Impact of the cost-of-living crisis on patient preferences towards virtual consultations.

INTRODUCTION: Since 2021, the world has been facing a cost-of-living crisis which has negatively affected population health. Meanwhile, little is known about its impact on patients' preferences to access care. We aimed to analyse public preference for the modality of consultation (virtual vs face-to-face) before and after the onset of crisis and factors associated with these preferences. METHODS: An online cross-sectional survey was administered to the public in the United Kingdom, Germany, Italy and Sweden. McNemar tests were conducted to analyse pre- and post-crisis differences in preferences; logistic regression was used to examine the demographic factors associated with public preferences. RESULTS: Since the onset of crisis, the number of people choosing virtual consultations has increased in the United Kingdom (7.0% vs 9.5% P < 0.001), Germany (6.6% vs 8.6%, P < 0.008) and Italy (6.0% vs 9.8%, P < 0.001). Before the crisis, a stronger preference for virtual consultations was observed in people from urban areas (OR 1.28, 95% CI 1.05-1.56), while increasing age was associated with a lower preference for virtual care (OR 0.966, 95% CI 0.961-0.972). Younger people were more likely to switch to virtual care, while change to face-to-face was associated with younger age and lower income (OR 1.34, 95% CI 1.12-1.62). Older adults were less likely to change preference. CONCLUSIONS: Since the onset of the cost-of-living crisis, public preference for virtual consultations has increased, particularly in younger population. This contrasts with older adults and people with lower-than-average incomes. The rationale behind patients' preferences should be investigated to ensure patients can access their preferred modality of care.

Identifying barriers to outpatient appointment attendance in patient groups at risk of inequity: a mixed methods study in a London NHS trust.

BACKGROUND: There is significant health inequity in the United Kingdom (U.K.), with different populations facing challenges accessing health services, which can impact health outcomes. At one London National Health Service (NHS) Trust, data showed that patients from deprived areas and minority ethnic groups had a higher likelihood of missing their first outpatient appointment. This study's objectives were to understand barriers to specific patient populations attending first outpatient appointments, explore systemic factors and assess appointment awareness. METHODS: Five high-volume specialties identified as having inequitable access based on ethnicity and deprivation were selected as the study setting. Mixed methods were employed to understand barriers to outpatient attendance, including qualitative semi-structured interviews with patients and staff, observations of staff workflows and interrogation of quantitative data on appointment communication. To identify barriers, semi-structured interviews were conducted with patients who missed their appointment and were from a minority ethnic group or deprived area. Staff interviews and observations were carried out to further understand attendance barriers. Patient interview data were analysed using inductive thematic analysis to create a thematic framework and triangulated with staff data. Subthemes were mapped onto a behavioural science framework highlighting behaviours that could be targeted. Quantitative data from patient interviews were analysed to assess appointment awareness and communication. RESULTS: Twenty-six patients and 11 staff were interviewed, with four staff observed. Seven themes were identified as barriers - communication factors, communication methods, healthcare system, system errors, transport, appointment, and personal factors. Knowledge about appointments was an important identified behaviour, supported by eight out of 26 patients answering that they were unaware of their missed appointment. Environmental context and resources were other strongly represented behavioural factors, highlighting systemic barriers that prevent attendance. CONCLUSION: This study showed the barriers preventing patients from minority ethnic groups or living in deprived areas from attending their outpatient appointment. These barriers included communication factors, communication methods, healthcare the system, system errors, transport, appointment, and personal factors. Healthcare services should acknowledge this and work with public members from these communities to co-design solutions supporting attendance. Our work provides a basis for future intervention design, informed by behavioural science and community involvement.

Testing the impact of differing behavioural science informed text message content in COVID-19 vaccination invitations on vaccine uptake: A randomised clinical trial.

Behavioural science constructs can be incorporated into messaging strategies to enhance the effectiveness of public health campaigns by increasing the occurrence of desired behaviours. This study investigated the impact of behavioural science-informed text message strategies on COVID-19 vaccination rates in 18-39-year-olds in an area of low uptake in London during the first vaccination offer round in the United Kingdom. This three-armed randomised trial recruited unvaccinated residents of an urban Central London suburb being offered their first vaccination between May and June 2021. Participants were randomised to receive the control (current practice) text message or one of two different behavioural science-informed COVID-19 vaccine invitation strategies. Both intervention strategies contained the phrase "your vaccine is ready and waiting for you", aiming to evoke a sense of ownership, with one strategy also including a pre-alert message. The main outcome measures were vaccination rates at 3 and 8 weeks after message delivery. A total of 88,820 residents were randomly assigned to one of the three trial arms. Each arm had a vaccine uptake rate of 27.2 %, 27.4 % and 27.3 % respectively. The mean age of participants was 28.2 years (SD ± 5.7), the mean index of multiple deprivation was 4.3 (SD ± 2.0) and 50.4 % were women. Vaccine uptake varied by demographics, however there was no significant difference between trial arms (p = 0.872). Delivery was successful for 53.6 % of text messages. Our choice of behavioural science informed messaging strategies did not improve vaccination rates above the rate seen for the current practice message. This likely reflects the wide exposure to public health campaigns during the pandemic, as such text messages nudges were unlikely to alter existing informed decision-making processes. Text message delivery was relatively low, indicating a need for accurate mobile phone number records and multi-modal approaches to reach eligible patients for vaccination. The protocol was registered at clinicaltrials.gov (NCT04895683) on 20/05/2021.

Understanding the facilitators and barriers to barcode medication administration by nursing staff using behavioural science frameworks. A mixed methods study.

INTRODUCTION: Barcode medication administration (BCMA) technology helps ensure correct medications are administered by nursing staff through scanning of patient and medication barcodes. In many hospitals scanning rates are low, limiting the potential safety benefits. We aimed to explore the barriers and facilitators to BCMA use in a London hospital. METHODS: In this mixed methods study we used local quantitative data on BCMA scanning rates to identify clinically similar wards (in terms of patient acuity and workload) with different scanning rates for qualitative exploration. Interviews designed to elicit barriers to using BCMA technology were conducted with nursing staff, supported by observations of medication administration. Qualitative data were analysed inductively and a thematic framework constructed housing key themes, subsequently categorised into barriers and facilitators. To explore patient perspectives of BCMA scanning, a purposive sample of patients were also interviewed. These patient data were analysed deductively according to the thematic framework. Themes were mapped to behavioural science frameworks to further understand the behaviours involved. RESULTS: BCMA was operational on 15 wards, with only six having medication scan rates of more than 10% of scannable doses. Of three wards selected for qualitative investigation, the lowest scan rate was 6.7%. Twenty-seven nurses and 15 patients were interviewed. Eleven key themes were identified, encompassing both barriers and facilitators to BCMA use. Barriers included poor trolley ergonomics and perceived time inefficiency. Facilitators included a streamlined process and thorough training. All nurses described BCMA as positive for patient safety. Patients described BCMA as making them "feel safer". Behavioural science frameworks highlighted the importance of professional role and an individual's belief in their capability. CONCLUSION: We present a novel exploration of facilitators and barriers to BCMA use from the viewpoint of both patients and nursing staff, highlighting a strong perception that BCMA enhances safety. Barriers were reported on both high and low usage wards, demonstrating the importance of behaviours and motivations. These findings provide a detailed understanding from which to design interventions to support behaviour change and increase BCMA use.

Perspectives of healthcare professionals and older patients on shared decision-making for treatment escalation planning in the acute hospital setting: a systematic review and qualitative thematic synthesis.

Background: Shared Decision-Making (SDM) between patients and clinicians is increasingly considered important. Treament Escalation Plans (TEP) are individualised documents outlining life-saving interventions to be considered in the event of clinical deterioration. SDM can inform subjective goals of care in TEP but it remains unclear how much it is considered beneficial by patients and clinicians. We aimed to synthesise the existing knowledge of clinician and older patient (generally aged ≥65 years) perspectives on patient involvement in TEP in the acute setting. Methods: Systematic database search was performed in MEDLINE, EMBASE, PsycInfo and CINAHL databases as well as grey literature from database inception to June 8, 2023, using the Sample (older patients, clinicians, acute setting; studies relating to patients whose main diagnosis was cancer or single organ failure were excluded as these conditions may have specific TEP considerations), Phenomenon of Interest (Treatment Escalation Planning), Design (any including interview, observational, survey), Evaluation (Shared Decision-Making), Research type (qualitative, quantitative, mixed methods) tool. Primary data (published participant quotations, field notes, survey results) and descriptive author comments were extracted and qualitative thematic synthesis was performed to generate analytic themes. Quality assessment was made using the Critical Appraisal Skills Programme and Mixed Methods Appraisal Tools. The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) approach was used to assess overall confidence in each thematic finding according to methodology, coherence, adequacy and relevance of the contributing studies. The study protocol was registered on PROSPERO, CRD42022361593. Findings: Following duplicate exclusion there were 1916 studies screened and ultimately 13 studies were included, all from European and North American settings. Clinician-orientated themes were: treatment escalation is a medical decision (high confidence); clinicians want the best for their patients amidst uncertainty (high confidence); involving patients and families in decisions is not always meaningful and can involve conflict (high confidence); treatment escalation planning exists within the clinical environment, organisation and society (moderate confidence). Patient-orientated themes were: patients' relationships with Treatment Escalation Planning are complex (low confidence); interactions with doctors are important but communication is not always easy (moderate confidence); patients are highly aware of their families when considering TEP (moderate confidence). Interpretation: Based on current evidence, TEP decisions appear dominated by clinicians' perspectives, motivated by achieving the best for patients and challenged by complex decisions, communication and environmental factors; older patients' perspectives have seldom been explored, but their input on decisions may be modest. Presenting the context and challenge of SDM during professional education may allow reflection and a more nuanced approach. Future research should seek to understand what approach to TEP decision-making patients and clinicians consider to be optimum in the acute setting so that a mutually acceptable standard can be defined in policy. Funding: HCA International and the NIHR Imperial Biomedical Research Centre.

Ambient temperature and mental health: a systematic review and meta-analysis.

BACKGROUND: Increasing evidence indicates that ambient outdoor temperature could affect mental health, which is especially concerning in the context of climate change. We aimed to comprehensively analyse the current evidence regarding the associations between ambient temperature and mental health outcomes. METHODS: We did a systematic review and meta-analysis of the evidence regarding associations between ambient outdoor temperature and changes in mental health outcomes. We searched WebOfScience, Embase, PsychINFO, and PubMed for articles published from database origin up to April 7, 2022. Eligible articles were epidemiological, observational studies in humans of all ages, which evaluated real-world responses to ambient outdoor temperature, and had mental health as a documented outcome; studies of manipulated or controlled temperature or those with only physical health outcomes were excluded. All eligible studies were synthesised qualitatively. If three or more studies reported the same or equivalent effect statistics and if they had equivalent exposure, outcome, and metrics, the studies were pooled in a random-effects meta-analysis. The risk of bias for individual studies was assessed using the Newcastle-Ottawa Scale. The quality of evidence across studies was assessed using the Office of Health Assessment and Translation (OHAT) approach. FINDINGS: 114 studies were included in the systematic review, of which 19 were suitable for meta-analysis. Three meta-analyses were conducted for suicide outcomes: a 1°C increase in mean monthly temperature was associated with an increase in incidence of 1·5% (95% CI 0·8-2·2, p<0·001; n=1 563 109, seven effects pooled from three studies); a 1°C increase in mean daily temperature was associated with an increase in incidence of 1·7% (0·3-3·0, p=0·014; n=113 523, five effects pooled from five studies); and a 1°C increase in mean monthly temperature was associated with a risk ratio of 1·01 (95% CI 1·00-1·01, p<0·001; n=111 794, six effects pooled from three studies). Three meta-analyses were conducted for hospital attendance or admission for mental illness: heatwaves versus non-heatwave periods were associated with an increase in incidence of 9·7% (95% CI 7·6-11·9, p<0·001; n=362 086, three studies); the risk ratio at the 99th percentile of daily mean temperature compared with the 50th percentile was 1·02 (95% CI 1·01-1·03, p=0·006; n=532 296, three studies); and no significant association was found between a 10°C increase in daily mean temperature and hospital attendance. In a qualitative narrative synthesis, we found that ambient outdoor temperature (including absolute temperatures, temperature variability, and heatwaves) was positively associated with attempted and completed suicides (86 studies), hospital attendance or admission for mental illness (43 studies), and worse outcomes for community mental health and wellbeing (19 studies), but much of the evidence was of low certainty with high heterogeneity. INTERPRETATION: Increased temperature and temperature variability could be associated with increased cases of suicide and suicidal behaviour, hospital attendance or admission for mental illness, and poor community health and wellbeing. Climate change is likely to increase temperature anomalies, variability, and heatwaves as well as average temperatures; as such, health system leaders and policy makers must be adequately prepared and should develop adaptation strategies. More high-quality, standardised research is required to improve our understanding of these effects. FUNDING: None.

The influence of personality on psychological safety, the presence of stress and chosen professional roles in the healthcare environment.

Healthcare teams are expected to deliver high quality and safe clinical care, a goal facilitated by an environment of psychological safety. We hypothesised that an individual's personality would influence psychological safety, perceived stressors in the clinical environment and confer a suitability for different professional roles. Staff members were recruited from the Emergency or Critical Care Departments of one National Health Service Trust. Qualitative interviews explored participants' experiences of personality, incorporating quantitative surveys to evaluate psychological safety and perceived stressors. The 16 Primary Factor Assessment provided a quantitative measure of personality. Participants demonstrated midrange scores for most personality traits, highlighting an ability to adapt to changing environments and requirements. There was a signal that different personality traits predominated between the two professional groups, and that certain traits were significantly associated with higher psychological safety and certain perceived stressors. Personality was described as having a strong influence on teamwork, the working environment and leadership ability. Our analysis highlights that personality can influence team dynamics and the suitability of individuals for certain clinical roles. Understanding the heterogeneity of personalities of team members and their likely responses to challenge may help leaders to support staff in times of challenge and improve team cohesiveness.

Exploring the working environment of Hospital Managers: a mixed methods study investigating stress, stereotypes, psychological safety and individual resilience.

BACKGROUND: Hospital managers are responsible for the delivery of organisational strategy, development of clinical services and maintaining quality standards. There is limited research on hospital managers, in particular how stress manifests and impacts managers and the presence of individual resilience. Managers must work closely with clinical colleagues, however these relationships can be hindered by the perception of stereotyping and differing priorities. This study aimed to explore the working environment of hospital managers, focusing upon the unique stresses faced, psychological safety and the presence of resilience. METHODS: This study utilised mixed methodology using an embedded approach. Participants were purposively recruited from all levels of hospital management within one National Health Service Trust in London, United Kingdom. An exploration of managers experiences was undertaken using semi-structured qualitative interviews. Psychological safety and individual resilience were additionally assessed using validated surveys. Qualitative data were analysed iteratively using inductive thematic analysis, and triangulated with quantitative data. Kruskal-Wallis statistical analysis was performed to evaluate differences in resilience and psychological safety according to seniority and background experience. RESULTS: Twenty-two managers were recruited and interviewed, with 20 returning completed surveys. Key findings from the thematic analysis included the importance of good working relationships with clinical colleagues, the persistence of some stereotyping, and feeling unsupported in times of challenge. Stresses described included the bureaucracy involved when delivering change, conflict with colleagues and target driven expectations. Participants described their own psychological safety as lower than desired, supported by quantitative data; but recognised its importance and strived to create it within their own teams. Sixteen participants had 'normal' scores for resilience, with senior managers more likely to have higher scores than those more junior (p=0.011). CONCLUSION: Positive working relationships, high psychological safety and individual resilience are important for organisational safety and individual wellbeing. Our data illustrate unique stressors faced by hospital managers, provide detail on sometimes challenging working relationships, and demonstrate scope to improve both the psychological safety and resilience of those in managerial positions. A map for senior healthcare leaders was constructed, facilitating the identification of modifiable areas within their organisation to promote good working relationships and improve the working environment of hospital managers.

Implementing behavioural science informed letter interventions to increase COVID-19 vaccination uptake in uncontactable London residents: a difference-in-difference study in London, UK.

BACKGROUND: The UK COVID-19 vaccination programme began in December, 2020. By February, 2021, eight North West London Clinical Commissioning Groups (CCGs) had the lowest vaccination rates nationally. This study evaluated the impact of behavioural science-informed (BI) letters on vaccination uptake. METHODS: Unvaccinated residents of the Central London CCG who were deemed uncontactable (through text messaging and phone calls) were identified with the whole systems integrated care database. BI letters were sent to residents in the intervention CCG between May and June, 2021. Three neighbouring CCGs in London with similar non-responder data were used as control groups. A linear difference-in-difference analysis was undertaken to assess change in vaccine uptake rate across all four CCGs. Percentage point change was adjusted for selected covariates including ethnicity, age, gender, and index of multiple deprivation (IMD) quintiles. Approval was obtained from the quality improvement and audit office of Imperial College Healthcare NHS Trust (London, UK). FINDINGS: Within the intervention Central London CCG, 10 161 residents received the BI letter. The control CCGs contained 27 383 uncontactable residents. All CCGs showed an increase in vaccination rates in this population. The linear difference-in-difference analysis showed an increase in vaccination uptake in the intervention CCG (relative change 31·9% (95% CI 30·5-33·3; p<0·0001). Residents in IMD quintile 5 (least deprived) showed the largest rate of change (4·1%; p<0·0001). Residents with a mixed or multiple ethnic background were less likely to receive a COVID-19 vaccine (-4·1%, p<0·0001). INTERPRETATION: BI letters improved the rate of vaccine uptake. The percentage point increase of 31·9% equates to 436 additional previously uncontactable residents being vaccinated. Our data highlighted differences in the effect of BI-informed interventions in population subgroups. BI letters are a cost-effective and trusted communication tool, effectively engaging residents where other communication strategies did not work. FUNDING: None.

Exploring the factors that promote or diminish a psychologically safe environment: a qualitative interview study with critical care staff.

OBJECTIVES: This study aimed to quantify the presence of psychological safety (defined as an environment 'safe for interpersonal risk taking') in critical care staff, exploring the ways in which this manifested. DESIGN: Qualitative interview study incorporating a short quantitative survey. SETTING: Three intensive care units within one National Health Service Trust in London. PARTICIPANTS: Thirty participants were recruited from all levels of seniority and roles within the multidisciplinary team. A purposive sampling technique was used, with recruitment ceasing at the point of thematic saturation. INTERVENTIONS: Semistructured interviews explored attitudes towards psychological safety and contained a quantitative assessment measuring the climate of psychological safety present. RESULTS: Twenty-eight participants agreed that it was easy to ask for help, with 20 agreeing it is safe to take a risk on the team, demonstrating a strong perception of psychological safety in this group.Our thematic analysis highlighted areas where the context influenced an individual's psychological safety including personality, culture and leadership. Possible negative consequences of psychological safety included distraction and fatigue for the team leader. We demonstrated that speaking up can be influenced by motivations other than patient safety, such as undermining or self-promotion. CONCLUSIONS: Our data demonstrate reassuring levels of psychological safety within the participants studied. This allowed us to explore in depth the participant experience of working within a psychologically safe environment. We add to the current literature by uniquely demonstrating there can be negative consequences to a psychologically safe environment in the healthcare setting. We expand on the influence of context on psychological safety by developing a model, allowing leaders to identify which elements of context can be modified in order to promote speaking up. Team leaders can use these data to help foster a culture of openness, innovation and error prevention while minimising the risk of negative implications.

Lived experiences of healthcare workers on the front line during the COVID-19 pandemic: a qualitative interview study.

OBJECTIVES: This study aimed to investigate the presence of perceived stressors, psychological safety and teamwork in healthcare professionals. As the timeframe for this study spanned the first wave of the COVID-19 pandemic, data were captured demonstrating the impact of the pandemic on these factors. DESIGN: Qualitative interview study. SETTING: All staff working within the emergency and critical care departments of one National Health Service Trust in London, UK. PARTICIPANTS: Forty-nine participants were recruited using a purposive sampling technique and interviewed when the first wave of the COVID-19 pandemic had subsided. MAIN OUTCOME MEASURES: Evaluation of changes in perceived stressors, psychological safety and teamwork in individuals working during the COVID-19 pandemic. RESULTS: The thematic analysis relating to a participant's lived experiences while working during COVID-19 led to the construction of five key themes, including 'psychological effects' and 'changes in team dynamics'. Several psychological effects were described, including the presence of psychological distress and insights into the aetiology of moral injury. There was marked heterogeneity in participants' response to COVID-19, particularly with respect to changes in team dynamics and the perception of a psychologically safe environment. Descriptions of improved team cohesiveness and camaraderie contrasted with stories of new barriers, notably due to the high workload and the impact of personal protective equipment. Building on these themes, a map of key changes arising due to the pandemic was developed, highlighting potential opportunities to provide targeted support. CONCLUSIONS: Working on the front line of a pandemic can have significant implications for healthcare workers, putting them at risk of psychological distress and moral injury, as well as affecting team dynamics. There is striking heterogeneity in the manifestation of these challenges. Team leaders can use the themes and qualitative data from this study to help identify areas for management focus and individual and team support.

Perioperative medicine, interventions in surgical care: the role of replacing the late-night review with daytime leadership.

As the ambitions of surgery have continued to develop, it has resulted in medical advancements that challenge the current paradigms of hospital medicine. Patients previously deemed unsuitable for surgery are now undergoing potentially lifesaving treatments, but are nonetheless still being managed within a model of care that fails to meet their individual needs. Termed 'high risk', these patients, who are frequently elderly or with multiple comorbidities, embark on a surgical journey that is often fragmented and disjointed. Such patients contribute a startlingly high mortality and morbidity rate for non-cardiac elective surgery during the perioperative period, and as a result provide an added demand on already strained hospital resources. 'Perioperative medicine' has been proposed as a possible solution to this problem as it attempts to create a bespoke patient-centric model of care from the moment the need for surgery is identified, through to patient recovery. It is envisaged that the role of a perioperative physician would be to oversee this journey, uniting varying specialties along the way to ensure the best possible patient outcomes.