An examination of relational dynamics of power in the context of supported (assisted) decision-making with older people and those with disabilities in an acute healthcare setting.

INTRODUCTION: Supported (assisted) healthcare decision-making (ADM) focuses attention on how people with disabilities, including cognitive impairments, can be best supported to make decisions about their health and social care on an equitable basis with others. Meaningful implementation of legal frameworks for ADM challenges long-held presumptions about who has access to valued decision-making resources, influence and power within a particular socio-cultural setting. This study aims to explore the relational power dynamics around ADM with older people in acute care settings. METHODS: This study adopts a critical hermeneutic approach to qualitatively explore the lived experience of ADM from the perspectives of Health and Social Care Professionals (N = 26). This is supported by an exploration of the experiences of older people (N = 4), older people with a diagnosis of dementia (N = 4) and family carers (N = 5). RESULTS: We present three themes of data analysis that represent three spaces where the relational aspects of power in ADM are manifested. The first space, centralising decision-making power within multidisciplinary teams identified the privileging of physicians in traditional hierarchical leadership models that may lead to the implicit exclusion of family carers and some Health and Social Care Professionals in the ADM process. Privileging cognitive and communication competence identified a tendency to attribute decision-making autonomy to those with cognitive and communication competency. The final space, balancing the duty of care and individual autonomy, recognises acute care settings as typically risk-averse cultures that limit autonomy for decisions that carry risk, especially for those with cognitive impairment. CONCLUSION: Findings indicate the need to address cultural sources of power operating through social norms premised on ageist and ableist ideologies. It is necessary to challenge institutional barriers to meaningful ADM including positional power that is associated with hierarchies of influence and protectionism. Finally, meaningful ADM requires resistance to the disempowerment created by structural, economic and social circumstances which limit choices for decision-making. PATIENT OR PUBLIC CONTRIBUTION: A public and patient involvement panel of older people were consulted in the development of the grant application (HRB: APA-2016-1878). Representatives from Alzheimer's Society Ireland and Family Carers Ireland were steering committee members guiding design and strategy.

What constitutes brilliant aged care? A qualitative study of practices that exceed expectation.

AIM: This study aimed to explore what constitutes brilliant aged care. BACKGROUND: Although many aged care services do not offer the care that older people and carers need and want, some perform better. Rather than focus on problems with aged care, this study examined brilliant aged care-practices that exceeded expectation. DESIGN: The methodology for this study was informed by grounded theory, underpinned by constructionism to socially construct meaning. METHODS: This study invited nominations for a Brilliant Award via a survey, and interviews with the nominees via web conference. After receiving survey responses from 10 nominators, interviews were conducted with 12 nominees. Data were analysed using reflexive thematic analysis and documented according to COREQ guidelines to optimise rigour and transparency. RESULTS: According to participants, brilliant aged care involved being relationally attuned to older people, a deep understanding of the older person, recognition of aged care as more than a job, innovative practices and permission to reprioritise. CONCLUSIONS: This study suggests that, in aged care, brilliance happens. It emphasises the importance of meaningful connections and relationships in aged care, where thoughtful acts acknowledge an older person's value and humanity as well as creativity and innovation. RELEVANCE TO CLINICAL PRACTICE: For those who manage and deliver aged care, the findings suggest that small practice changes can make a positive difference to older people. Brilliant aged care can involve acts of empathy; enthusiasm for aged care; innovative practices, even those that are small scale; and reprioritising workplace tasks to spend time with older people. For policymakers, this study highlights the need to recognise and raise the profile of the pockets of brilliance within the aged care sector. This might be achieved via awards and other initiatives that serve to celebrate and learn from brilliance in its myriad forms. PATIENT OR PUBLIC CONTRIBUTION: The nominees, who included carers, were invited to participate in workshops with other carers and older people to co-design a model of brilliant aged care, during which workshop participants discussed and critiqued the findings constructed from the data.

Developing competence in interprofessional collaboration within integrated care teams for older people in the Republic of Ireland: A starter kit.

Current evidence offers little guidance as to how interprofessional collaboration can be fostered within the context of integrated care and older people. This research describes the co-design of core competencies for interprofessional collaboration within integrated care teams for older people and the development of practical guidance to support teams in building proficiency. Using a co-design approach, we conducted three studies (co-design workshops, qualitative interviews, and an online validation forum), the combined output of which is a Core Competency Framework, that includes three domains describing six competencies for proficiency in interprofessional collaboration within integrated care of older people. Domain one, Knowledge of the Team, includes the competencies; understanding roles, and making referrals. Domain two, Communication, includes the competencies; sharing information and communicating effectively and Domain three, Shared Decision-making, includes the final two competencies; supporting decision making with older people and collective clinical decision-making. In presenting a formal understanding of the competencies for interprofessional collaboration in the integrated care of older people and practical guidance for developing proficiency, this framework provides direction for future health service workforce development.

Involving older people in co-designing an intervention to reverse frailty and build resilience.

BACKGROUND: An essential consideration in health research is to conduct research with members of the public rather than for them. Public and patient involvement (PPI) of older people in research can improve enrolment, relevance and impact. However, few studies with PPI in frailty research have been identified. PPI has fallen during the Covid-19 pandemic. OBJECTIVE: We aimed to involve older people in co-designing a randomised control trial (RCT) intervention to reverse frailty and build resilience. We also wished to encourage wider use of PPI with older people by outlining our approach. METHODS: Involvement of older people was undertaken in three stages. Eighteen over 65-year-olds helped co-design an exercise intervention in two group discussions using the Socratic education method. Ninety-four contributed intervention feedback in one-on-one telephone interviews over nine months. Ten contributors helped optimise the intervention in three online workshops. Multidisciplinary team input and systematic review supported co-design. RESULTS: Eleven home-based resistance exercises were co-designed by group discussion contributors (mean age 75, 61% female). Frailty intervention format, gender balance and GP follow-up were shaped in telephone interviews (mean age 77, 63% female). Dietary guidance and patient communication were co-designed in workshops (mean age 71, 60% females). Technology proved no barrier to PPI. The co-designed frailty intervention is being evaluated in a definitive RCT. CONCLUSIONS: We enabled meaningful the involvement of 112 older people in the co-design of an intervention to reverse frailty and build resilience in diverse ways. Inclusive involvement can be achieved during a pandemic. Feedback enhanced intervention feasibility for real-world primary-care.

Our research paper describes how we involved 112 older adults in the co-design of an intervention aiming to reverse frailty and build resilience. Involving participants in research can improve its feasibility and impact. However, there have been few studies involving older people in frailty research and involvement has fallen further during the Covid-19 pandemic. Involvement of older people was undertaken in three stages. Eighteen over 65-year-olds helped co-design an exercise intervention in two group discussions. Ninety-four older adults contributed intervention feedback in one-on-one telephone interviews over nine months. Ten contributors helped optimise the intervention in three online workshops. The co-designed intervention involved resistance exercises and dietary guidance and will be tested in a full randomised control trial. We enabled the meaningful involvement of 112 older people in our research in diverse ways. Inclusive involvement can be achieved during a pandemic.

Mitigating unintended consequences of co-design in health care.

BACKGROUND: Co-design and associated terms are increasingly being used to facilitate values-based approaches to health-care improvement. It is messy and complex, involving diverse actors. METHODS: We explore the notion that initiatives have outcomes other than initially planned is neither new nor novel but is overlooked when thinking about co-design. We explore some of the unintended consequences and outline some optimal conditions that can mitigate challenges. DISCUSSION: Although co-design approaches are being applied in health care, questions remain regarding its ability to produce gains in health outcomes. Little is known about determining whether co-design is the most suitable approach to achieve the given project goals, the levels of involvement required to realize the benefits of co-design or the potential unintended consequences. There is a risk of further marginalizing or adding burden to under-represented populations and/or over-researched populations. CONCLUSION: Undertaking a co-design approach without the optimal conditions for inclusive involvement by all may not result in an equal partnership or improve health or care quality outcomes. Co-design requires on-going reflective discussions and deliberative thinking to remove any power imbalances. However, without adequate resources, a focus on implementation and support from senior leaders, it is a tough ask to achieve. PATIENT OR PUBLIC CONTRIBUTION: This viewpoint article was written by two academics who have undertaken a significant amount of PPI and co-design work with members of the public and patient's right across the health system. Our work guided the focus of this viewpoint as we reflected on our experiences.

Assisted decision-making and interprofessional collaboration in the care of older people: a qualitative study exploring perceptions of barriers and facilitators in the acute hospital setting.

In recent years, there has been a move toward a more human rights-based approach to the issue of supported and assisted decision-making (ADM) with legislative changes strengthening the formal right for older people to participate in care planning and decision-making. Ireland's Assisted Decision-Making (Capacity) Act, 2015 breaks from traditional views of capacity to consider the uniqueness of each decision in relation to topic, time and place for those with impaired or fluctuating capacity. This study set out to explore experiences of assisted decision making (ADM) in acute care hospitals in Ireland and to identify the barriers and enablers to ADM for older people and people with dementia from the perspective of different Health and Social Care Professionals (HSCPs) involved in their care. We carried out 26 semi-structured audio-recorded interviews with a convenience sample of HSCPs working in two acute hospitals and subsequently confirmed the results. HSCPs identified several barriers to, and enablers of, ADM in acute hospitals that were categorized into three key themes: Building meaningful engagement with older people and their family carers; barriers and enablers associated with interprofessional collaboration and barriers and enablers associated with the environment. Our findings suggest that despite concrete policy and legislative underpinnings to ADM, this was not always evident in practice and suggests the need for specialized education and training on ADM in practice settings.

Clarifying the mechanisms and resources that enable the reciprocal involvement of seldom heard groups in health and social care research: A collaborative rapid realist review process.

OBJECTIVE: Public and patient involvement is increasingly embedded as a core activity in research funding calls and best practice guidelines. However, there is recognition of the challenges that prevail to achieve genuine and equitable forms of engagement. Our objective was to identify the mechanisms and resources that enable the reciprocal involvement of seldom heard groups in health and social care research. METHODS: A rapid realist review of the literature that included: (a) a systematic search of CINAHL, PsycINFO, PubMed and Open Grey (2007-2017); (b) documents provided by expert panel members of relevant journals and grey literature. Six reference panels were undertaken with homeless, women's, transgender, disability and Traveller and Roma organizations to capture local insights. Data were extracted into a theory-based grid linking context to behaviour change policy categories. MAIN RESULTS: From the review, 20 documents were identified and combined with the reference panel summaries. The expert panel reached consensus about 33 programme theories. These relate to environmental and social planning (7); service provision (6); guidelines (4); fiscal measures (6); communication and marketing (4); and regulation and legislation (6). CONCLUSIONS: While there is growing evidence of the merits of undertaking PPI, this rarely extends to the meaningful involvement of seldom heard groups. The 33 programme theories agreed by the expert panel point to a variety of mechanisms and resources that need to be considered. Many of the programme theories identified point to the need for a radical shift in current practice to enable the reciprocal involvement of seldom heard groups.

What are the mechanisms that support healthcare professionals to adopt assisted decision-making practice? A rapid realist review.

BACKGROUND: The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) establishes a right to legal capacity for all people, including those with support needs. People with disabilities have a legal right to be given the appropriate supports to make informed decisions in all aspects of their lives, including health. In Ireland, the Assisted Decision-Making (Capacity) Act (2015) ratifies the Convention and has established a legal framework for Assisted Decision Making (ADM). The main provisions of the Act are not yet implemented. Codes of Practice to guide health and social care professionals are currently being developed. Internationally, concerns are expressed that ADM implementation is poorly understood. Using realist synthesis, this study aims to identify Programme Theory (PT) that will inform ADM implementation in healthcare. METHODS: A Rapid Realist Review using collaborative methods was chosen to appraise relevant literature and engage knowledge users from Irish health and social care. The review was led by an expert panel of relevant stakeholders that developed the research question which asks, 'what mechanisms enable healthcare professionals to adopt ADM into practice?' To ensure the PT was inclusive of local contextual influences, five reference panels were conducted with healthcare professionals, family carers and people with dementia. PT was refined and tested iteratively through knowledge synthesis informed by forty-seven primary studies, reference panel discussions and expert panel refinement and consensus. RESULTS: The review has developed an explanatory PT on ADM implementation in healthcare practice. The review identified four implementation domains as significant. These are Personalisation of Health & ADM Service Provision, Culture & Leadership, Environmental & Social Re-structuring and Education, Training & Enablement. Each domain is presented as an explanatory PT statement using realist convention that identifies context, mechanism and outcome configurations. CONCLUSIONS: This realist review makes a unique contribution to this field. The PT can be applied by policymakers to inform intervention development and implementation strategy. It informs the imminent policy and practice developments in Ireland and has relevance for other worldwide healthcare systems dealing with similar legislative changes in line with UNCRPD.

Enabling public, patient and practitioner involvement in co-designing frailty pathways in the acute care setting.

BACKGROUND: Although not an inevitable part of ageing, frailty is an increasingly common condition in older people. Frail older patients are particularly vulnerable to the adverse effects of hospitalisation, including deconditioning, immobility and loss of independence (Chong et al, J Am Med Dir Assoc 18:638.e7-638.e11, 2017). The 'Systematic Approach to improving care for Frail older patients' (SAFE) study co-designed, with public and patient representatives, quality improvement initiatives aimed at enhancing the delivery of care to frail older patients within an acute hospital setting. This paper describes quality improvement initiatives which resulted from a co-design process aiming to improve service delivery in the acute setting for frail older people. These improvement initiatives were aligned to five priority areas identified by patients and public representatives. METHODS: The co-design work was supported by four pillars of effective and meaningful public and patient representative (PPR) involvement in health research (Bombard et al, Implement Sci 13:98, 2018; Black et al, J Health Serv Res Policy 23:158-67, 2018). These pillars were: research environment and receptive contexts; expectations and role clarity; support for participation and inclusive representation and; commitment to the value of co-learning involving institutional leadership. RESULTS: Five priority areas were identified by the co-design team for targeted quality improvement initiatives: Collaboration along the integrated care continuum; continence care; improved mobility; access to food and hydration and improved patient information. These priority areas and the responding quality improvement initiatives are discussed in relation to patient-centred outcomes for enhanced care delivery for frail older people in an acute hospital setting. CONCLUSIONS: The co-design approach to quality improvement places patient-centred outcomes such as dignity, identity, respectful communication as well as independence as key drivers for implementation. Enhanced inter-personal communication was consistently emphasised by the co-design team and much of the quality improvement initiatives target more effective, respectful and clear communication between healthcare personnel and patients. Measurement and evaluation of these patient-centred outcomes, while challenging, should be prioritised in the implementation of quality improvement initiatives. Adequate resourcing and administrative commitment pose the greatest challenges to the sustainability of the interventions developed along the SAFE pathways. The inclusion of organisational leadership in the co-design and implementation teams is a critical factor in the success of interventions targeting service delivery and quality improvement.

Reducing risk of development or exacerbation of nutritional deficits by optimizing patient access to mealtime assistance.

OBJECTIVE: Optimize patient access to mealtime assistance, decrease missed meal incidence, risk of malnutrition, reduce food waste and staff rework. DESIGN: Lean Six Sigma methodology informed a pre/post intervention design. SETTING: 31 bed ward including Specialist Geriatric services and Acute Stroke Unit within an Irish University teaching hospital. PARTICIPANTS: Clinical and non-clinical staff including catering, nursing, speech and language therapy, dietetics and nutrition; patients, relatives. INTERVENTIONS: An interdisciplinary team used the structured Define/Measure/Analyse/Improve/Control (DMAIC) framework to introduce visual aids and materials to improve the access of patients to assistance at mealtimes. MAIN OUTCOME MEASURES: Pre and post outcomes measures were taken for the number and cost of uneaten meals, rework for staff, staff and patient satisfaction, patient outcomes. RESULTS: Following a 1-month pilot of a co-designed process for ensuring access to assistance at mealtimes, average wasted meals due to staff not being available to assist patients requiring mealtime assistance went from 3 per day to 0 corresponding to an average reduction of 0.43 kg per participating patient in food waste per day. Patients receiving assistance did not require additional oral therapeutic nutritional supplements, evidenced no new incidences of aspiration pneumonia or swallowing difficulties and were discharged without requirement for ongoing Dietetics and Nutrition support. Following a 6 month Control period comprising repeated PDCA cycles, the initiative was incrementally introduced to a further 10 wards/units, with positive feedback from patients and staff alike. CONCLUSION: The co-designed new process highlights the importance of staff and patient collaboration, inclusion and participation in designing quality improvement projects.

The co-design, implementation and evaluation of a serious board game 'PlayDecide patient safety' to educate junior doctors about patient safety and the importance of reporting safety concerns.

BACKGROUND: We believe junior doctors are in a unique position in relation to reporting of incidents and safety culture. They are still in training and are also 'fresh eyes' on the system providing valuable insights into what they perceive as safe and unsafe behaviour. The aim of this study was to co-design and implement an embedded learning intervention - a serious board game - to educate junior doctors about patient safety and the importance of reporting safety concerns, while at the same time shaping a culture of responsiveness from senior medical staff. METHODS: A serious game based on the PlayDecide framework was co-designed and implemented in two large urban acute teaching hospitals. To evaluate the educational value of the game voting on the position statements was recorded at the end of each game by a facilitator who also took notes after the game of key themes that emerged from the discussion. A sample of players were invited on a voluntary basis to take part in semi-structured interviews after playing the game using Flanagan's Critical Incident Technique. A paper-based questionnaire on 'Safety Concerns' was developed and administered to assess pre-and post-playing the game reporting behaviour. Dissemination workshops were held with senior clinicians to promote more inclusive leadership behaviours and responsiveness to junior doctors raising of safety concerns from senior clinicians. RESULTS: The game proved to be a valuable patient safety educational tool and proved effective in encouraging deep discussion on patient safety. There was a significant change in the reporting behaviour of junior doctors in one of the hospitals following the intervention. CONCLUSION: In healthcare, limited exposure to patient safety training and narrow understanding of safety compromise patients lives. The existing healthcare system needs to value the role that junior doctors and others could play in shaping a positive safety culture where reporting of all safety concerns is encouraged. Greater efforts need to be made at hospital level to develop a more pro-active safe and just culture that supports and encourages junior doctors and ultimately all doctors to understand and speak up about safety concerns.

Using geographic information systems to map older people's emergency department attendance for future health planning.

OBJECTIVES: This study aimed to assess the pattern of use of EDs, factors contributing to the visits, geographical distribution and outcomes in people aged 65 years or older to a large hospital in Dublin. METHODS: A retrospective analysis of 2 years of data from an urban university teaching hospital ED in the southern part of Dublin was reviewed for the period 2014-2015 (n=103 022) to capture the records of attenders. All ED presentations by individuals 65 years and older were extracted for analysis. Address-matched records were analysed using QGIS, a geographic information systems (GIS) analysis and visualisation tool to determine straight-line distances travelled to the ED by age. RESULTS: Of the 49 538 non-duplicate presentations in the main database, 49.9% of the total are women and 49.1% are men. A subset comprised of 40 801 had address-matched records. When mapped, the data showed a distinct clustering of addresses around the hospital site but this clustering shows different patterns based on age cohort. Average distances travelled to ED are shorter for people 65 and older compared with younger patients. Average distances travelled for those aged 65-74 was 21 km (n=4177 presentations); for the age group 75-84, 18 km (n=2518 presentations) and 13 km for those aged 85 and older (n=2104 presentations). This is validated by statistical tests on the clustered data. Self-referral rates of about 60% were recorded for each age group, although this varied slightly, not significantly, with age. CONCLUSIONS: Health planning at a regional level should account for the significant number of older patients attending EDs. The use of GIS for health planning in particular can assist hospitals to improve their understanding of the origin of the cohort of older ED patients.

Developing outcome, process and balancing measures for an emergency department longitudinal patient monitoring system using a modified Delphi.

BACKGROUND: Early warning score systems have been widely recommended for use to detect clinical deterioration in patients. The Irish National Emergency Medicine Programme has developed and piloted an emergency department specific early warning score system. The objective of this study was to develop a consensus among frontline healthcare staff, quality and safety staff and health systems researchers regarding evaluation measures for an early warning score system in the Emergency Department. METHODS: Participatory action research including a modified Delphi consensus building technique with frontline hospital staff, quality and safety staff, health systems researchers, local and national emergency medicine stakeholders was the method employed in this study. In Stage One, a workshop was held with the participatory action research team including frontline hospital staff, quality and safety staff and health systems researchers to gather suggestions regarding the evaluation measures. In Stage Two, an electronic modified-Delphi study was undertaken with a panel consisting of the workshop participants, key local and national emergency medicine stakeholders. Descriptive statistics were used to summarise the characteristics of the panellists who completed the questionnaires in each round. The mean Likert rating, standard deviation and 95% bias-corrected bootstrapped confidence interval for each variable was calculated. Bonferroni corrections were applied to take account of multiple testing. Data were analysed using Stata 14.0 SE. RESULTS: Using the Institute for Healthcare Improvement framework, 12 process, outcome and balancing metrics for measuring the effectiveness of an ED-specific early warning score system were developed. CONCLUSION: There are currently no published measures for evaluating the effectiveness of an ED early warning score system. It was possible in this study to develop a suite of evaluation measures using a modified Delphi consensus approach. Using the collective expertise of frontline hospital staff, quality and safety staff and health systems researchers to develop and categorise the initial set of potential measures was an innovative and unique element of this study.

Moving regional health services planning and management to a population-based approach: implementation of the Regional Operating Model (ROM) in Victoria, Australia.

Various jurisdictions are moving towards population-based approaches to plan and manage healthcare services. The evidence on the implementation of these models remains limited. The aim of this study is to evaluate the effect of a regional operating model (ROM) on internal functioning and stakeholder engagement of a regional office. Semi-structured interviews and focus groups with staff members and stakeholders of the North West Metropolitan Regional office in Victoria, Australia, were conducted. Overall, the ROM was perceived as relevant to staff and stakeholders. However, creating shared objectives and priorities across a range of organisations remained a challenge. Area-based planning and management is seen as simplifying management of contracts; however, reservations were expressed about moving from specialist to more generalist approaches. A clearer articulation of the knowledge, skills and competencies required by staff would further support the implementation of the model. The ROM provides a platform for public services and stakeholders to discuss, negotiate and deliver on shared outcomes at the regional level. It provides an integrated managerial platform to improve service delivery and avoid narrow programmatic approaches.

Scoping of models to support population-based regional health planning and management: comparison with the regional operating model in Victoria, Australia.

Objective The aim of the present study was to try to understand the breadth and comprehensiveness of a regional operating model (ROM) developed within the Victorian Department of Health's North West Metropolitan Region office in Melbourne, Australia. Methods A published literature search was conducted, with additional website scanning, snowballing technique and expert consultation, to identify existing operating models. An analytical grid was developed covering 16 components to evaluate the models and assess the exhaustiveness of the ROM. Results From the 34 documents scoped, 10 models were identified to act as a direct comparator to the ROM. These concerned models from Australia (n=5) and other comparable countries (Canada, UK). The ROM was among the most exhaustive models, covering 13 of 16 components. It was one of the few models that included intersectoral actions and levers of influence. However, some models identified more precisely the planning tools, prioritisation criteria and steps, and the allocation mechanisms. Conclusions The review finds that the ROM appears to provide a wide coverage of aspects of planning and integrates into a single model some of the distinctive elements of the other models scoped. What is known about the topic? Various jurisdictions are moving towards a population-based approach to manage public services with regard to the provision of individual medical and social care. Various models have been proposed to guide the planning of services from a population health perspective. What does this paper add? This paper assesses the coverage of attributes of operating models supporting a population health planning approach to the management of services at the regional or local level. It provides a scoping of current models proposed to organise activities to ensure an integrated approach to the provision of services and compares the scoped models to a model recently implemented in Victoria, Australia. What are the implications for practitioners? This paper highlights the relative paucity of operating models describing in concrete terms how to manage medical and social services from a population perspective and encourages organisations that are accountable for securing population health to clearly articulate their own operating model. It outlines strengths and potential gaps in current models.

Trust in embedding co-design for innovation and change: considering the role of senior leaders and managers.

PURPOSE: In this viewpoint article, the authors recognize the increased focus in health systems on co-design for innovation and change. This article explores the role of leaders and mangers in developing and enhancing a culture of trust in their organizations to enable co-design, with the potential to drive innovation and change in healthcare. DESIGN/METHODOLOGY/APPROACH: Using social science analyses, the authors argue that current co-design literature has limited focus on interactions between senior leaders and managers, and healthcare staff and service users in supporting co-designed innovation and change. The authors draw on social and health science studies of trust to highlight how the value-based co-design process needs to be supported and enhanced. We outline what co-design innovation and change involve in a health system, conceptualize trust and reflect on its importance within the health system, and finally note the role of senior leaders and managers in supporting trust and responsiveness for co-designed innovation and change. FINDINGS: Healthcare needs leaders and managers to embrace co-design that drives innovation now and in the future through people - leading to better healthcare for society at large. As authors we argue that it is now the time to shift our focus on the role of senior managers and leaders to embed co-design into health and social care structures, through creating and nurturing a culture of trust. ORIGINALITY/VALUE: Building public trust in the health system and interpersonal trust within the health system is an ongoing process that relies upon personal behavior of managers and senior leaders, organizational practices within the system, as well as political processes that underpin these practices. By implementing managerial, leadership and individual practices on all levels, senior managers and leaders provide a mechanism to increase both trust and responsiveness for co-design that supports innovation and change in the health system.

Exploring the needs and experiences of contact tracing staff during the COVID-19 pandemic in Ireland.

BACKGROUND: Contact tracing is a key component in controlling the spread of COVID-19, however little research has focused on learning from the experiences of contact tracing staff. Harnessing learning from those in this role can provide valuable insights into the process of contact tracing and how best to support staff in this crucial role. METHODS: Thematic analysis was used to analyse 47 semi-structured interviews conducted with contact tracing staff via telephone or Zoom at three time points in 2021: March, May and September-October. RESULTS: Six themes related to the contact tracing role were identified, including training, workforce culture, systems issues, motivation and support. While initially nervous in the role, participants were motivated to contribute to the pandemic response and believed the role provided them with valuable transferable skills. Participants described the training as having improved over time while desiring more proactive training. Sources of frustration included a perceived lack of opportunity for feedback and involvement in process changes, feelings of low autonomy, and a perception of high staff turnover. Participants expressed a need for improved communication of formal emotional supports. Increased managerial support and provision of opportunities for career advancement may contribute to increased motivation among staff. CONCLUSIONS: These findings identify the experiences of contact tracing staff working during the COVID-19 pandemic, and have important implications for the improvement of the contact tracing system. Recommendations based on learning from participants offer suggestions as to how best to support the needs of contact tracing staff during a pandemic response.

A realist process evaluation of an intervention to promote competencies in interprofessional collaboration among interdisciplinary integrated care teams for older people: Study protocol.

Background: International policy is increasingly committed to placing interdisciplinary team-working at the centre of health and social care integration across the lifespan. The National Clinical Programme for Older People in Ireland has a critical role in the design and implementation of the National Older Person's Service Model, which aims to shift the delivery of care away from acute hospitals towards community-based care. Interdisciplinary Community Specialist Teams for older persons (CST-OPs) play an important role in this service model. To support the development of competencies for interprofessional collaboration and an interdisciplinary team-based approach to care integration, a culture shift will be required within care delivery. Design:This study builds upon a collaborative partnership project which co-designed a framework describing core competencies for interprofessional collaboration in CST-OPs. A realist-informed process evaluation of the framework will be undertaken as the competencies described in the framework are being fostered in newly developed CST-OPs under the national scale-up of the service model. Realist evaluation approaches reveal what worked, why it worked (or did not), for whom and under what circumstances. Three iterative and integrated work packages are proposed which combine multiple methods of data collection, analysis and synthesis. Prospective data collection will be undertaken within four CST-OPs, including qualitative exploration of the care experiences of older people and family carers. Discussion: The realist explanatory theory will provide an understanding of how interprofessional collaboration can be fostered and sustained in various contexts of care integration for older people. It will underpin curriculum development for team-based education and training of health and social care professionals, a key priority area in the national Irish health strategy. It will provide healthcare leaders with knowledge of the resources and supports required to harness the benefits of interprofessional collaboration and to realise the goals of integrated care for older people.

What does co-design mean for Australia’s diverse clinical workforce?

Co-design is increasingly employed as a user-centric method to create healthcare change. In healthcare co-design, small groups of consumers and healthcare workers come together to identify processes, policies or service elements that require improvement and to design solutions. Multiple frameworks have emerged to guide the health work force and health researchers how to conduct co-design and support consumer members to engage in the process effectively. Frameworks have sought to address the propensity for co-design to exacerbate inequities for consumers with complex care needs or in under-served populations. Advice regarding the need to consider and ensure co-design is accessible to an increasingly diverse health workforce is, however, lacking. Drawing on our experience co-designing with diverse consumer and healthcare-worker populations, we discuss the implications of co-design for the healthcare workforce.

Enabling the space and conditions for co-leadership in co-design: an evaluation of co-facilitator training for culturally and linguistically diverse consumers.

Objectives and importance of study: We report the evaluative findings from the first stage of a project designed to co-produce strategies which improve the safety of culturally and linguistically diverse (CALD) patients in cancer care. Co-leadership is developed via training and supporting consumers, multilingual fieldworkers and researchers to co-facilitate co-design. Our aim was to evaluate the training undertaken with CALD co-facilitators to prepare for co-leadership of the co-design process within the CanEngage project. Study type and methods: A qualitative evaluation was conducted, consisting of semi-structured interviews with co-facilitators. Data were thematically analysed. Results: Analysis of interviews with 12 co-facilitators generated three themes: creating the conditions for co-leadership; developing the space for connections during training; and readiness for co-design. Conclusions: Providing opportunities for informal, social interactions during the training aided relationship-building among co-facilitators. The co-creation of terms of reference for the project encouraged a process of shared ownership and generated a path forward from the training to the upcoming co-design activities. We found that the recruitment process offered an initial forum to discuss the alignment of the motivations and expectations of those interested in becoming involved with the aims of the project and goals of the co-design.