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In broad terms, current thinking and literature on the spread of innovations in health care presents it as the study of two unconnected processes—diffusion across adopting organizations and implementation within adopting organizations. Evidence from the health care environment and beyond, however, shows the significance and systemic nature of postadoption challenges in sustainably implementing innovations at scale. There is often only partial diffusion of innovative practices, initial adoption that is followed by abandonment, incomplete or tokenistic implementation, and localized innovation modifications that do not provide feedback to inform global innovation designs.Critical Theoretical Analysis Such important barriers to realizing the benefits of innovation question the validity of treating diffusion and implementation as unconnected spheres of activity. We argue that theorizing the spread of innovations should be refocused toward what we call embedding innovation—the question of how innovations are successfully implemented at scale. This involves making the experience of implementation a central concern for the system-level spread of innovations rather than a localized concern of adopting organizations.Insight/Advance To contribute to this shift in theoretical focus, we outline three mechanisms that connect the experience of implementing innovations locally to their diffusion globally within a health care system: learning, adapting, and institutionalizing. These mechanisms support the distribution of the embedding work for innovation across time and space.Practical Implications Applying this focus enables us to identify the self-limiting tensions within existing top-down and bottom-up approaches to spreading innovation. Furthermore, we outline new approaches to spreading innovation, which better exploit these embedding mechanisms.

Physical activity (PA) has been found to be beneficial for people with multiple sclerosis (pwMS) outside of the relapse period. However, little is known about how people experience PA during a relapse. This study investigates the experiences of pwMS engaging with PA during a relapse. The study followed an interpretivist approach, adopting a qualitative exploratory design. Semi-structured interviews were conducted with a purposive sample of 15 adults following a recent relapse. Transcripts were analysed in NVivo using framework analysis. The experiences of participants were synthesised in three overarching themes: “on the road to recovery”, “getting active but fearing repercussions”, and “self-directed versus guided recovery”. Barriers to PA included: feeling unwell, physical limitations, concerns about causing deterioration, worries that others would recognise their disability, and lack of professional support. Facilitators included: awareness of the benefits of PA, access to exercise resources, individualised advice and support from practitioners, and PA pitched at the right level. Relapses can disrupt normal PA routines, making it challenging to return to PA. This article makes recommendations for supporting people to undertake PA, the timing and form of support, along with suggestions for further research exploring the safety of PA during a relapse. Implications for rehabilitationPeople with RRMS find it difficult to be physically active during a relapse.There are complex personal, social and environmental reasons why people find it hard to engage with physical activity (PA).Improved timely advice and customised support during a relapse can help reduce fears and enhance confidence with returning to PA.Physical activity recommendations should be tailored to individual’s abilities to make them achievable, giving a sense of accomplishment and boosting motivation. People with RRMS find it difficult to be physically active during a relapse. There are complex personal, social and environmental reasons why people find it hard to engage with physical activity (PA). Improved timely advice and customised support during a relapse can help reduce fears and enhance confidence with returning to PA. Physical activity recommendations should be tailored to individual’s abilities to make them achievable, giving a sense of accomplishment and boosting motivation.

OBJECTIVES: Planning and implementing public health initiatives in mass gatherings such as the Olympic Games pose unique challenges for interorganizational collaboration, which involves interaction among multiple and diverse agencies. Nonetheless, there is limited empirical evidence to support interagency collaboration and public health planning decisions in mass gatherings and how leadership can shape such interactions. We empirically explored these topics in the 2012 London Olympics to identify lessons to inform planning for future mass gatherings.\ud \ud STUDY DESIGN: This is a qualitative case study. \ud \ud METHODS: Data comprised 39 semistructured interviews with key informants conducted before, during, and after the games; in addition, direct observations of field exercises and documentary analysis were also used. Open coding and thematic analysis was used to analyze the data.\ud \ud RESULTS: We identified two main leadership challenges that influenced interagency collaboration: organizational public health leadership and coordinating collaborative decision-making. Two facilitative conditions helped overcome the previous challenges: nurturing interorganizational linkages and creating shared understanding by activating codified frameworks at the organizational level.\ud \ud CONCLUSIONS: Our study highlights leadership issues in interagency collaboration in mass gatherings. Practical implications arising from this study may inform the ways the organizers of mass gatherings, public health and safety agencies, and professionals can engage in effective partnerships and joint working.

We investigate how established professionals manage their identities in the face of identity threats from a contested shift in the professional logic that characterizes their field. To do so, we draw on interviews with 113 physicians from five European transition countries who faced pressure for change in their professional identities due to a shift in the logic of healthcare from a logic of “narrow specialism” in primary care that characterized the Soviet health system to a new logic of “generalism” that characterizes primary care in the West. We found three important forms of professional identity threats experienced by physicians during this period – professional values conflict, status loss, and social identity conflict. In addition, we identified three forms of identity work – authenticating, reframing, and cultural repositioning – that the professionals who successfully transitioned to the new identity performed in order to reconstruct their professional identities so that they were aligned with the new logic. Based on these findings, we present a model of how established professionals change their professional identities as a result of a contested shift in the professional logic of their field and discuss the underlying mechanisms through which this occurs.

Despite committed policy, regulative and professional efforts on healthcare safety, little is known about how such macro-interventions permeate organisations and shape culture over time. Informed by neo-institutional theory, we examined how inter-organisational influences shaped safety practices and inter-subjective meanings following efforts for coerced culture change. We traced macro-influences from 2000 to 2015 in infection prevention and control (IPC). Safety perceptions and meanings were inductively analysed from 130 in-depth qualitative interviews with senior- and middle-level managers from 30 English hospitals. A total of 869 institutional interventions were identified; 69% had a regulative component. In this context of forced implementation of safety practices, staff experienced inherent tensions concerning the scope of safety, their ability to be open and prioritisation of external mandates over local need. These tensions stemmed from conflicts among three co-existing institutional logics prevalent in the NHS. In response to requests for change, staff flexibly drew from a repertoire of cognitive, material and symbolic resources within and outside their organisations. They crafted 'strategies of action', guided by a situated assessment of first-hand practice experiences complementing collective evaluations of interventions such as 'pragmatic', 'sensible' and also 'legitimate'. Macro-institutional forces exerted influence either directly on individuals or indirectly by enriching the organisational cultural repertoire.

Background\ud National responses to healthcare-associated infections vary between high-income countries but when analysed for contextual comparability, interventions can be assessed for transferability.\ud \ud Aim\ud To identify learning from country-level approaches to addressing meticillin-resistant Staphylococcus aureus (MRSA) in Japan and England.\ud \ud Methods\ud A longitudinal analysis (2000-17), comparing epidemiological trends and policy interventions. Data from 441 textual sources concerning infection prevention and control (IPC), surveillance, and antimicrobial stewardship interventions were systematically coded for: type - mandatory requirements, recommendations, or national campaigns; method - restrictive, persuasive, structural in nature; level of implementation - macro (national), meso (organisational), micro (individual) levels. Healthcare organisational structures and role of media were also assessed.\ud \ud Findings\ud In England significant reduction has been achieved in number of reported MRSA bloodstream infections. In Japan, in spite of reductions, MRSA remains a predominant infection. Both countries face new threats in the emergence of drug-resistant Escherichia coli. England has focused on national mandatory and structural interventions, supported by a combination of outcomes-based incentives and punitive mechanisms, and multidisciplinary IPC hospital teams. Japan has focused on (non-mandatory) recommendations and primarily persuasive interventions, supported by process-based incentives, with voluntary surveillance. Areas for development in Japan include resourcing of dedicated data management support and implementation of national campaigns for healthcare professionals and the public.\ud \ud Conclusion\ud Policy interventions need to be relevant to local epidemiological trends, while acceptable within health system cultures and public expectations. Cross-national learning can help inform the right mix of interventions to create sustainable and resilient systems for future infection and economic challenges.

Objectives To assess hospital emergency nurses' self-reported knowledge, role awareness and skills in disaster response with respect to the Hajj mass gathering in Mecca.Design Cross-sectional online survey with primary data collection and non-probabilistic purposive sample conducted in late 2014.Setting All 4 public hospitals in Mecca, Saudi Arabia.Participants 106 registered nurses in hospital emergency departments.Main outcome measure Awareness, knowledge, skills and perceptions of emergency nurses in Mecca with regard to mass gathering disaster preparedness.Results Although emergency nurses' clinical role awareness in disaster response was reported to be high, nurses reported limited knowledge and awareness of the wider emergency and disaster preparedness plans, including key elements of their hospital strategies for managing a mass gathering disaster. Over half of the emergency nurses in Mecca's public hospitals had not thoroughly read the plan, and almost 1 in 10 were not even aware of its existence. Emergency nurses reported seeing their main role as providing timely general clinical assessment and care; however, fewer emergency nurses saw their role as providing surveillance, prevention, leadership or psychological care in a mass gathering disaster, despite all these broader roles being described in the hospitals' emergency disaster response plans. Emergency nurses' responses to topics where there are often misconceptions on appropriate disaster management indicated a significant knowledge deficit with only 1 in 3 nurses at best or 1 in 6 at worst giving correct answers. Respondents identified 3 key training initiatives as opportunities to further develop their professional skills in this area: (1) hospital education sessions, (2) the Emergency Management Saudi Course, (3) bespoke short courses in disaster management.Conclusions Recommendations are suggested to help enhance clinical and educational efforts in disaster preparedness.

Prescribing etiquette is an important determinant of antimicrobial prescribing behaviors. Prescribing etiquette recognizes clinical decision-making autonomy and the role of hierarchy in influencing practice. Existing clinical groups and clinical leadership should be utilized to influence antimicrobial prescribing behaviors., Background. There is limited knowledge of the key determinants of antimicrobial prescribing behavior (APB) in hospitals. An understanding of these determinants is required for the successful design, adoption, and implementation of quality improvement interventions in antimicrobial stewardship programs. Methods. Qualitative semistructured interviews were conducted with doctors (n = 10), pharmacists (n = 10), and nurses and midwives (n = 19) in 4 hospitals in London. Interviews were conducted until thematic saturation was reached. Thematic analysis was applied to the data to identify the key determinants of antimicrobial prescribing behaviors. Results. The APB of healthcare professionals is governed by a set of cultural rules. Antimicrobial prescribing is performed in an environment where the behavior of clinical leaders or seniors influences practice of junior doctors. Senior doctors consider themselves exempt from following policy and practice within a culture of perceived autonomous decision making that relies more on personal knowledge and experience than formal policy. Prescribers identify with the clinical groups in which they work and adjust their APB according to the prevailing practice within these groups. A culture of “noninterference” in the antimicrobial prescribing practice of peers prevents intervention into prescribing of colleagues. These sets of cultural rules demonstrate the existence of a “prescribing etiquette,” which dominates the APB of healthcare professionals. Prescribing etiquette creates an environment in which professional hierarchy and clinical groups act as key determinants of APB. Conclusions. To influence the antimicrobial prescribing of individual healthcare professionals, interventions need to address prescribing etiquette and use clinical leadership within existing clinical groups to influence practice.

Health systems need efficient and effective innovation decisions to provide maximum benefit to patients, particularly in a climate of financial constraints. Although evidence-based innovations exist for helping to address healthcare-associated infections, the uptake and implementation of these is highly variable and in some cases very slow.To investigate innovation adoption decisions and implementation processes from an organizational perspective, focusing on the implications of stakeholder involvement during the innovation process.Thirty-eight technology adoption decisions and implementation processes were examined through 121 qualitative interviews in 12 National Health Service healthcare organizations across England.Stakeholder involvement varied across organizations with decisions highly exclusive to the infection prevention and control (IPC) team, to highly inclusive of wider organizational members. The context, including organizational culture, previous experience, and logistical factors influenced the level of stakeholder engagement. The timing of stakeholder involvement in the process impacted on: (i) the range of innovations considered; (ii) the technologies selected, and (iii) the success of technology implementation. Cases of non-adoption, discontinued adoption, and of successful implementation are presented to share learning. The potential benefits of stakeholder involvement for 'successful' innovation adoption are presented including a goal-oriented framework for involvement.Key stakeholder involvement can lead to innovation adoption and implementation compatible with structural and cultural contexts, particularly when involvement crosses the phases of initiation, decision-making and implementation. Involving members of the wider healthcare organization can raise the profile of IPC and reinforce efforts to make IPC everybody's business.

Although emergency nurses, being the frontline workers in mass-gatherings, are essential for providing an effective public health response, little is known about the skills that emergency nurses have, or require, in order to respond effectively to a disaster event. This paper is designed to address this gap in the literature by conducting an empirical study on emergency nurses’ preparedness at the mass-gathering event of Hajj in Mecca city. To achieve this aim, this study conducted a cross-sectional survey among 106 emergency department nurses in all the public hospitals in Mecca in 2014. The results revealed that although emergency nurses’ role understanding is high; they have limited knowledge and awareness of how to respond appropriately to mass-gathering disaster events. To address this knowledge gap, the top three most beneficial types of education and training courses suggested are: hospital education sessions, the Emergency Management Saudi Course and workshop; and short courses in disaster management. Finally, recommendations and constructive strategies are developed to provide the best practice in enhancing disaster preparedness. This paper adds to the body of knowledge regarding emergency nurses and mass gathering disasters. This paper measures the level of disaster knowledge, previous disaster response experience and disaster education and training amongst emergency nurses in Mecca, Saudi Arabia. It is anticipated that this study will provide a foundation for future studies aimed at better preparing emergency nurses for disaster response. This paper employs new strategies to improve the emergency nurses’ response during mass gatherings for the Hajj. Increasing the emergency nurses’ knowledge will develop their effective responses in mass-gathering disasters., {"references":["R.A. DeLorenzo, \"Mass gathering medicine: a review,\" Prehospital and Disaster Medicine, no. 12, pp. 68–72, 1997.","K. Hammad, P. Arbon, and K. Gebbie, \"Emergency nurses and disaster response: An exploration of South Australian emergency nurses' knowledge and perceptions of their roles in disaster response,\" Australasian Emergency, no. 14,2, pp. 87-94, 2011.","K. Imran, and R. McLeod, \"Managing hajj crowd complexity: superior throughput satisfaction health and safety,\" Kuwait Chapter of Arabian Journal of Business and Management Review, vol. 2, no. 4, pp. 45–59, 2012.","Q. Ahmed, M. Barbeschi, and Z. Memish, 'The quest for public health security at Hajj: The WHO guidelines on communicable disease alert and response during mass gatherings,\" Travel Medicine and Infectious Disease, vol. 7, no. 1, pp. 226–230, 2009.","W. Higgins, C. Wainwright, L. 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Memish, \"Mass gathering medicine: 2014 Hajj and Umra preparation as a leading example\", International Journal of Infectious Diseases, vol. 27, no.1, pp. 26–31, 2014.\n[14]\tS. Shafi, B. Booy, E. Haworth, H. Rashid, and Z. Memish, \"Hajj: Health lessons for mass gatherings,\" Journal of Infection and Public Health, vol. 1, no. 1 pp. 27–32, 2008.\n[15]\tI. Khan, and R. McLeod, \"Managing Hajj crowd complexity: Superior throughput, satisfaction, health, & safety,\" Arabian Journal of Business and Management Review, vol. 2, no. 4, pp. 45-59, 2012. \n[16]\tL. Conlon, and R. Wiechula, \"Preparing nurses for future disasters: The Sichuan experience,\" Australasian Emergency Nursing Journal, vol. 14, no.1, pp. 246–250, 2011.\n[17]\tQ. Ahmed, Y. Arabi, and Z. Memish, \"Health risks at the Hajj,\" Lancet, vol. 367, no. 1, pp. 1008–1015, 2006.\n[18]\tJ. Schriver, R. Talmadge, R. Chuong, and J. Hedges, \"Emergency nursing: historical, current, and future roles,\" Journal of Emergency Learning, vol. 29, no. 5, pp. 431–439, 2003.\n[19]\tJ. Burstein, \"The Myths of Disaster Education,\" Annals of Emergency Medicine, vol. 47, no. 1, pp. 50–52, 2006.\n[20]\tL. Cusack, P. Arbon, and J. Ranse, \"What is the role of nursing students and schools of nursing during disaster? A discussion paper,\" Collegian, vol.17, no.1, pp. 193–197, 2010."]}

Results of the application of the proposed analytic framework. Results of the four studies using the proposed analytic framework of intervention formulation and evaluation. (DOCX 61Â kb)

Flow chart depicting the selection of studies. Flow chart depicting the selection of studies in the scoping review. (DOCX 86Â kb)

Search strings in five electronic databases and Google Scholar. Search strings in Ovid MEDILINE, Embase Classic + Embase, PsycINFO, Scopus, The Cochrane Library Database, and Google Scholar. (DOCX 43 kb)

Objective: This article aims to outline the historical development of medical leadership in the United Kingdom (UK), present recent advances, and discuss professional development and future prospects. Conclusions: With increasing involvement of medical professionals in top managerial roles in the UK over the last 30 years, leadership development initiatives have been growing steadily and there is increasing recognition of the need for leadership and management skills for doctors. Such skills can help to greatly improve patient care as well as enhance organisational effectiveness and productivity. The central involvement of professional bodies such as the UK Faculty of Medical Leadership and Management, and the establishment of medical fellowship schemes, have provided a solid foundation for a new generation of aspiring medical leaders but there is still a long way to go to achieve a higher degree of professionalism for clinical leadership in the UK. The evidence base is weak such that integrated efforts by clinicians and management academics have much to offer in achieving the vision of socially responsible, clinically relevant and research informed medical leadership training.

Objectives To examine the experiences of mental health service users who took part in an arts-based programme at Tate Modern, a major London art gallery. Study design Exploratory qualitative design. Methods Data were collected using in-depth semi-structured interviews with 10 mental health service users who had taken part in a community-based programme at Tate Modern. Additionally, six art educators from Tate Modern were interviewed. Concepts that emerged from the text were identified using thematic analysis. Results All participants valued the gallery-based programme. The three overarching thematic areas were: the symbolic and physical context in which the programme workshops were located; the relational and social context of the programme workshops; and reflections on the relationship between the arts-based programme and subsequent mental health. Conclusions Art galleries are increasingly seen to function as vehicles for popular education with mental health service users. This study adds to the growing body of evidence related to how mental health service users experience and reflect on arts-related programmes targeted at them. This study indicates that emphasis on how users experience gallery-based programmes may contribute to a more nuanced understanding of the relationship between art and mental health.

Background We know that patient care can be improved by implementing evidence-based innovations and applying research findings linked to good practice. Successfully implementing innovations in complex organisations, such as the UK's National Health Service (NHS), is often challenging as multiple contextual dynamics mediate the process. Research studies have explored the challenges of introducing innovations into healthcare settings and have contributed to a better understanding of why potentially useful innovations are not always implemented in practice, even if backed by strong evidence. Mediating factors include health policy and health system influences, organisational factors, and individual and professional attitudes, including decision makers' perceptions of innovation evidence. There has been limited research on how different forms of evidence are accessed and utilised by organisational decision makers during innovation adoption. We also know little about how diverse healthcare professionals (clinicians, administrators) make sense of evidence and how this collective sensemaking mediates the uptake of innovations. Methods The study will involve nine comparative case study sites of acute care organisations grouped into three regional clusters across England. Each of the purposefully selected sites represents a variety of trust types and organisational contexts. We will use qualitative methods, in-depth interviews, observation of key meetings, and systematic analysis of relevant secondary data to understand the rationale and challenges involved in sourcing and utilising innovation evidence in the empirical setting of infection prevention and control. We will use theories of innovation adoption and sensemaking in organisations to interpret the data. The research will provide lessons for the uptake and continuous use of innovations in the English and international health systems. Discussion Unlike most innovation studies, which involve single-level analysis, our study will explore the innovation-adoption process at multiple embedded levels: micro (individual), meso (organisational), and macro (interorganisational). By comparing and contrasting across the nine sites, each with different organisational contexts, local networks, leadership styles, and different innovations considered for adoption, the findings of the study will have wide relevance. The research will produce actionable findings responding to the political and economic need for healthcare organisations to be innovation-ready.

Objectives To understand organisational technology adoption (initiation, adoption decision, implementation) by looking at the different types of innovation knowledge used during this process. Design Qualitative, multisite, comparative case study design. Setting One primary care and 11 acute care organisations (trusts) across all health regions in England in the context of infection prevention and control. Participants and data analysis 121 semistructured individual and group interviews with 109 informants, involving clinical and non-clinical staff from all organisational levels and various professional groups. Documentary evidence and field notes were also used. 38 technology adoption processes were analysed using an integrated approach combining inductive and deductive reasoning. Main findings Those involved in the process variably accessed three types of innovation knowledge: ‘awareness’ (information that an innovation exists), ‘principles’ (information about an innovation's functioning principles) and ‘how-to’ (information required to use an innovation properly at individual and organisational levels). Centralised (national, government-led) and local sources were used to obtain this knowledge. Localised professional networks were preferred sources for all three types of knowledge. Professional backgrounds influenced an asymmetric attention to different types of innovation knowledge. When less attention was given to ‘how-to’ compared with ‘principles’ knowledge at the early stages of the process, this contributed to 12 cases of incomplete implementation or discontinuance after initial adoption. Conclusions Potential adopters and change agents often overlooked or undervalued ‘how-to’ knowledge. Balancing ‘principles’ and ‘how-to’ knowledge early in the innovation process enhanced successful technology adoption and implementation by considering efficacy as well as strategic, structural and cultural fit with the organisation's context. This learning is critical given the policy emphasis for health organisations to be innovation-ready., Article summary Article focus Despite policy support and the development of a dedicated evidence dissemination infrastructure in the NHS, why is technology adoption and implementation still a challenge? We need to understand better how the innovation process unfolds in organisations to build on what we know about individual behaviours. In particular, how the use of different types of knowledge about an innovation impacts its adoption and implementation. Key messages In our study, centralised dissemination of evidence had minimal to moderate impact on organisational innovation adoption decisions. Practice-based, peer-mediated and local dissemination systems were perceived more relevant. In contrast to technology adoption by individuals, organisational adoption required a wider multifaceted conceptualisation of ‘how-to’ knowledge in line with the more complex dynamics in organisations. When ‘how-to’ knowledge was undervalued and considered late, important strategic, structural and cultural elements of the trust's context were overlooked. This had negative implications for technology adoption and implementation. Professional backgrounds of those involved in the process influenced the types of innovation knowledge considered, which had implications for implementation. The involvement of diverse professionals in decision-making improves the chances of successful implementation through a balanced consideration of the strength of scientific evidence and practical application. Strengths and limitations of this study The scale of the study, its real time and longitudinal nature provide a rich data set. Our study is theory driven and comprises multisite comparative case studies, which enhance the generalisability of findings beyond the context of the studied trusts. We explicitly studied cases of non-adoption and discontinuation after initial adoption to provide important learning often missing from innovation diffusion research. On limitations, we were not able to follow implementation past the end of August 2010 and therefore do not have information on routinised use of the implemented technologies.

Whilst evidence based innovations exist for helping to address Health Care Associated Infections (HCAIs), the uptake and implementation of these is highly variable and in some cases very slow. We aimed to investigate organisational innovation adoption decisions and implementation processes in the context of Infection Prevention and Control (IPC). Here we focus on the implications of stakeholder involvement during these processes.

The nature, sources and format of evidence used by managers and clinicians is important in introducing innovations in healthcare. We investigate the organisational decision making process focusing on the adoption of innovative technologies in the context of infection prevention and control (IPC) and the nature of evidence used.

This report summarizes the findings of four case studies that review the experience of family medicine in Europe and Central Asia (ECA) Region. It is part of a study comprising five volumes that review the experience of family medicine in four countries in ECA--Armenia, Bosnia and Herzegovina, Kyrgyz Republic and Moldova. The report reviews the experience, draws lessons, and establishes an evidence base for detailed analysis. The study presents best practices for policy dialogue and future investments by the World Bank and other financial institutions. The detailed case studies compare these countries and draw common themes and issues. Comparisons are made with best-developed or existing models in the OECD and other countries in the Europe and Central Asia Region that have already undertaken family medicine reform.

This report summarizes the findings of four case studies that review the experience of family medicine in Europe and Central Asia (ECA) Region. It is part of a study comprising five volumes that review the experience of family medicine in four countries in ECA--Armenia, Bosnia and Herzegovina, Kyrgyz Republic and Moldova. The report reviews the experience, draws lessons, and establishes an evidence base for detailed analysis. The study presents best practices for policy dialogue and future investments by the World Bank and other financial institutions. The detailed case studies compare these countries and draw common themes and issues. Comparisons are made with best-developed or existing models in the OECD and other countries in the Europe and Central Asia Region that have already undertaken family medicine reform.