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Aims: To explore registered nurses' experiences of patient safety in intensive care during COVID-19.Design: A qualitative interview study informed by constructivism. Method: Semi- structured interviews were conducted and audio- recorded with 19 registered nurses who worked in intensive care during COVID-19 between May and July 2021. Interviews were transcribed verbatim and thematically analysed utilizing framework. Results: Two key themes were identified. ‘On a war footing’—an unprecedented situation which describes the situation nurses faced, and the actions are taken to prepare for the safe delivery of care. ‘Doing the best we can’—Safe Delivery of Care which describes the ramifications of the actions taken on short- and long-term patient safety including organization of care, missed and suboptimal care and communication. Both themes were embedded in the landscape of Staff Well-being and Peer Support. Conclusion: Nurses reported an increase in patient safety risks which they attributed to the dilution of skill mix and fragmentation of care. Nurses demonstrated an under-standing of the holistic and long-term impacts on patient safety and recovery from critical illness. Impact: This study explored the perceived impact of COVID-19 on patient safety in intensive care from a nursing perspective. Dilution of skill mix, where specialist critical care registered nurses were diluted with registered nurses with no critical care experience, and the fragmentation of care was perceived to lead to reduced quality of care and increased adverse events and risk of harm which were not consistently formally reported. Furthermore, nurses demonstrated a holistic and long-term appreciation of patient safety. These findings should be considered as part of future nursing work-force modelling and patient safety strategies by intensive care leaders and managers. No public or patient contribution to this study. The study aims and objectives were developed in collaboration with health care professionals.

This chapter focuses on the introduction and implementation of the Health and Social Care Act (UK Legislation 2012) in England which reignited the debate about the extent to which the government-funded National Health Service (NHS) is being privatised and/or marketised. It analyses past health service policy developments as they relate to the role of the private health sector, providing a broad sociological and policy context for the most recent legislation and considering the extent to which these represent a radical shift or an incremental policy change. The chapter draws on an ethnographic study of decision-making by the newly created Clinical Commissioning Groups about the extent to which privatisation is taking place. The central argument is that while there has been a considerable change in the commissioning apparatus, private providers have not yet made inroads into the NHS. The chapter concludes by discussing the possible long-term implications of the legislation, considering the extent to which it may have indirectly, rather than directly, encouraged a drift towards privatisation.

BackgroundInternational guidelines for the management of acute coronary syndromes (ACS) recommend use of the prehospital 12-lead electrocardiogram (PHECG). Research conducted before the primary PCI era suggested that PHECG is not always performed for those receiving a hospital diagnosis of ACS, with the patient’s gender and ethnicity speculated as influential.AimAs part of a mixed methods study investigating the use and impact of the PHECG in the primary PCI era, we explored the factors emergency medical services (EMS) clinicians report as influencing their decision to perform a PHECG.MethodsWe conducted a qualitative phenomenological study, in six focus groups with a semi structured topic guide, in three UK regions involving 47 EMS clinicians with experience ranging from nine months to 31 years. We recorded, transcribed and anonymised each focus group; familiarised ourselves with the data including notes and reflections; formed and iterated a coding framework; and constructed themes with the study team, including patient and public representatives.ResultsAll participants expressed a desire to perform a prehospital ECG in patients suspected with ACS but described a setting characterised by uncertainty and ‘messy’ context. We drew out three themes of influence on the decision to perform an ECG: surface characteristics (age, sex, ethnicity, privacy, presenting condition of the patient); pattern recognition (training, experience of atypical presentations, equipment availability, confidence in interpretation); and tensions/external pressures (distance to PCI, guidelines, organisational pressures). These were interwoven by the concept of clinical autonomy.ConclusionFactors identified as influencing clinicians’ decision to perform a PHECG ranged from straightforward to complex and were difficult to unpick. Whilst qualitatively clinicians reported performing 12 lead PHECG wherever possible in suspected ACS, the reported multifaceted influences on the decision reinforce the need for the quantitative arm of this study to examine this nationally, alongside its association with patient outcomes.

Theoretical and empirical evidence suggests that trust relations are crucial to healthcare in relation to its use, provision and organization. The body of literature about medical tourism, however, has tended not to explore trust relations, suggesting either it is not salient in this context or it has been overlooked. This chapter argues for the latter, suggesting that trust relations are fundamental to understanding the use, provision and organization of healthcare because trust is a common means for managing and bridging the uncertainties and unpredictabilities that are inherent in it. These uncertainties and unpredictabilities might be exacerbated in the context of healthcare provided in an unfamiliar setting. This chapter explores the importance of trust and trust relations in the study of medical tourism, setting out an agenda for future research in this field.

Theoretical and empirical evidence suggests that trust relations are crucial to healthcare in relation to its use, provision and organization. The body of literature about medical tourism, however, has tended not to explore trust relations, suggesting either it is not salient in this context or it has been overlooked. This chapter argues for the latter, suggesting that trust relations are fundamental to understanding the use, provision and organization of healthcare because trust is a common means for managing and bridging the uncertainties and unpredictabilities that are inherent in it. These uncertainties and unpredictabilities might be exacerbated in the context of healthcare provided in an unfamiliar setting. This chapter explores the importance of trust and trust relations in the study of medical tourism, setting out an agenda for future research in this field.