Regulation of long-term care for older persons: a scoping review of empirical research.

OBJECTIVE: Not only care professionals are responsible for the quality of care but other stakeholders including regulators also play a role. Over the last decades, countries have increasingly invested in regulation of Long-Term Care (LTC) for older persons, raising the question of how regulation should be put into practice to guarantee or improve the quality of care. This scoping review aims to summarize the evidence on regulatory practices in LTC for older persons. It identifies empirical studies, documents the aims and findings, and describes research gaps to foster this field. DESIGN: A literature search (in PubMed, Embase, Cinahl, APA PsycInfo and Scopus) was performed from inception up to December 12th, 2022. Thirty-one studies were included. RESULTS: All included studies were from high-income countries, in particular Australia, the US and Northwestern Europe, and almost all focused on care provided in LTC facilities. The studies focused on different aspects of regulatory practice, including care users' experiences in collecting intelligence, impact of standards, regulatory systems and strategies, inspection activities and policies, perception and style of inspectors, perception and attitudes of inspectees and validity and reliability of inspection outcomes. CONCLUSION: With increasingly fragmented and networked care providers, and an increasing call for person-centred care, more flexible forms of regulatory practice in LTC are needed, organized closer to daily practice, bottom-up. We hope that this scoping review will raise awareness of the importance of regulatory practice and foster research in this field, to improve the quality of LTC for older persons, and optimize their functional ability and well-being.

Achieving research impact in medical research through collaboration across organizational boundaries: Insights from a mixed methods study in the Netherlands.

BACKGROUND: In the Netherlands, university medical centres (UMCs) bear primary responsibility for conducting medical research and delivering highly specialized care. The TopCare program was a policy experiment lasting 4 years in which three non-academic hospitals received funding from the Dutch Ministry of Health to also conduct medical research and deliver highly specialized care in specific domains. This study investigates research collaboration outcomes for all Dutch UMCs and non-academic hospitals in general and, more specifically, for the domains in the non-academic hospitals participating in the TopCare program. Additionally, it explores the organizational boundary work employed by these hospitals to foster productive research collaborations. METHODS: A mixed method research design was employed combining quantitative bibliometric analysis of publications and citations across all Dutch UMCs and non-academic hospitals and the TopCare domains with geographical distances, document analysis and ethnographic interviews with actors in the TopCare program. RESULTS: Quantitative analysis shows that, over the period of study, international collaboration increased among all hospitals while national collaboration and single institution research declined slightly. Collaborative efforts correlated with higher impact scores, and international collaboration scored higher than national collaboration. A total of 60% of all non-academic hospitals' publications were produced in collaboration with UMCs, whereas almost 30% of the UMCs' publications were the result of such collaboration. Non-academic hospitals showed a higher rate of collaboration with the UMC that was nearest geographically, whereas TopCare hospitals prioritized expertise over geographical proximity within their specialized domains. Boundary work mechanisms adopted by TopCare hospitals included aligning research activities with organizational mindset (identity), bolstering research infrastructure (competence) and finding and mobilizing strategic partnerships with academic partners (power). These efforts aimed to establish credibility and attractiveness as collaboration partners. CONCLUSIONS: Research collaboration between non-academic hospitals and UMCs, particularly where this also involves international collaboration, pays off in terms of publications and impact. The TopCare hospitals used the program's resources to perform boundary work aimed at becoming an attractive and credible collaboration partner for academia. Local factors such as research history, strategic domain focus, in-house expertise, patient flows, infrastructure and network relationships influenced collaboration dynamics within TopCare hospitals and between them and UMCs.

Job crafting as retention strategy: An ethnographic account of the challenges faced in crafting new nursing roles in care practice.

Nursing shortages in the global north are soaring. Of particular concern is the high turnover among bachelor-trained nurses. Nurses tend to leave the profession shortly after graduating, often citing a lack of appreciation and voice in clinical and organisational decision-making. Healthcare organisations seek to increase the sustainability of the nursing workforce by enhancing nursing roles and nurses' organisational positions. In the Netherlands, hospitals have introduced pilots in which nurses craft new roles. We followed two pilots ethnographically and examined how nurses and managers shaped new nursing roles and made sense of their (expected) impact on workforce resilience. Informed by the literature on professional ecologies and job crafting, we show how managers and nurses defined new roles by differentiating between training levels and the uptake of care-related organisational responsibilities beyond the traditional nursing role. We also show how, when embedding such new roles, nurses needed to negotiate specific challenges associated with everyday nursing practice, manifested in distinct modes of organising, work rhythms, embodied expertise, socio-material arrangements, interprofessional relationships, and conventions about what is considered important in nursing. We argue that our in-depth case study provides a relational and socio-material understanding of the organisational politics implicated in organising care work in the face of workforce shortages.

Navigating the Future of Organisational Health Services Research in Germany and beyond: a Position Paper. / Die Zukunft der organisationsbezogenen Versorgungsforschung in Deutschland und darüber hinaus ­ ein Positionspapier.

BACKGROUND: Recent analyses have shown that in health services research in Germany, healthcare organisations are often considered primarily as a study setting, without fully taking their complex organisational nature into account, neither theoretically nor methodologically. Therefore, an initiative was launched to analyse the state of Organisational Health Services Research (OHSR) in Germany and to develop a strategic framework and road map to guide future efforts in the field. This paper summarizes positions that have been jointly developed by consulting experts from the interdisciplinary and international scientific community. METHODS: In July 2023, a scoping workshop over the course of three days was held with 32 (inter)national experts from different research fields centred around OHSR topics using interactive workshop methods. Participants discussed their perspectives on OHSR, analysed current challenges in OHSR in Germany and developed key positions for the field's development. RESULTS: The seven agreed-upon key positions addressed conceptual and strategic aspects. There was consensus that the field required the development of a research agenda that can guide future efforts. On a conceptual level, the need to address challenges in terms of interdisciplinarity, terminology, organisation(s) as research subjects, international comparative research and utilisation of organisational theory was recognized. On a strategic level, requirements with regard to teaching, promotion of interdisciplinary and international collaboration, suitable funding opportunities and participatory research were identified. CONCLUSIONS: This position paper seeks to serve as a framework to support further development of OHSR in Germany and as a guide for researchers and funding organisations on how to move OHSR forward. Some of the challenges discussed for German OHSR are equally present in other countries. Thus, this position paper can be used to initiate fruitful discussions in other countries.

Factors affecting the feelings of safety among individuals with mild intellectual disabilities and severe challenging behaviour in residential care: A qualitative study of professional and service users' perspectives.

Background: This study focuses on what feeling safe means for people with mild intellectual disabilities and severe challenging behaviour, and which factors affect their sense of safety. Method: Thematic analysis was used to analyse data collected during (1) ethnographic longitudinal research and (2) interviews and focus groups among professionals and service users. Results: Feelings of safety can relate to three main themes: (1) a physical environment that reduces risks and temptations; (2) a reliable, predictable, and supportive environment; and (3) an accepting environment that enables service users to establish a normal life. An analysis of which factors affect service users' sense of safety identified 20 themes (e.g. team climate) and 34 subthemes (e.g. interactions with other service users). Conclusions: A range of interconnected factors can affect service users' feelings of safety. Future research should explore what organisations and external actors (e.g. the police) can do to promote those feelings.

Toward a Values-Informed Approach to Complexity in Health Care: Hermeneutic Review.

Policy Points The concept of value complexity (complexity arising from differences in people's worldviews, interests, and values, leading to mistrust, misunderstanding, and conflict among stakeholders) is introduced and explained. Relevant literature from multiple disciplines is reviewed. Key theoretical themes, including power, conflict, language and framing, meaning-making, and collective deliberation, are identified. Simple rules derived from these theoretical themes are proposed.

Does structural form matter? A comparative analysis of pooled procurement mechanisms for health commodities.

INTRODUCTION: Pooled procurement can be seen as a collaboration initiative of buyers. Such mechanisms have received increased attention during the Covid-19 pandemic to improve access to affordable and quality-assured health commodities. The structural form of pooled procurement mechanisms ranges from a third-party organization that procures on behalf of its buyers to a buyer's owned mechanism in which buyers operate more collaboratively. However, little is known about how these types of pooled procurement mechanisms differ in terms of characteristics, implementation and developmental process. To fill this gap, we compared four pooled procurement mechanisms. Two buyer's owned mechanisms: the Organisation of the Eastern Caribbean States (OECS) and the Pacific Island Countries (PIC). And two third-party mechanisms: the Global Drug Facility (GDF) and the Asthma Drug Facility (ADF). METHODS: For this qualitative study, we used a multiple case-study design. The cases were purposefully selected, based on a most-similar case study design. We used the Pooled Procurement Guidance to collect data on individual cases and compared our findings between the case studies. For our analysis, we drew upon peer-reviewed academic articles, grey literature documents and 9 semi-structured interviews with procurement experts. RESULTS: Buyers within a buyer's owned mechanisms differ in procurement systems, financing structures, product needs and regulatory and legal frameworks. Therefore, buyers within such mechanisms require relative alignment on motivations, goals and operations of the mechanism. Our study showed that buyers' relative homogeneity of characteristics and their perceived urgency of the problems was particularly relevant for achieving that alignment. Third-party organization mechanisms require less alignment and consensus-building between buyers. To participate, buyers need to align with the operations of the third-party organization, instead of other buyers. Elements that were essential for the successful implementation and operation of such mechanisms included the procurement secretariat's ability to create local and global awareness around the problem, to induce political will to act upon the problem, to mobilize sufficient funding and to attract qualified staff. CONCLUSION: To successfully sustain pooled procurement mechanisms over time, key actors should drive the mechanism through continuous and reflexive work on stakeholder engagement, mobilization of funding and alignment of interests and needs.

"And when will you install the new water pump?": disconcerted reflections on how to be a 'good' Global Health scholar.

BACKGROUND: While critique on Global Health is not new, recent years show a surge of criticism on the field's colonial legacy and practices specifically. Such accounts argue that despite Global Health's strive for universality and equity in health, its activities regularly produce the opposite. The epistemic privileging of Northern academics and scientific method, further augmented by how Global Health funding is arranged, paints a picture of a fragmented field in which 'doing good' has become a normatively laden and controversial term. It is specifically this controversy that we seek to unpack in this paper: what does it take to be a 'good' Global Health scholar? RESULTS: We used Helen Verran's notion of 'disconcertment' to analyse three auto-ethnographic vignettes of Robert's Global Health 'fieldwork'. We illustrate that disconcertment, a bodily and personalised experience of unease and conflicting feelings, may serve as an important diagnostic of conflicting imperatives in Global Health. Robert's fieldwork was entangled with incongruous imperatives which he constantly had to navigate through and that repeatedly produced disconcertment. The contribution that we seek to make here is that such disconcertment is not something to defuse or ignore, but to take seriously and stay with instead. CONCLUSION: Staying with the disconcertment serves as a starting point for conversations about 'doing good' in Global Health fieldwork and creates opportunity for making Global Health teaching and projects more reflexive. The paper thereby positions itself in discussions about fair collaborations between the Global North and South and our analysis offers a set of considerations that can be used by Northern scholars to critically reflect on their own role within Global Health.

The patient representation struggle during the COVID-19 pandemic: Missed opportunities for resilient healthcare systems.

BACKGROUND: The role of patient participation and representation during crises, such as the COVID-19 pandemic, has been under-researched. Existing studies paint a pessimistic picture of patient representation during the pandemic. However, there are indications that patient representatives have adapted to the new situation and can contribute to the resilience of healthcare systems. This paper aims to further explore the potential contribution of patient representatives for healthcare system resilience during the COVID-19 pandemic. METHODS: The study used a qualitative approach. We conducted a thematic analysis on the following data: interviews with client council members (n = 32) and representatives from patient organizations (n = 6) and focus groups (n = 2) to investigate patient representation on both the national policy level and organizational level in the Netherlands. RESULTS: We identified the crisis discourse, the dependent position, the diversity of patient perspectives and the layered decision-making structure as themes that help to understand what made patient representation in pandemic times a struggle for national and local patient representatives. The analysis of the subjects these representatives put forward during decision-making shows that their input can play an important role in broadening discussions, challenging decisions, and suggesting alternatives during a crisis. We identified several strategies (e.g., collaborating with other actors, proactively putting subjects on the policy agenda, finding new ways of contacting their 'constituency') used by the patient representatives studied to exert influence despite the difficulties encountered. CONCLUSIONS: The struggle for patient representation during pandemic decision-making is a missed opportunity for resilient healthcare systems as these representatives can play a role in opening up discussions and putting different perspectives to the fore. Moreover, the adaptive strategies used by representatives to influence decision-making offer lessons for future representation activities. However, adaptations to the crisis decision-making structure are also needed to enable patient representatives to play their role. PATIENT CONTRIBUTION: We conducted interviews with patient representatives and discussed our preliminary findings with patient representatives during the focus groups. Zorgbelang, a patient organization supporting client councils and enabling and organizing patient participation for organizations and municipalities, was partner in this research and contributed to the interview guide, conducting interviews and focus groups. Additionally, the analysis made by the first author was discussed and refined multiple times with the partners of Zorgbelang and one of them co-authored this paper.

Room for resilience: a qualitative study about accountability mechanisms in the relation between work-as-done (WAD) and work-as-imagined (WAI) in hospitals.

BACKGROUND: Central to Safety-II is promoting resilience of healthcare practices. In the "Room for Resilience" research project we focus on the role of horizontal and vertical accountability in healthcare teams and aim to discover how the relation between the two impacts team reflections and discussions. In this article, we report on an explorative study at the start of the project which aimed to assess the structures and dynamics of horizontal and vertical accountability. METHODS: A qualitative study in six teams in three hospitals in the Netherlands. For the project, each team selected a specific clinical process to work on (e.g. pain assessment). We interviewed healthcare professionals, managers, and quality advisors about these processes, how they are discussed in practice and how teams need to account for them. Additionally, we observed the processes and how teams discuss them in practice. In total, we conducted 35 interviews and 67.5 h of observation. Transcripts and field notes were analyzed using thematic analysis. RESULTS: Professionals at times varied in what they considered the right approach in the clinical process, with differing views on the importance of certain actions. When processes were discussed, this mostly was done during clinical work, and it often concerned reflections about the care for a specific patient instead of reflecting on the team's general approach of the clinical process. Organized reflections on the processes were sparse. How processes were conducted in practice deviated from guidelines, mainly due to staff shortages, a perceived lack of value of a guideline, equipment issues, and collaboration issues. For most processes, accountability to hierarchical layers consisted of quality indicator scores. Professionals were tasked with registering indicator data but did not find this meaningful for their work. CONCLUSIONS: The observed different perspectives within teams on what good quality care is show the importance of having team reflections about these processes. How vertical accountability was organized at times impacted the conditions for teams to discuss resilient performance. Following these findings, we recommend that reflection on resilient practice and the role of accountability processes is organized on all levels in (and outside) the organization.

A resilience view on health system resilience: a scoping review of empirical studies and reviews.

BACKGROUND: Prompted by recent shocks and stresses to health systems globally, various studies have emerged on health system resilience. Our aim is to describe how health system resilience is operationalised within empirical studies and previous reviews. We compare these to the core conceptualisations and characteristics of resilience in a broader set of domains (specifically, engineering, socio-ecological, organisational and community resilience concepts), and trace the different schools, concepts and applications of resilience across the health literature. METHODS: We searched the Pubmed database for concepts related to 'resilience' and 'health systems'. Two separate analyses were conducted for included studies: a total of n = 87 empirical studies on health system resilience were characterised according to part of health systems covered, type of threat, resilience phase, resilience paradigm, and approaches to building resilience; and a total of n = 30 reviews received full-text review and characterised according to type of review, resilience concepts identified in the review, and theoretical framework or underlying resilience conceptualisation. RESULTS: The intersection of health and resilience clearly has gained importance in the academic discourse with most papers published since 2018 in a variety of journals and in response to external threats, or in reference to more frequent hospital crisis management. Most studies focus on either resilience of health systems generally (and thereby responding to an external shock or stress), or on resilience within hospitals (and thereby to regular shocks and operations). Less attention has been given to community-based and primary care, whether formal or informal. While most publications do not make the research paradigm explicit, 'resilience engineering' is the most prominent one, followed by 'community resilience' and 'organisational resilience'. The social-ecological systems roots of resilience find the least application, confirming our findings of the limited application of the concept of transformation in the health resilience literature. CONCLUSIONS: Our review shows that the field is fragmented, especially in the use of resilience paradigms and approaches from non-health resilience domains, and the health system settings in which these are used. This fragmentation and siloed approach can be problematic given the connections within and between the complex and adaptive health systems, ranging from community actors to local, regional, or national public health organisations to secondary care. Without a comprehensive definition and framework that captures these interdependencies, operationalising, measuring and improving resilience remains challenging.

All the good care: Valuation and task differentiation in older person care.

Task reallocation is increasingly foregrounded as a promising solution for capacity problems. Numerous studies show, however, that task reallocation between medical professionals is a highly contested issue and difficult to institutionalise. Conflicts are omnipresent and often arise from 'intraprofessional competition': Zero-sum games between professionals from different disciplinary backgrounds where one party's gains require another party's losses. In this article, we build on calls to enrich the sociology of professions with new concepts and theories. We analyse a case of task reallocation between medical professionals in a nursing home using concepts from empirical ethics and valuation studies. We argue that modes of good care offer a valuable framework for analysing the reorganisation of professional work because they provide an empirically grounded and fine-grained conceptual toolkit for understanding the dynamics among professionals and between professionals and managers. Enactment of different modes of good care inspires innovation in service provision but at the same time creates new tensions between those involved. We show how, in times of scarcity, a dynamic emerges between professionals attempting to stave off and reallocate work, thereby restricting their professional domains.

What makes knowledge translation work in practice? Lessons from a demand-driven and locally led project in Cameroon, Jordan and Nigeria.

BACKGROUND: Over the years, the knowledge translation (KT) field has moved from promoting linearized models to embracing the importance of interaction and learning. Likewise, there is now increased attention on the transfer of KT approaches to new environments. Some scholars, however, have warned that ideas about transferability still hinge on linear thinking and doing. In the current study, we therefore sought to use a more reflexive approach to KT and to study how actors align KT approaches with their local environments. METHODS: Our (auto) ethnographic study took place in a wider KT project. This project intended to combine three components: (1) co-organizing demand-driven, locally led and embedded KT cycles in Cameroon, Jordan, and Nigeria, (2) building upon established KT methods and (3) equipping and empowering local teams. We conducted 63 semi-structured interviews with key KT actors, observed 472 h of KT practices, and collected a paper trail of documents. At the same time, we also compiled project exchanges, such as project documents, plans, protocols, field notes, meeting notes and an archive of (email) correspondence between project members. We analysed all data abductively. RESULTS: We show that there were numerous moments where the design of our project indeed enabled us to align with local practices and needs. Yet this often did not suffice, and the project design sometimes conflicted with other logics and values. By analysing these tensions, we want to show that doing KT work which acts upon different values and knowledges and is sensitive towards the different effects that it produces demands both structuring projects in a specific way and requires significant alignment work of KT actors in practice. CONCLUSIONS: We show that practising KT more reflexively relies on two important conditions. First, KT projects have to be structured with sufficient discretionary space. Second, even though the structure of a project is important, there will be continuous need for alignment work. It is important to facilitate such alignment work and to further support it. In the discussion of this paper, we therefore articulate three design principles and three sensitivities. These elements can be used to make future KT projects more reflexive and sensitive to (social) complexity.

Involvement of Patients and Medical Professionals in the Assessment of Relative Effectiveness: A Need for Closer Cooperation.

OBJECTIVES: Involvement of patients and medical professionals in assessment of relative effectiveness (relative effectiveness assessment) contributes to an efficient and effective health technology assessment (HTA) process and supports acceptance and implementation of the outcome. This study aimed to analyze stakeholder involvement in assessing relative effectiveness and how the parties involved value this collaboration. METHODS: This is a document analysis of all drug assessments completed in 2019 (20) by the public HTA agency of The Netherlands, enriched with semistructured interviews with employees of the HTA agency (18) and representatives of patient (5) and medical (11) associations involved in these assessments. Data were analyzed, coded, and categorized. RESULTS: In almost half of the assessments, there was no coordination with the medical associations at the start of the relative effectiveness assessment and no patient associations involved in this phase. During the assessment procedure, patient and medical associations were always asked to comment on the draft report. Nevertheless, the strict 5-day deadline that the HTA agency uses as a response period often hampered a proper response and involvement. According to interviewees of the HTA agency, this leads to a great diversity in the substantive quality of their input. Patient and medical associations indicated that the HTA agency relies too much on "paper knowledge," which leads to a (perceived) lack of alignment with clinical practice. CONCLUSIONS: The limited involvement results in a lack of coordination and mutual trust. Optimizing involvement of patients and medical professionals in HTA practice requires effort from all parties involved. Procedural adjustments and better coordination, especially at the start of the assessment, would probably improve cooperation.

A systematic review of pooled procurement of medicines and vaccines: identifying elements of success.

INTRODUCTION: Pooled procurement of health commodities has increasingly been promoted as a solution to reduce prices, increase availability, and achieve more efficient procurement processes. However, little is known about what is required to implement pooled procurement mechanisms successfully and how they function under specific circumstances. Therefore, the aim of this systematic review is to synthesize empirically grounded insights by identifying the elements that are essential for setting up and operating pooled procurement mechanisms of medicines and vaccines. METHODS: Our review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed, Scopus and Web of Science for empirical studies on pooled procurement of medicines and vaccines using various search terms. Publications were assessed based on predetermined eligibility criteria. RESULTS: Our initial search yielded 1596 publications, of which 44 were eventually included in our review. Most of the included articles focused on pooled procurement mechanisms that operated on a sub-national level (43%), procured a variety of products (38%), and were set up with the goal to contain costs (64%). The review identified several elements that are essential for pooled procurement mechanisms to function. We organized these elements around three key actors in the mechanism: buyers, the pooled procurement organization, and suppliers. To participate in pooled procurement, buyers need a sufficient level of technical capacity, financial capacity and compatible laws and regulations. To carry out pooled procurement, the pooled procurement organization needs sufficient financial capacity, technical capacity, and independent operations. To supply the mechanism with health commodities, suppliers need sufficient incentives, such as a sufficient market size and a prompt payment mechanism. CONCLUSION: Pooled procurement mechanisms are very diverse. They differ in characteristics and organizational structures and are set up to achieve a variety of goals. While certain essential elements are more likely to increase successful implementation and functioning of pooled procurement mechanisms, the organizational structure must be aligned with the goals of the mechanism, and adapted to the local contextual environment.

Ask us! Adjusting experience-based codesign to be responsive to people with intellectual disabilities, serious mental illness or older persons receiving support with independent living.

INTRODUCTION: Experience-based codesign (EBCD) is a valuable tool for participatory quality improvement. However, the EBCD process needs to be adjusted to make it suitable for long-term care. The focus of the improvement process needs to shift to the care relationship, as this is an important part of the quality of care in these settings. Furthermore, the EBCD process needs to be made more accessible to vulnerable populations. METHODS: Through a participatory research approach, EBCD was adjusted to long-term care. The research was conducted in two care organisations: one supporting people with serious mental illness and intellectual disabilities in independent living and one providing homecare services for older persons. RESULTS: The participatory research resulted in the development of 'Ask us!'-a method for critical reflective codesign. The research furthermore provided valuable lessons for participatory projects with vulnerable clients. A common problem with participatory research in long-term care is ensuring the involvement of clients and informal carers. We report on various strategies developed to include experiences of a diverse set of services users, such as combining interviews with participant observation, photo-voice and involving experts-by-experiences as co-ethnographers. In close collaboration with an inclusive theatre company, these experiences were translated into 42 short videos on complex situations in the care relationship from the perspective of clients, professionals or informal carers. These videos instigate critical reflection and accelerate the participatory quality improvement process. Moreover, practical tools were developed to overcome barriers regarding the involvement of people with disabilities. These include the use of photo-elicitation to enable participation of clients with disabilities in heterogeneous group discussions and involving experts-by-experience as proxies to share experiences of clients for whom participation in the 'Ask us' method remains inaccessible. CONCLUSION: The result of a robust participatory process, 'Ask us!' is a promising method for participatory quality improvement in long-term care. The research furthermore generated lessons for involving vulnerable populations in participatory research and codesign. PATIENT OR PUBLIC CONTRIBUTION: Clients were involved as informants, sharing their experiences with the care relationship in interviews, photovoice and observations. They were also involved as consultants, helping to analyse input for the film scripts during data validation sessions.

Mediating scarcity in pandemic times: an ethnographic study on the prevention and control of SARS-CoV-2 infections during the emergence of the corona crisis in the Netherlands.

BACKGROUND: In this paper we explore how staff involved with infection prevention managed the emerging COVID-19 crisis in the context of scarcity of Personal Protective Equipment (PPE), focussing specifically on the (re)writing of guidelines. We conceptualize guidelines as 'mediating devices' as they translate between evidence and clinical practice, between management and the workplace, as well as the different values embedded in these domains. It is this mediation, we argue, that adds to the resilience of healthcare organizations. The setting for this research is an elite academic hospital in the Netherlands during the emergence of the COVID-19 pandemic. METHODS: We conducted non-participative observations, semi-structured interviews, and document analysis during the emerging pandemic (March-July 2020). We observed meetings from the crisis team and the unit for infection prevention (210 hours), interviewed members of these teams (21 interviews) and analysed guidelines and flowcharts concerning infection prevention, as such collecting a unique and rich qualitative dataset. Analysis was done through thematic coding. RESULTS: Our results show the writing and rewriting of guidelines as a fundamental characteristic of dealing with scarcity and adding to resilience. We found three main practices our research participants engage in while trying to manage the uncertain situations emerging from the scarcity of personal protection equipment. The first practice we observe is defining safety; dealing with different perspectives and experiences of what 'working safely' means. The second entails the anticipation of scarcity by which our participants aim to control the situation through monitoring, research and creating scenarios. The third practice we observe is finding new ways to use PPE that is available, by experimenting and tinkering with the material. CONCLUSION: Infection prevention guidelines are crucial in managing the emerging crisis. We discuss how the writing of guidelines mediates between different settings, timeframes, and different worlds of quality. Through (re)writing there is a constant negotiation and discussion with the various actors about what works, and there is a continuous adaptive attitude. At the cost of a lot of work and struggle, this creates a resilient and inclusive work environment useful in a long-lasting crisis.

Fostering a just culture in healthcare organizations: experiences in practice.

BACKGROUND: A just culture is regarded as vital for learning from errors and fostering patient safety. Key to a just culture after incidents is a focus on learning rather than blaming. Existing research on just culture is mostly theoretical in nature. AIM: This study aims to explore requirements and challenges for fostering a just culture within healthcare organizations. METHODS: We examined initiatives to foster the development of a just culture in five healthcare organizations in the Netherlands. Data were collected through interviews with stakeholders and observations of project group meetings in the organizations. RESULTS: According to healthcare professionals, open communication is particularly important, paying attention to different perspectives on an incident. A challenge related to open communication is how to address individual responsibility and accountability. Next, room for emotions is regarded as crucial. Emotions are related to the direct consequences of incidents, but also to the response of the outside world, including the media and the health inspectorate. CONCLUSIONS: A challenge in relation to emotions is how to combine attention for emotions with focusing on facts, both within and outside the organization. Finally, healthcare professionals attach importance to commitment and exemplary behavior of management. A challenge as a manager here is how to keep distance while also showing commitment. Another challenge is how to combine openness with privacy of the parties involved, and how to deal with less nuanced views in other layers of the organization and in the outside world. Organizing reflection on the experienced tensions may help to find the right balance.

Assembling care: How nurses organise care in uncharted territory and in times of pandemic.

This article draws on ethnographic research to conceptualise how nurses mobilise assemblages of caring to organise and deliver COVID care; particularly so by reorganising organisational infrastructures and practices of safe and good care. Based on participatory observations, interviews and nurse diaries, all collected during the early phase of the pandemic, the research shows how the organising work of nurses unfolds at different health-care layers: in the daily care for patients and their families, in the coordination of care in and between hospitals, and at the level of the health-care system. These findings contrast with the dominant pandemic-image of nurses as 'heroes at the bedside', which fosters the classic and microlevel view of nursing and leaves the broader contribution of nurses to the pandemic unaddressed. Theoretically, the study adds to the literature on translational mobilisation and assemblage theory by focussing on the layered and often invisible organising work of nurses in health care.

Combining rules and dialogue: exploring stakeholder perspectives on preventing sexual boundary violations in mental health and disability care organizations.

BACKGROUND: Sexual boundary violations (SBV) in healthcare are harmful and exploitative sexual transgressions in the professional-client relationship. Persons with mental health issues or intellectual disabilities, especially those living in residential settings, are especially vulnerable to SBV because they often receive long-term intimate care. Promoting good sexual health and preventing SBV in these care contexts is a moral and practical challenge for healthcare organizations. METHODS: We carried out a qualitative interview study with 16 Dutch policy advisors, regulators, healthcare professionals and other relevant experts to explore their perspectives on preventing SBV in mental health and disability care organizations. We used inductive thematic analysis to interpret our data. RESULTS: We found three main themes on how healthcare organizations can prevent SBV in mental health and disability care: (1) setting rules and regulations, (2) engaging in dialogue about sexuality, and (3) addressing systemic and organizational dimensions. CONCLUSION: Our findings suggest that preventing SBV in mental health and disability care organizations necessitates setting suitable rules and regulations and facilitating dialogue about positive aspects of sexuality and intimacy, as well as about boundaries, and inappropriate behaviors or feelings. Combining both further requires organizational policies and practices that promote transparency and reflection, and focus on creating a safe environment. Our findings will help prevent SBV and promote sexual health in mental health and disability care organizations.