Strengthening the role of the executive nurse director: A qualitative interview study.

AIM: To explore the challenges and opportunities facing executive nurse directors in the UK and identify factors to strengthen their role and support more effective nurse leadership. DESIGN: A qualitative descriptive study using reflexive thematic analysis. METHODS: Semi-structured, telephone interviews were carried out with 15 nurse directors and 9 nominated colleagues. RESULTS: Participants described a uniquely complex role with a broader scope than any other executive board member. Seven themes were identified: preparation for the role, length of time in role, role expectations, managing complexity, status, being political and influencing. Strengthening factors included successful working relationships with other board colleagues, development of political skills and personal status, coaching and mentoring, working within a supportive team culture and having strong professional networks. CONCLUSION: Executive nurse leaders are key to the transmission of nursing values and the delivery of safety and quality in healthcare settings. To strengthen this role, the limiting factors and the recommended shared learning identified here should be recognized and addressed at an individual, organizational and professional level. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: Given the pressure on all health systems to retain nurses, the role of executive nurse leaders needs to be seen as an important source of professional leadership and their value in actioning health policy into practice recognized. IMPACT: New insights have been provided into the executive nurse director role across the UK. Findings have demonstrated challenges and opportunities to strengthen the executive nurse director role. These include recognition of the need for support, preparation, networking and more realistic expectations of this unique nursing role. REPORTING METHOD: The study adhered to the Consolidated Criteria for Reporting Qualitative Research. PATIENT OR PUBLIC CONTRIBUTION: There was no patient or public contribution.

Perceptions, knowledge, and practices of breastfeeding in indigenous regions of Mexico during Covid-19 pandemic.

OBJECTIVE: To explore the perceptions, knowledge, and practices of breastfeeding in the context of Covid-19 of pregnant and postpartum women, midwives, and health providers in an indigenous region of Chiapas, Mexico. MATERIALS AND METHODS: Qualitative thematic analysis study involving semi-structured interviews (n = 46) with pregnant women (n = 19), postpartum women (n = 6), health providers (n = 10, i.e., doctors/nurses), and midwives (n = 11). RESULTS: Among mothers, 47% (n = 11) did not know if Covid-19 is transmitted through breastfeeding. They mentioned that they would stay away from their newborns if infected. Health providers and midwives have not received education or any supporting material on the value of breastfeeding during Covid-19 infection. CONCLUSION: Breastfeeding mothers' promotion and counseling remain poor in indigenous communities and have worsened during the Covid-19 pandemic. Breastfeeding training among health providers and midwives should be provided or strengthened even more in emergency situations.

A survey of the training and working arrangements of general practitioners providing asthma and chronic obstructive pulmonary disease care in a rural area of Maharashtra State.

Background: Chronic respiratory diseases (CRD), especially asthma and chronic obstructive pulmonary disease (COPD), are common public health problems resulting in a substantial burden of disease for individuals. There is a need to understand the perceptions and practices of primary care physicians ("general practitioners [GPs]") who provide most of the health care in rural India. We surveyed all private and public practitioners listed as practising in a rural area of Western India with the aim of identifying GPs (GPs: graduates, registered and allowed to practice in India) to understand their training, working arrangements, and asthma/COPD workload. Methodology: We administered a short questionnaire at educational meetings or via e-mail to all private and public practitioners listed as providing community-based services in the Junnar block, Pune district, Maharashtra. The survey asked about qualifications, experience, and working arrangements, and about current asthma and COPD workload. A descriptive analysis was performed. Results: We approached 474 practitioners (434 from private sector and 40 from public sector). Eighty-eight were no longer practising in the study area. The response rate was 330/354 (93.2%) of private and 28/32 (87.5%) of public sector practitioners. We excluded 135 nonrespiratory hospital specialists and 23 private practitioners whose highest qualification was a diploma. Our final sample of 200 GPs (70% males) was 177 from private sector and 23 from public sector. The private GPs had more experience in clinical practice in comparison to public GPs (18.6 vs. 12.8 years). Eighty-four percent of GPs from the private sector only had Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homoeopathy (AYUSH) qualifications, though >90% provided "modern medicine" services. In the public sector, 43.5% GPs only had AYUSH qualifications, though all provided "modern medicine" services. A minority (9% of private GPs and 16% of public GPs) provided both services. Nearly two-thirds (62%) of private GPs had inpatient facilities compared to only 9% of public sector GPs. In both sectors, more GPs stated that they managed people with asthma than treated COPD (Private: 97% vs. 75%; Public 87% vs. 57%). Conclusion: Many GPs practising "modern medicine" only had qualifications in Ayurveda/Homeopathy and fewer GPs are involved in the management of COPD as compared to asthma. These are important factors that form the context for initiatives seeking to improve the quality of community-based care for people with CRD in Maharashtra state in India.

Patient and public involvement in palliative care research: What works, and why? A qualitative evaluation.

BACKGROUND: Public involvement is increasingly considered a prerequisite for high-quality research. However, involvement in palliative care is impeded by limited evidence on the best approaches for populations affected by life-limiting illness. AIM: To evaluate a strategy for public involvement in palliative care and rehabilitation research, to identify successful approaches and areas for improvement. DESIGN: Co-produced qualitative evaluation using focus groups and interviews. Thematic analysis undertaken by research team comprising public contributors and researchers. SETTING/PARTICIPANTS: Researchers and public members from a palliative care and rehabilitation research institute, UK. RESULTS: Seven public members and 19 researchers participated. Building and maintaining relationships, taking a flexible approach and finding the 'right' people were important for successful public involvement. Relationship building created a safe environment for discussing sensitive topics, although public members felt greater consideration of emotional support was needed. Flexibility supported involvement alongside unpredictable circumstances of chronic and life-limiting illness, and was facilitated by responsive communication, and opportunities for in-person and virtual involvement at a project- and institution-level. However, more opportunities for two-way feedback throughout projects was suggested. Finding the 'right' people was crucial given the diverse population served by palliative care, and participants suggested more care needed to be taken to identify public members with experience relevant to specific projects. CONCLUSION: Within palliative care research, it is important for involvement to focus on building and maintaining relationships, working flexibly, and identifying those with relevant experience. Taking a strategic approach and developing adequate infrastructure and networks can facilitate public involvement within this field.

Interplaying role of healthcare activist and homemaker: a mixed-methods exploration of the workload of community health workers (Accredited Social Health Activists) in India.

BACKGROUND: Globally, community health workers (CHWs) are integral contributors to many health systems. In India, Accredited Social Health Activists (ASHAs) have been deployed since 2005. Engaged in multiple health care activities, they are a key link between the health system and population. ASHAs are expected to participate in new health programmes prompting interest in their current workload from the perspective of the health system, community and their family. METHODS: This mixed-methods design study was conducted in rural and tribal Primary Health Centers (PHCs), in Pune district, Western Maharashtra, India. All ASHAs affiliated with these PHCs were invited to participate in the quantitative study, those agreeing to contribute in-depth interviews (IDI) were enrolled in an additional qualitative study. Key informants' interviews were conducted with the Auxiliary Nurse Midwife (ANM), Block Facilitators (BFF) and Medical Officers (MO) of the same PHCs. Quantitative data were analysed using descriptive statistics. Qualitative data were analysed thematically. RESULTS: We recruited 67 ASHAs from the two PHCs. ASHAs worked up to 20 h/week in their village of residence, serving populations of approximately 800-1200, embracing an increasing range of activities, despite a workload that contributed to feelings of being rushed and tiredness. They juggled household work, other paid jobs and their ASHA activities. Practical problems with travel added to time involved, especially in tribal areas where transport is lacking. Their sense of benefiting the community coupled with respect and recognition gained in village brought happiness and job satisfaction. They were willing to take on new tasks. ASHAs perceived themselves as 'voluntary community health workers' rather than as 'health activists". CONCLUSIONS: ASHAs were struggling to balance their significant ASHA work and domestic tasks. They were proud of their role as CHWs and willing to take on new activities. Strategies to recruit, train, skills enhancement, incentivise, and retain ASHAs, need to be prioritised. Evolving attitudes to the advantages/disadvantages of current voluntary status and role of ASHAs need to be understood and addressed if ASHAs are to be remain a key component in achieving universal health coverage in India.

Classification of patient-safety incidents in primary care.

Primary care lags behind secondary care in the reporting of, and learning from, incidents that put patient safety at risk. In primary care, there is no universally agreed approach to classifying the severity of harm arising from such patient-safety incidents. This lack of an agreed approach limits learning that could lead to the prevention of injury to patients. In a review of research on patient safety in primary care, we identified 21 existing approaches to the classification of harm severity. Using the World Health Organization's (WHO's) International Classification for Patient Safety as a reference, we undertook a framework analysis of these approaches. We then developed a new system for the classification of harm severity. To assess and classify harm, most existing approaches use measures of symptom duration (11/21), symptom severity (11/21) and/or the level of intervention required to manage the harm (14/21). However, few of these approaches account for the deleterious effects of hospitalization or the psychological stress that may be experienced by patients and/or their relatives. The new classification system we developed builds on WHO's International Classification for Patient Safety and takes account not only of hospitalization and psychological stress but also of so-called near misses and uncertain outcomes. The constructs we have outlined have the potential to be applied internationally, across primary-care settings, to improve both the detection and prevention of incidents that cause the most severe harm to patients.

Les soins primaires ont du retard sur les soins secondaires en ce qui concerne l'établissement de rapports sur les incidents qui menacent la sécurité des patients et les enseignements qui en découlent. Dans le cas des soins primaires, il n'existe pas de méthode universellement acceptée pour classifier la gravité des dommages résultant d'incidents liés à la sécurité des patients. L'absence d'une telle méthode limite les enseignements qui pourraient favoriser la prévention des traumatismes chez les patients. Dans le cadre d'une analyse documentaire sur la sécurité des patients en matière de soins primaires, nous avons repéré l'existence de 21 méthodes de classification de la gravité des dommages. En prenant comme référence la Classification internationale pour la sécurité des patients de l'Organisation mondiale de la Santé (OMS), nous avons entrepris une analyse du cadre de ces méthodes. Nous avons ensuite conçu un nouveau système de classification de la gravité des dommages. Pour évaluer et classifier les dommages, la plupart des méthodes existantes utilisent des mesures portant sur la durée des symptômes (11/21), la gravité des symptômes (11/21) et/ou le niveau d'intervention requis pour prendre en charge les dommages (14/21). Néanmoins, rares sont celles qui tiennent compte des effets délétères de l'hospitalisation ou du stress psychologique que peuvent ressentir les patients et/ou leurs proches. Le nouveau système de classification que nous avons élaboré repose sur la Classification internationale pour la sécurité des patients de l'OMS et tient compte non seulement de l'hospitalisation et du stress psychologique, mais aussi de ce qu'il est convenu d'appeler les accidents évités de justesse et des résultats incertains. Les concepts que nous avons définis peuvent être appliqués dans les établissements de soins primaires du monde entier pour améliorer la détection et la prévention des incidents qui provoquent les plus graves dommages pour les patients.

La atención primaria queda por debajo de la atención secundaria en la notificación y el aprendizaje de incidentes que ponen en riesgo la seguridad del paciente. En la atención primaria, no existe un enfoque universalmente aceptado para clasificar la gravedad del daño que surge de tales incidentes que afectan a la seguridad del paciente. Esta falta de un enfoque consensuado limita el aprendizaje que podría conducir a la prevención de lesiones a los pacientes. En una revisión de la investigación sobre la seguridad del paciente en la atención primaria, se identificaron 21 enfoques existentes para la clasificación de la gravedad del daño. Con la Clasificación Internacional para la Seguridad del Paciente de la Organización Mundial de la Salud (OMS) como referencia, se llevó a cabo un análisis del marco de estos enfoques. A continuación, se desarrolló un nuevo sistema para la clasificación de la gravedad del daño. Para evaluar y clasificar el daño, la mayoría de los enfoques existentes usan medidas de la duración de los síntomas (11/21), la gravedad de los síntomas (11/21) y/o el nivel de intervención necesario para gestionar el daño (14/21). Sin embargo, pocos de estos enfoques explican los efectos nocivos de la hospitalización o el estrés psicológico que pueden experimentar los pacientes y/o sus familiares. El nuevo sistema de clasificación desarrollado se basa en la Clasificación Internacional para la Seguridad del Paciente de la OMS y tiene en cuenta no solo la hospitalización y el estrés psicológico, sino también los denominados casi accidentes y los resultados inciertos. Los constructos descritos tienen el potencial de aplicarse internacionalmente, en entornos de atención primaria, para mejorar tanto la detección como la prevención de incidentes que causan los daños más graves a los pacientes.

New forms of development: branding innovative ideas and bidding for foreign aid in the maternal and child health service in Nepal.

BACKGROUND: Nepal has been receiving foreign aid since the early 1950s. Currently, the country's health care system is heavily dependent on aid, even for the provision of basic health services to its people. Globally, the mechanism for the dispersal of foreign aid is becoming increasingly complex. Numerous stakeholders are involved at various levels: donors, intermediary organisations, project-implementing partners and the beneficiaries, engaging not only in Nepal but also globally. To illustrate how branding and bidding occurs, and to discuss how this process has become increasingly vital in securing foreign aid to run MCH activities in Nepal. METHOD: This paper is based on a qualitative study. The data collection method includes Key Informant Interviews, the review of relevant policy documents and secondary data, and finally field observation visits to four maternal and child health (MCH) projects, currently funded by foreign aid. Through these methods we planned to gain a comprehensive understanding of the aid dispersing mechanism, and the aid-securing strategies, used by organisations seeking funds to provide MCH services in Nepal. RESULTS: Study findings suggest that foreign aid for the provision of MCH services in Nepal is channeled increasingly to its beneficiaries, not through the Government system, but rather via various intermediary organisations, employing branding and bidding processes. These organisations adapt commercial models, seeking to justify their 'cost-effectiveness'. They argue that they are 'yielding good value for money', with short-term target oriented projects. This ethos is evident throughout the aid dispersing chain. Organisations use innovative ideas and intervention packages, branded internationally and nationally, and employ the appropriate language of commerce in their bid to secure funds. The paper raises an important question as to whether the current mechanisms of channeling foreign aid in the MCH sector, via intermediary organisations, can actually be cost-effective, given the complex bureaucratic processes involved. CONCLUSIONS: The study findings are very important, for Nepal's development in particular, and for international development in general. The paper concludes by recommending strongly that foreign aid should concentrate on supporting and strengthening the national government system. Complex bureaucratic process must be minimised and streamlined in order to provide quality care to the beneficiaries.

Learning lessons from the analysis of patient complaints relating to staff attitudes, behaviour and communication, using the concept of emotional labour.

AIMS AND OBJECTIVES: This article explores the content of letters of complaint by patients and carers about the behaviour, attitudes and communication of healthcare staff. BACKGROUND: The most common focus of patient complaints in the UK and other high-income countries is staff attitudes, behaviour and communication. There is a move to learn lessons from patient complaints, which can be used to improve patient care and experience. METHODS: Fifty letters of complaint made by patients and carers relating to the behaviour, attitudes and communication of healthcare staff were analysed. RESULTS: Poor attitudes, behaviours and communication have significant negative impact on the emotional well-being of patients and carers. Many patients and carers have heightened sensitivities due to both health-related stresses and also other factors. The healthcare role is expected to include compassion and kindness. The concept of emotional labour is useful in explaining the skills and effort required of staff in this often invisible and undervalued aspect of health care. CONCLUSIONS: Given the increasing focus on patient experience, it is important that the importance of good staff attitudes, behaviours and communication is understood and that the emotional labour associated with this is recognised. RELEVANCE TO CLINICAL PRACTICE: An understanding of emotional intelligence can protect staff from burnout and other negative outcomes which those in a caring role can experience.

A hermeneutic phenomenological study exploring the experience health practitioners have when working with families to safeguard children and the invisibility of the emotions work involved.

AIMS AND OBJECTIVES: To explore the emotions work undertaken by practitioners with responsibility for the safeguarding of child well-being and establish whether there is a relationship between emotion work, role visibility, professional well-being and effectiveness of supportive frameworks. BACKGROUND: Protecting children is the responsibility of everyone in society with health, social care and public health services leading this worldwide. To safeguard children effectively, it is known that practitioners build relationships with families in sometimes challenging situations, which involve the management of emotions. However, irrespective of this current knowledge; health practitioners who work in this area suggest that their child safeguarding role is not recognised, respected or valued in professional and societal settings. The purpose of this study was to report on a qualitative study which set out to explore the relationship between the known relational-based emotions work of practitioners' and the reported lack of visibility. METHODS: Hermeneutic phenomenology underpinned the study. Semistructured interviews were employed for data collection. Ten participants actively working with preschool children and families in healthcare organisations were recruited. RESULTS: The emotional-, relationship- and communicative-based work crucial to effectively safeguard children may influence the visibility of the role. Poor role visibility influences the morale of practitioners and the support they receive. CONCLUSION: In conclusion this study proposes that when there is poor role recognition; there is ineffective clinical support. This reduces professional well-being, which in turn will impact practitioner abilities to safeguard children. RELEVANCE TO CLINICAL PRACTICE: This study highlights that to sustain safe and effective health and social care practice, organisational leads require an understanding of the impact emotional- and relational-based work can have on practitioners and provide supportive frameworks that will effectively promote professional well-being.

In extreme conditions, stay in the zone.

Nurses working in extreme conditions are caught between job demands and cash-strapped healthcare systems. They encounter challenging environments daily, and risk of stress and burnout in intensive care settings. Nursing at the extremes gives rise to debates about the value of care and emotions as well as the capacity of nurses to remain engaged on the frontline.