Situations of anomie and the health workforce crisis: Policy implications of a socially sensitive and inclusive approach to human resources.

Health systems in most jurisdictions are facing an unprecedented workforce crisis, manifesting as labour shortages, high staff turnover, and increasing rates of absenteeism and burnout. These issues affect professional and occupational groups in both health and social care and individuals at early and later stages of their career. The intensity and pervasiveness of the crisis suggests that it is a multicausal phenomenon. Studies have focused on the relationship between working environments and worker satisfaction and well-being. However, these are of limited use in understanding the deeper mechanisms behind the large-scale workforce crisis. The subjective experience of work, while rooted in a particular work context, is also shaped by broader social and cultural phenomena that put social norms and individuals' ability to conform to them in tension. The concept of anomie, initially developed by Durkheim and redefined by Merton, focuses on the way social norms that guide conduct and aspirations lose influence and become incompatible with each other or unsuited to contemporary work contexts. Understanding the workforce crisis from the perspective of anomie enables the development and implementation of novel policies based on co-production strategies where concerned publics engage collaboratively in framing the problem and searching for solutions.

Equilibrium in the governance of cross-sectoral policies: how does it translate into practice?

BACKGROUND: There is growing interest from health researchers in the governance of Health in All Policies (HiAP). Furthermore, the COVID-19 pandemic has re-ignited managers' interest in HiAP governance and in health prevention activities that involve actors from outside health ministries. Since the dynamics of these multi-actor, multi-sectoral policies are complex, the use of systems theory is a promising avenue toward understanding and improving HiAP governance. We focus on the concept of equilibrium within systems theory, especially as it points to the need to strike a balance between actors that goes beyond synergies or mimicry-a balance that is essential to HiAP governance. METHOD: We mobilized two sources of data to understand how the concept of equilibrium applies to HiAP governance. First, we reviewed the literature on existing frameworks for collaborative governance, both in general and for HiAP specifically, in order to extract equilibrium-related elements. Second, we conducted an in-depth case study over three years of an HiAP implemented in Quebec, Canada. RESULTS: In total, we identified 12 equilibrium-related elements relevant to HiAP governance and related to knowledge, actors, learning, mindsets, sustainability, principles, coordination, funding and roles. The equilibria were both operational and conceptual in nature. CONCLUSIONS: We conclude that policy makers and policy implementers could benefit from mobilizing these 12 equilibrium-related elements to enhance HiAP governance. Evaluators of HiAP may also want to consider and integrate them into their governance assessments.

How can entrepreneurs experience inform responsible health innovation policies? A longitudinal case study in Canada and Brazil.

AIM: To foster equity and make health systems economically and environmentally more sustainable, Responsible Innovation in Health (RIH) calls for policy changes advocated by mission-oriented innovation policies. These policies focus, however, on instruments to foster the supply of innovations and neglect health policies that affect their uptake. Our study's aim is to inform policies that can support RIH by gaining insights into RIH-oriented entrepreneurs' experience with the policies that influence both the supply of, and the demand for their innovations. METHODS: We recruited 16 for-profit and not-for-profit organisations engaged in the production of RIH in Brazil and Canada in a longitudinal multiple case study. Our dataset includes three rounds of interviews (n = 48), self-reported data, and fieldnotes. We performed qualitative thematic analyses to identify across-cases patterns. FINDINGS: RIH-oriented entrepreneurs interact with supply side policies that support technology-led solutions because of their economic potential but that are misaligned with societal challenge-led solutions. They navigate demand side policies where market approval and physician incentives largely condition the uptake of technology-led solutions and where emerging policies bring some support to societal challenge-led solutions. Academic intermediaries that bridge supply and demand side policies may facilitate RIH, but our findings point to an overall lack of policy directionality that limits RIH. CONCLUSION: As mission-oriented innovation policies aim to steer innovation towards the tackling of societal challenges, they call for a major shift in the public sector's role. A comprehensive mission-oriented policy approach to RIH requires policy instruments that can align, orchestrate, and reconcile health priorities with a renewed understanding of innovation-led economic development.

Web-based comparative study of some national experiences of health care quality management.

Since the publication of study results on adverse events to health care in OECD countries, the importance of the national quality improvement strategies has been recognised. To examine how these strategies have been shaped in different jurisdictions, we carried out this study. We conducted a web-based comparative study of international practices. We first defined seven key health care and services quality management functions. We then drew on the experience of authors to make a reasoned selection of 13 countries or states across the world. We determined the distance that separates each of these functions from a country's Ministry of Health (MoH); and examined whether these functions are concentrated in a single organisation or dispersed across several organisations. Afterwards, we correlated our results with the quality level of these countries based on the OECD's health care indicators. Overall, Netherlands, Québec (Canada), Korea, Germany, England (UK), and the United States had at least 50% of their quality management functions controlled by self-regulated organisations. The Market Concentration Index ranged from 937 for the United States to 6800 for Russia. Graphical representation has shown us two health system models. Our results also clearly showed that countries had a better quality of care most often when they belong to model 1 of our taxonomy. These findings will help countries design and implement large-scale health care and services quality strategies for better and safer health care and services.

A New and Rapid HPLC Method to Determine the Degree of Deacetylation of Glutaraldehyde-Cross-Linked Chitosan.

Chitosan is a linear biopolymer composed of D-glucosamine and N-acetylglucosamine units. The percentage of D-glucosamine in the polymeric chain can vary from one sample to another and is expressed as the degree of deacetylation (DDA). Since this parameter has an impact on many properties, its determination is often critical, and potentiometric titration is a common analytical technique to measure the DDA. Cross-linking with glutaraldehyde is one of the most explored modifications of chitosan; however, the determination of the DDA for the resulting reticulated chitosan resins can be challenging. In this paper, we report a new, rapid, and efficient method to determine the DDA of glutaraldehyde-cross-linked chitosan resins via HPLC. This method relies on the use of 2,4-dinitrophenylhydrazine (DNPH) as a derivatizing agent to measure the level of reticulation of the polymer (LR) after the reticulation step. In this study, we prepare three calibration curves (with an R2 value over 0.92) for three series of reticulated polymers covering a large range of reticulation levels to demonstrate that a correlation can be established between the LR established via HPLC and the DDA obtained via titration. The polymers are derived from three different chitosan starting materials. These standard calibration curves are now used on a routine basis in our lab, and the HPLC method has allowed us to change our DDA analysis time from 20 h to 5 min.

Network-building by community actors to develop capacities for coproduction of health services following reforms: A case study.

INTRODUCTION: Responsive, integrated and sustainable health systems require that communities take an active role in service design and delivery. Much of the current literature focuses on provider-led initiatives to gain community input, raising concerns about power imbalances inherent in invited forms of participation. This paper provides an alternate view, exploring how, in a period following reforms, community actors forge network alliances to (re)gain legitimacy and capacities to coproduce health services with system providers. METHODS: A longitudinal case study traced the network-building efforts over 3 years of a working group formed by citizens and community actors working with seniors, minorities, recent immigrants, youth and people with disabilities. The group came together over concerns about reforms that impacted access to health services and the ability of community groups to mediate access for vulnerable community residents. Data were collected from observation of the group's meetings and activities, documents circulated within and by the group, and semi-directed interviews. The first stage of analysis used social network mapping to reveal the network development achieved by the working group; a second traced network maturation, based on actor-network theory. RESULTS: Network mapping revealed how the working group mobilized existing links and created new links with health system actors to explore access issues. Problematization appeared as an especially important stage in network development in the context of reforms that disrupted existing collaborative relationships and introduced new structures and processes. CONCLUSION: Network-building strategies enable community actors to enhance their capacity for coproduction. A key contribution lies in the creation of 'organizational infrastructure'. PATIENT OR PUBLIC CONTRIBUTION: The lead researcher was embedded over 3 years in the activities of the community groups and community residents. Several group members provided comments on an initial draft of this paper. To preserve the anonymity of the group, their names do not appear in the acknowledgements section.

Climate Change Vulnerability Assessment in Mangrove-Dependent Communities of Manoka Island, Littoral Region of Cameroon.

This study was conducted on Manoka Island (Littoral Region of Cameroon) with the aim of analyzing climate change vulnerability and local adaptation strategies based on the local community's perceptions and biophysical evidence. We used household surveys, focus group discussions, field observation, GIS, and remote sensing to collect data on variables of exposure, sensitivity, and adaptive capacity. Historical changes in rainfall and temperature, mangrove cover, and the occurrence of extreme climatic events were used as indicators of exposure. Property losses and income structure were used as indicators of sensitivity, while human, natural, social, financial, and physical assets represented adaptive capacity. 89 households were interviewed in the nine settlements of the island. Results show that Manoka Island is experiencing irregular rainfall patterns (with average annual values deviating from the mean by -1.9 to +1.8 mm) and increasing temperature (with annual values deviating from the mean by -1.2 to +3.12). The dynamics of the coastline between 1975 and 2017 using EPR show average setbacks of more than ±3 m/year, with erosion levels varying depending on the period and location. The number of households perceiving extreme climatic events like seasonal variability, flood, and rain storm was higher. From respondents' perception, housing and health are the sectors most affected by climate change. The reported high dependence of households on fishing for income, their overall low livelihood diversification, and their poor access to climate information reported by 65% of respondents portray their poor adaptive capacity. Local response initiatives are ineffective and include among others constructing buildings on stilts and using car wheels to counter the advancement of seawater inland. The study concludes that households on Manoka Island are vulnerable to the impacts of climate change. Income diversification, mangrove reforestation, the development of sustainable supply chains for wood fuel, and sustainable fish smoking devices are the main pathways for adaptation planning in this area.

Interprofessional collaboration and health policy: results from a Quebec mixed method legal research.

Interprofessional collaboration (IPC) is central to effective care. This practice is structured by an array of laws, regulations and policies but the literature on their impact on IPC is scarce. This study aims to illustrate the gap between the texts and clinicians' knowledge of the legal framework using an anonymous web-based survey. The survey, sent to nurses and physicians in Quebec, Canada, focused on the IPC legal framework, legal knowledge sources and IPC perceptions or beliefs. The primary outcome was to determine the gap between the law and understanding of the law. The secondary outcome was to identify legal knowledge sources for clinicians in Quebec. A total of 267 participants filled in the survey. For knowledge acquisition, 40% of physicians turned to insurers whereas 43% of nurses turned to their regulatory body. Only 30% of physicians correctly identified what activity is reserved for physicians while 39% of nurses correctly identified their reserved activity. Regarding legal perceptions, 28% of physicians and 39% of nurses thought IPC could increase their liability. These participants have a higher tendency to name liability-related issues as barriers to IPC. These results show an important discrepancy between clinicians' knowledge about law and policies, and the actual texts themselves. This gap can lead to misinterpretations of the law by clinicians, ineffective policy changes by policymakers and can perpetuate ineffective implementation of IPC.

Global health and innovation: A panoramic view on health human resources in the COVID-19 pandemic context.

While policy-makers in many jurisdictions are paying increasing attention to health workforce issues, human resources remain at best only partially aligned with population health needs. This paper explores the governance of human resources during the pandemic, looking at the Quebec health system as a revelatory case. We identify three issues related to health human resource (HHR) policies: working conditions, recognition at work and scope of practice. We empirically probe these issues based on an analysis of popular media, policy reports and participant observation by the lead authors in various forums and research projects. Using an integrated model of HHR, we identify major vulnerabilities in this domain. Persistent labour shortages, endemic deficiencies in working environments and inequity across occupational categories limit the ability to address critical HHR issues. We propose three ways to eliminate HHR vulnerabilities: reorganize work through participatory initiatives, implement joint policy making to rebalance power across the health workforce, and invest in the development of capacities at all system levels.

Activation of Smad2 but not Smad3 is required to mediate TGF-ß signaling during axolotl limb regeneration.

Axolotls are unique among vertebrates in their ability to regenerate tissues, such as limbs, tail and skin. The axolotl limb is the most studied regenerating structure. The process is well characterized morphologically; however, it is not well understood at the molecular level. We demonstrate that TGF-ß1 is highly upregulated during regeneration and that TGF-ß signaling is necessary for the regenerative process. We show that the basement membrane is not prematurely formed in animals treated with the TGF-ß antagonist SB-431542. More importantly, Smad2 and Smad3 are differentially regulated post-translationally during the preparation phase of limb regeneration. Using specific antagonists for Smad2 and Smad3 we demonstrate that Smad2 is responsible for the action of TGF-ß during regeneration, whereas Smad3 is not required. Smad2 target genes (Mmp2 and Mmp9) are inhibited in SB-431542-treated limbs, whereas non-canonical TGF-ß targets (e.g. Mmp13) are unaffected. This is the first study to show that Smad2 and Smad3 are differentially regulated during regeneration and places Smad2 at the heart of TGF-ß signaling supporting the regenerative process.

New understanding of primary health care nurse practitioner role optimisation: the dynamic relationship between the context and work meaning.

BACKGROUND: Optimising health professionals' contribution is an essential step in effective and efficient health human resources utilisation. However, despite the considerable efforts made to implement advanced practice nursing roles, including those in primary care settings (PHCNP), the optimisation of these roles remains variable. In this investigation, we report on the subjective work experience of a group of PHCNPs in the province of Quebec (Canada). METHODS: We used Giddens' structuration theory to guide our study given its' facilitation of the understanding of the dynamic between structural constraints and actors' actions. Using a qualitative descriptive study design, and specifically both individual and focus group interviews, we conducted our investigation within three health care regions in Quebec during 2016-2017. RESULTS: Forty-one PHCNPs participated. Their descriptions of their experience fell into two general categories. The first of these, their perception of others' inadequate understanding and valuing of their role, included the influence of certain work conditions, perceived restrictions on professional autonomy and the feeling of being caught between two professional paradigms. The second category, the PHCNPs' sense of engagement in their work, included perspectives associated with the specific conditions in which their work is situated, for example, the fragility of the role depending on the particular clinic/s in which they work or on the individuals with whom they work. This fragility was also linked with certain health care reforms that had been implemented in Quebec (e.g., legislation requiring greater physician productivity). CONCLUSION: Several new insights emerged, for example, the sense of role fragility being experienced by PHCNPs. The findings suggest an overarching link between the work context, the meaning attributed by PHCNPs to their work and their engagement. The optimisation of their role at the patient care level appears to be influenced by elements at the organisational and health system context levels. It appears that role optimisation must include the establishment of work environments and congruent health context structures that favour the implementation and deployment of new professional roles, work engagement, effective collaboration in interprofessional teams, and opportunities to exercise agency. Further research is necessary to evaluate initiatives that endeavour to achieve these objectives.

Collaborative governance in the Quebec Cancer Network: a realist evaluation of emerging mechanisms of institutionalization, multi-level governance, and value creation using a longitudinal multiple case study design.

BACKGROUND: People living with and beyond cancer (PLC) receive various forms of specialty care at different locations and many interventions concurrently or over time. They are affected by the operation of professional and organizational silos. This results in undue delays in access, unmet needs, sub-optimal care experiences and clinical outcomes, and human and financial costs for PLCs and healthcare systems. National cancer control programs advocate organizing in a network to coordinate actions, solve fragmentation problems, and thus improve clinical outcomes and care experiences for every dollar invested. The variable outcomes of such networks and factors explaining them have been documented. Governance is the "missing link" for understanding outcomes. Governance refers to the coordination of collective action by a body in a position of authority in pursuit of a common goal. The Quebec Cancer Network (QCN) offers the opportunity to study in a natural environment how, why, by whom, for whom, and under what conditions collaborative governance contributes to practices that produce value-added outcomes for PLCs, healthcare providers, and the healthcare system. METHODS/DESIGN: The study design consists of a longitudinal case study, with multiple nested cases (4 local networks nested in the QCN), mobilizing qualitative and quantitative data and mixed data from various sources and collected using different methods, using the realist evaluation approach. Qualitative data will be used for a thematic analysis of collaborative governance. Quantitative data from validated questionnaires will be analyzed to measure relational coordination and teamwork, care experience, clinical outcomes, and health-related health-related quality of life, as well as a cost analysis of service utilization. Associations between context, governance mechanisms, and outcomes will be sought. Robust data will be produced to support decision-makers to guide network governance towards optimized clinical outcomes and the reduction of the economic toxicity of cancer for PLCs and health systems.

The unpredictable journeys of spreading, sustaining and scaling healthcare innovations: a scoping review.

Innovation has the potential to improve the quality of care and health service delivery, but maximising the reach and impact of innovation to achieve large-scale health system transformation remains understudied. Interest is growing in three processes of the innovation journey within health systems, namely the spread, sustainability and scale-up (3S) of innovation. Recent reviews examine what we know about these processes. However, there is little research on how to support and operationalise the 3S. This study aims to improve our understanding of the 3S of healthcare innovations. We focus specifically on the definitions of the 3S, the mechanisms that underpin them, and the conditions that either enable or limit their potential. We conducted a scoping review, systematically investigating six bibliographic databases to search, screen and select relevant literature on the 3S of healthcare innovations. We screened 641 papers, then completed a full-text review of 112 identified as relevant based on title and abstract. A total of 24 papers were retained for analysis. Data were extracted and synthesised through descriptive and inductive thematic analysis. From this, we develop a framework of actionable guidance for health system actors aiming to leverage the 3S of innovation across five key areas of focus, as follows: (1) focus on the why, (2) focus on perceived-value and feasibility, (3) focus on what people do, rather than what they should be doing, (4) focus on creating a dialogue between policy and delivery, and (5) focus on inclusivity and capacity building. While there is no standardised approach to foster the 3S of healthcare innovations, a variety of practical frameworks and tools exist to support stakeholders along this journey.

Advanced practice nursing: Qualitative study of implications for family physicians' perceptions of their own work.

OBJECTIVE: To explore family physicians' perspectives on how best to exercise their role relative to that of primary health care nurse practitioners (PHCNPs). DESIGN: Qualitative case study. SETTING: Three Quebec health care regions. PARTICIPANTS: Sixteen physicians participated. To be eligible, family physicians were required to have worked with at least 1 PHCNP for a minimum of 6 months. METHODS: Semistructured individual and focus group interviews. MAIN FINDINGS: The implementation of the PHCNP role can be associated with considerable redesign of family physicians' habitual ways of functioning and with important transformations in their role within primary care teams, which can lead these professionals to reflect upon the meaning of their work. The physicians identified the following 4 elements that influenced their views: the nature of follow-up possible with patients, sharing the scope of practice, the patient profile, and new positive work experiences. CONCLUSION: The evolution of family physicians' role in the face of the PHCNP role must be situated within a discussion about the overall organization of care provision to patients and is not as straightforward as simply defining task division. This implementation also must take into account the frequently highly demanding context in which family physicians practise. Greater understanding is needed about contextual conditions that will facilitate physicians' practice within multidisciplinary teams, including the nature of, and interaction among, micro-, meso- and macro-level elements.

Mechanisms, contexts and points of contention: operationalizing realist-informed research for complex health interventions.

BACKGROUND: The concept of "mechanism" is central to realist approaches to research, yet research teams struggle to operationalize and apply the concept in empirical research. Our large, interdisciplinary research team has also experienced challenges in making the concept useful in our study of the implementation of models of integrated community-based primary health care (ICBPHC) in three international jurisdictions (Ontario and Quebec in Canada, and in New Zealand). METHODS: In this paper we summarize definitions of mechanism found in realist methodological literature, and report an empirical example of a realist analysis of the implementation ICBPHC. RESULTS: We use our empirical example to illustrate two points. First, the distinction between contexts and mechanisms might ultimately be arbitrary, with more distally located mechanisms becoming contexts as research teams focus their analytic attention more proximally to the outcome of interest. Second, the relationships between mechanisms, human reasoning, and human agency need to be considered in greater detail to inform realist-informed analysis; understanding these relationships is fundamental to understanding the ways in which mechanisms operate through individuals and groups to effect the outcomes of complex health interventions. CONCLUSIONS: We conclude our paper with reflections on human agency and outline the implications of our analysis for realist research and realist evaluation.

Introducing responsible innovation in health: a policy-oriented framework.

The scholarship on responsible research and innovation (RRI) aims to align the processes and outcomes of innovation with societal values by involving a broad range of stakeholders from a very early stage. Though this scholarship offers a new lens to consider the challenges new health technologies raise for health systems around the world, there is a need to define the dimensions that specifically characterise responsible innovation in health (RIH). The present article aims to introduce an integrative RIH framework drawing on the RRI literature, the international literature on health systems as well as specific bodies of knowledge that shed light on key dimensions of health innovations. Combining inductive and deductive theory-building strategies and concomitant with the development of a formal tool to assess the responsibility of innovations, we developed a framework that is comprised of nine dimensions organised within five value domains, namely population health, health system, economic, organisational and environmental. RIH provides health and innovation policy-makers with a common framework that supports the development of innovations that can tackle significant system-level challenges, including sustainability and equity.

Getting evidence to travel inside public systems: what organisational brokering capacities exist for evidence-based policy?

BACKGROUND: Implementing research findings into healthcare policy is an enduring challenge made even more difficult when policies must be developed and implemented with the help and support of multiple ideas, agendas and actors taking part in determinants of health. Only looking at mechanisms to feed policy-makers with evidence or to interest researchers in the policy process will simply bring partial clues; implementing evidence-based policy also requires organisations to lead and to partner in the production and intake of scientific evidence from academics and practical evidence from one another. MAIN BODY: This Commentary argues for the need to better understand the capacities required by organisations to foster evidence-based policy in a dispersed environment. It proposes a framework of 11 brokering capacities for organisations involved in evidence-based policy. Eight of these capacities are informed by streams of research related to the roles of knowledge broker, innovation broker and policy broker. Three complementary brokering capacities are informed by our experience studying real-life evidence-based policies; these are capturing boundary knowledge, trending know-how on scientific and practical evidence-based policy, and conveying evidence outward. CONCLUSIONS: Previous guidelines on brokering capacities focused on the individual level more than on the organisational level. Beyond the individual capacities of managers, designers and implementers of new policies, there is a need to identify and assess the brokering capacities of organisations involved in evidence-based policy. The three specific organisational brokering capacities for evidence-based policy that we present offer a means for policy-makers and policy designers to reflect upon favourable environments for evidence-based policy. These capacities could also help administrators and implementation scholars to think about and develop measurements to assess the quality and readiness of organisations involved in evidence-based policy design.

What do we know about the needs and challenges of health systems? A scoping review of the international literature.

BACKGROUND: While there is an extensive literature on Health System (HS) strengthening and on the performance of specific HSs, there are few exhaustive syntheses of the challenges HSs are facing worldwide. This paper reports the findings of a scoping review aiming to classify the challenges of HSs investigated in the scientific literature. Specifically, it determines the kind of research conducted on HS challenges, where it was performed, in which health sectors and on which populations. It also identifies the types of challenge described the most and how they varied across countries. METHODS: We searched 8 databases to identify scientific papers published in English, French and Italian between January 2000 and April 2016 that addressed HS needs and challenges. The challenges reported in the articles were classified using van Olmen et al.'s dynamic HS framework. Countries were classified using the Human Development Index (HDI). Our analyses relied on descriptive statistics and qualitative content analysis. RESULTS: 292 articles were included in our scoping review. 33.6% of these articles were empirical studies and 60.1% were specific to countries falling within the very high HDI category, in particular the United States. The most frequently researched sectors were mental health (41%), infectious diseases (12%) and primary care (11%). The most frequently studied target populations included elderly people (23%), people living in remote or poor areas (21%), visible or ethnic minorities (15%), and children and adolescents (15%). The most frequently reported challenges related to human resources (22%), leadership and governance (21%) and health service delivery (24%). While health service delivery challenges were more often examined in countries within the very high HDI category, human resources challenges attracted more attention within the low HDI category. CONCLUSIONS: This scoping review provides a quantitative description of the available evidence on HS challenges and a qualitative exploration of the dynamic relationships that HS components entertain. While health services research is increasingly concerned about the way HSs can adopt innovations, little is known about the system-level challenges that innovations should address in the first place. Within this perspective, four key lessons are drawn as well as three knowledge gaps.

Self-trapping and excited state absorption in fluorene homo-polymer and copolymers with benzothiadiazole and tri-phenylamine.

Excited state absorption (ESA) is studied using time-dependent density functional theory and compared with experiments performed in dilute solutions. The molecules investigated are a fluorene pentamer, polyfluorene F8, the alternating F8 copolymer with benzothiadiazole F8BT, and two blue-emitting random copolymers F8PFB and F8TFB. Calculated and measured spectra show qualitatively comparable results. The ESA cross-section of co-polymers at its maximum is about three times lower than that of F8. The ESA spectra are found to change little upon structural relaxation of the excited state, or change in the order of sub-units in a co-polymer, for all studied molecules. In all these molecules, the strongest ESA transition is found to arise from the same electronic process, exhibiting a reversal of the charge parity. In addition, F8PFB and F8TFB are found to possess almost identical electronic behaviour.