coordination between hospital services, community services and patients and their informal carers. The aim of this systematic review of international research is to explore which interventions have proved more or less effective in promoting personalized, recovery oriented care planning and coordination for community mental health service users.MethodsA systematic meta-narrative review of research from 1990 to the present was undertaken. From an initial return of 3940 papers a total of 50 research articles fulfilled the inclusion criteria, including research from the UK, Australia and the USA.FindingsThree research traditions are identified consisting of (a) research that evaluates the effects of government policies on the organization, management and delivery of services; (b) evaluations of attempts to improve organizational and service delivery efficiency; (c) service-users and carers experiences of community mental health care coordination and planning and their involvement in research. The review found no seminal papers in terms of high citation rates, or papers that were consistently cited over time. The traditions of research in this topic area have formed reactively in response to frequent and often unpredictable policy changes, rather than proactively as a result of intrinsic academic or intellectual activity. This may explain the absence of seminal literature within the subject field. As a result, the research tradition within this specific area of mental health service delivery has a relatively short history, with no one dominant researcher or researchers, tradition or seminal studies amongst or across the three traditions identified.ConclusionsThe research findings reviewed suggests a gap has existed internationally over several decades between policy aspirations and service level interventions aimed at improving personalised care planning and coordination and the realities of everyday practices and experiences of service users and carers. Substantial barriers to involvement are created through poor information exchange and insufficient opportunities for care negotiation.

It is inevitable that healthcare workers throughout their careers will witness actual or potential threats to patient safety in the course of their work. Some of these threats will result in serious harm occurring to others, whilst at other times such threats will result in minimal harm, or a ‘near miss’ where harm is avoided at the last minute. Despite organizations encouraging employees to ‘speak up’ about such threats, healthcare systems globally struggle to engage their staff to do so. Even when staff do raise concerns they are often ignored by those with a responsibility to listen and act. Learning how to create the conditions where employees continuously raise and respond to concerns is essential in creating a continuous and responsive learning culture that cherishes keeping patients and employees safe. Workplace culture is a real barrier to the creation of such a learning system but examples in healthcare exist from which we can learn.

Background: Mental health service users in acute inpatient wards, whether informal or detained, should be involved in planning and reviewing their care. Care planning processes should be personalised and focused on recovery, with goals that are specific to the individual and designed to maximise their achievements and social integration. Objective(s): We aimed to ascertain the views and experiences of service users, carers and staff to enable us to identify factors that facilitated or acted as barriers to collaborative, recovery-focused care and to make suggestions for future research. Design: A cross-national comparative mixed-methods study involving 19 mental health wards in six NHS sites in England and Wales included a metanarrative synthesis of policies and literature; a survey of service users (n = 301) and staff (n = 290); embedded case studies involving interviews with staff, service users and carers (n = 76); and a review of care plans (n = 51) and meetings (n = 12). Results: No global differences were found across the sites in the scores of the four questionnaires completed by service users. For staff, there was significant difference between sites in mean scores on recovery-orientation and therapeutic relationships. For service users, when recovery-orientated focus was high, the quality of care was viewed highly, as was the quality of therapeutic relationships. For staff, there was a moderate correlation between recovery orientation and quality of therapeutic relationships, with considerable variability. Across all sites, staff’s scores were significantly higher than service users’ scores on the scale to assess therapeutic relationships. Staff across the sites spoke of the importance of collaborative care planning. However, the staff, service user and carer interviews revealed gaps between shared aspirations and realities. Staff accounts of routine collaboration contrasted with service user accounts and care plan reviews. Definitions and understandings of recovery varied, as did views of the role of hospital care in promoting recovery. ‘Personalisation’ was not a familiar term, although there was recognition that care was often provided in an individualised way. Managing risk was a central issue for staff, and service users were aware of measures taken to keep them safe, although their involvement in discussions was less apparent. Conclusions: Our results suggest that there is positive practice taking place within acute inpatient wards, with evidence of widespread commitment to safe, respectful, compassionate care. Although ideas of recovery were evident, there was some uncertainty about and discrepancy in the relevance of recovery ideals to inpatient care and the ability of people in acute distress to engage in recovery-focused approaches. Despite the fact that staff spoke of efforts to involve them, the majority of service users and carers did not feel that they had been genuinely involved, although they were aware of efforts to keep them safe. Future work: Future research should investigate approaches that increase contact time with service users and promote personalised, recovery-focused working; introduce shared decision-making in risk assessment and management; and improve service user experiences of care planning and review and the use of recovery-focused tools during inpatient care. Funding: The National Institute for Health Research Health Services and Delivery Research programme.

Background: Concerns about fragmented community mental health care have led to the development of the care programme approach in England and care and treatment planning in Wales. These systems require those people receiving mental health services to have a care co-ordinator, a written care plan and regular reviews of their care. Care planning and co-ordination should be recovery-focused and personalised, with people taking more control over their own support and treatment. Objective(s): We aimed to obtain the views and experiences of various stakeholders involved in community mental health care; to identify factors that facilitated, or acted as barriers to, personalised, collaborative and recovery-focused care planning and co-ordination; and to make suggestions for future research. Design: A cross-national comparative mixed-methods study involving six NHS sites in England and Wales, including a meta-narrative synthesis of relevant policies and literature; a survey of recovery, empowerment and therapeutic relationships in service users (n = 449) and recovery in care co-ordinators (n = 201); embedded case studies involving interviews with service providers, service users and carers (n = 117); and a review of care plans (n = 33). Review methods: A meta-narrative mapping method. Results: Quantitative and qualitative data were analysed within and across sites using inferential statistics, correlations and the framework method. Our study found significant differences for scores on therapeutic relationships related to positive collaboration and clinician input. We also found significant differences between sites on recovery scores for care co-ordinators related to diversity of treatment options and life goals. This suggests that perceptions relating to how recovery-focused care planning works in practice are variable across sites. Interviews found great variance in the experiences of care planning and the understanding of recovery and personalisation within and across sites, with some differences between England and Wales. Care plans were seen as largely irrelevant by service users, who rarely consulted them. Care co-ordinators saw them as both useful records and also an inflexible administrative burden that restricted time with service users. Service users valued their relationships with care co-ordinators and saw this as being central to their recovery. Carers reported varying levels of involvement in care planning. Risk was a significant concern for workers but this appeared to be rarely discussed with service users, who were often unaware of the content of risk assessments. Limitations: Limitations include a relatively low response rate of between 9% and 19% for the survey and a moderate level of missing data on one measure. For the interviews, there may have been an element of self-selection or inherent biases that were not immediately apparent to the researchers. Conclusions: The administrative elements of care co-ordination reduce opportunities for recovery-focused and personalised work. There were few shared understandings of recovery, which may limit shared goals. Conversations on risk appeared to be neglected and assessments kept from service users. A reluctance to engage in dialogue about risk management may work against opportunities for positive risk-taking as part of recovery-focused work. Future work: Research should be commissioned to investigate innovative approaches to maximising staff contact time with service users and carers; enabling shared decision-making in risk assessments; and promoting training designed to enable personalised, recovery-focused care co-ordination. Funding: The National Institute for Health Research Health Services and Delivery Research programme.

The multidimensionality and complexity of assuring food security in a sustainable and inclusive way requires us to think in systems. Yet, sector specific models or agricultural productivity models are not able by construction to represent the non-linearity and time-dependent nature of the relations underpinning the agri-food system. Two alternative modelling approaches, i.e., System Dynamics (SD) and Agent Based Models (ABM), gained increasing attention in particular after the food commodities prices spikes in 2007 thanks to the conceptual and structural advantages that they provide to the study of food system complexity. In this paper, we develop a first, rigorous bibliometric analysis based on pattern recognition analysis reviewing the peer review journal publications focused on agri-food systems. Using the ISIWeb of Science dataset provided by Thomson Reuters, we apply citation/co-citation semantic metrics to analyse publications from 1970 to 2016 in the field of agricultural models divided in two categories that we define as: (i) agricultural complex systems modelling (ACSM) that includes SD and ABM modelling exercised; and (ii) agricultural modelling (AM) that includes traditional approaches to agri-food systems modelling rooted on the neoclassical approach (e.g., Computable General Equilibrium Models and Partial Equilibrium Models). The publications are identified by applying a filter of specific keywords to the search. We then compare how both approaches appear in the literature looking at the number of publications and citations by scientific journals, identifying key authors and journals, their frequency, the impact factor and citations, and looking at their trend through time. Results show the prevalence of AM approaches for the analysis of the agri-food sector on one side, and the smaller but growing contribution of the ACSM community and literature on the other. We conclude by remarking the need for more systematic analyses on the contribution of the two approaches to the analysis of the complex dynamics and behaviour of agri-food systems to inform evidence-based policies for sustainable and inclusive agriculture.

The provision of energy infrastructure is essential for economic growth, social cohesion, and environmental sustainability. Understanding the multiple functions and services it provides us requires firstly a deeper understanding of the factors that influence energy infrastructure itself. This paper focusses on the factors that influence the evolution of energy infrastructure in Nigeria. By studying different eras of energy use according to the technologies that were being implemented, resources that were available, and the political practice of the time it is possible to better frame the drivers of energy infrastructure. The paper explores the transitions of how Nigerians managed to obtain the vast majority of energy from food calories and traditional biomass, to the broad portfolio of energy sources that is in use today.