A systematic review of workplace triggers of emotions in the healthcare environment, the emotions experienced, and the impact on patient safety.

BACKGROUND: Healthcare staff deliver patient care in emotionally charged settings and experience a wide range of emotions as part of their work. These emotions and emotional contexts can impact the quality and safety of care. Despite the growing acknowledgement of the important role of emotion, we know very little about what triggers emotion within healthcare environments or the impact this has on patient safety. OBJECTIVE: To systematically review studies to explore the workplace triggers of emotions within the healthcare environment, the emotions experienced in response to these triggers, and the impact of triggers and emotions on patient safety. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, four electronic databases were searched (MEDLINE, PsychInfo, Scopus, and CINAHL) to identify relevant literature. Studies were then selected and data synthesized in two stages. A quality assessment of the included studies at stage 2 was undertaken. RESULTS: In stage 1, 90 studies were included from which seven categories of triggers of emotions in the healthcare work environment were identified, namely: patient and family factors, patient safety events and their repercussions, workplace toxicity, traumatic events, work overload, team working and lack of supervisory support. Specific emotions experienced in response to these triggers (e.g., frustration, guilt, anxiety) were then categorised into four types: immediate, feeling states, reflective, and longer-term emotional sequelae. In stage 2, 13 studies that explored the impact of triggers or emotions on patient safety processes/outcomes were included. CONCLUSION: The various triggers of emotion and the types of emotion experienced that have been identified in this review can be used as a framework for further work examining the role of emotion in patient safety. The findings from this review suggest that certain types of emotions (including fear, anger, and guilt) were more frequently experienced in response to particular categories of triggers and that healthcare staff's experiences of negative emotions can have negative effects on patient care, and ultimately, patient safety. This provides a basis for developing and tailoring strategies, interventions, and support mechanisms for dealing with and regulating emotions in the healthcare work environment.

Nurse-led sustainable plastic surgery trauma service transformation: a positive COVID-19 legacy.

The aim of this quality improvement was to develop a sustainable nurse-led 'See and Treat' service in a regional plastic surgery unit in England for patients requiring plastic surgery under local anaesthetic following traumatic injury.Trauma-related injuries are a substantial part of the workload in the plastic surgery department in question; with people with the most minor injuries requiring surgery under local anaesthetic accounting for 17%. COVID-19 threatened the continuation of any minor surgery service, but the initial crisis-driven response to the pandemic provided the opportunity to develop a new, more effective, nurse-led service for this patient group.The Model for Improvement was used and four 'Plan, Do, Study, Act' cycles deployed over an 8-week period, involving 102 patients. Routine quantitative and qualitative data in the form of a semistructured patient feedback proforma were used to guide the improvement process, optimising the new service design and delivery.The results demonstrated that 98% (n=100) of patients received same-day surgery via the new 'See and Treat' service. Staff and patient satisfaction remained high throughout; all patients preferred same-day surgery. No negative unintended consequences, for example, postoperative infections, were identified. One positive unintended consequence was the reduction in carbon footprint achieved by decreasing clinical waste and patient travel.Improvement methodology was successfully used by a nurse-led team to enable the continuation and enhancement of surgical services for trauma patients during COVID-19-driven service disruption. This service transformation has resulted in the retention of the revised service delivery model as the 'new normal' approximately 2 years later. The COVID-19 pandemic challenged the resilience of the trauma surgery service but led to a positive long-term legacy that sustainably improved waiting times and patient experience while maintaining safety.

Feedback for Emergency Ambulance Staff: A National Review of Current Practice Informed by Realist Evaluation Methodology.

Research suggests that feedback in Emergency Medical Services (EMS) positively affects quality of care and professional development. However, the mechanisms by which feedback achieves its effects still need to be better understood across healthcare settings. This study aimed to understand how United Kingdom (UK) ambulance services provide feedback for EMS professionals and develop a programme theory of how feedback works within EMS, using a mixed-methods, realist evaluation framework. A national cross-sectional survey was conducted to identify feedback initiatives in UK ambulance services, followed by four in-depth case studies involving qualitative interviews and documentary analysis. We used qualitative content analysis and descriptive statistics to analyse survey responses from 40 prehospital feedback initiatives, alongside retroductive analysis of 17 interviews and six documents from case study sites. Feedback initiatives mainly provided individual patient outcome feedback through "pull" initiatives triggered by staff requests. Challenges related to information governance were identified. Our programme theory of feedback to EMS professionals encompassed context (healthcare professional and organisational characteristics), mechanisms (feedback and implementation characteristics, psychological reasoning) and outcomes (implementation, staff and service outcomes). This study suggests that most UK ambulance services use a range of feedback initiatives and provides 24 empirically based testable hypotheses for future research.

Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis.

BACKGROUND: Extensive research has been conducted into the effects of feedback interventions within many areas of healthcare, but prehospital emergency care has been relatively neglected. Exploratory work suggests that enhancing feedback and follow-up to emergency medical service (EMS) staff might provide staff with closure and improve clinical performance. Our aim was to summarise the literature on the types of feedback received by EMS professionals and its effects on the quality and safety of patient care, staff well-being and professional development. METHODS: A systematic review and meta-analysis, including primary research studies of any method published in peer-reviewed journals. Studies were included if they contained information on systematic feedback to emergency ambulance staff regarding their performance. Databases searched from inception were MEDLINE, Embase, AMED, PsycINFO, HMIC, CINAHL and Web of Science, with searches last updated on 2 August 2022. Study quality was appraised using the Mixed Methods Appraisal Tool. Data analysis followed a convergent integrated design involving simultaneous narrative synthesis and random effects multilevel meta-analyses. RESULTS: The search strategy yielded 3183 articles, with 48 studies meeting inclusion criteria after title/abstract screening and full-text review. Interventions were categorised as audit and feedback (n=31), peer-to-peer feedback (n=3), postevent debriefing (n=2), incident-prompted feedback (n=1), patient outcome feedback (n=1) or a combination thereof (n=4). Feedback was found to have a moderate positive effect on quality of care and professional development with a pooled effect of d=0.50 (95% CI 0.34, 0.67). Feedback to EMS professionals had large effects in improving documentation (d=0.73 (0.00, 1.45)) and protocol adherence (d=0.68 (0.12, 1.24)), as well as small effects in enhancing cardiac arrest performance (d=0.46 (0.06, 0.86)), clinical decision-making (d=0.47 (0.23, 0.72)), ambulance times (d=0.43 (0.12, 0.74)) and survival rates (d=0.22 (0.11, 0.33)). The between-study heterogeneity variance was estimated at σ2=0.32 (95% CI 0.22, 0.50), with an I2 value of 99% (95% CI 98%, 99%), indicating substantial statistical heterogeneity. CONCLUSION: This review demonstrated that the evidence base currently does not support a clear single point estimate of the pooled effect of feedback to EMS staff as a single intervention type due to study heterogeneity. Further research is needed to provide guidance and frameworks supporting better design and evaluation of feedback interventions within EMS. PROSPERO REGISTRATION NUMBER: CRD42020162600.

Identifying Safety Practices Perceived as Low Value: An Exploratory Survey of Healthcare Staff in the United Kingdom and Australia.

OBJECTIVES: Up to 30% of healthcare spending is considered unnecessary and represents systematic waste. While much attention has been given to low-value clinical tests and treatments, much less has focused on identifying low-value safety practices in healthcare settings. With increasing recognition of the problem of "safety clutter" in organizations, it is important to consider deimplementing safety practices that do not benefit patients, to create the time needed to deliver effective, person-centered, and safe care. This study surveyed healthcare staff to identify safety practices perceived to be of low value. METHODS: Purposive and snowball sampling was used. Data collection was conducted from April 2018 to November 2019 (United Kingdom) and May 2020 to November 2020 (Australia). Participants completed the survey online or in hard copy to identify practices they perceived to not contribute to safe care. Responses were analyzed using content and thematic analysis. RESULTS: A total of 1394 responses from 1041 participants were analyzed. Six hundred sixty-three responses were collected from 526 UK participants and 515 Australian participants contributed 731 responses. Frequently identified categories of practices identified included "paperwork," "duplication," and "intentional rounding." Five cross-cutting themes (e.g., covering ourselves) offered an underpinning rationale for why staff perceived the practices to be of low value. CONCLUSIONS: Staff identified safety practices that they perceived to be low value. In healthcare systems under strain, removing existing low-value practices should be a priority. Careful evaluation of these identified safety practices is required to determine whether they are appropriate for deimplementation and, if not, to explore how to better support healthcare workers to perform them.

An international exploration of blended learning use in pre-registration nursing and midwifery education.

AIM: To explore international experiences of using blended learning in preparing nursing and midwifery students for initial professional registration to inform future education policy. BACKGROUND: The global nursing and midwifery skills shortage and need for an expanded nursing workforce that is fit for contemporary care delivery is widely acknowledged. The immense pressure the profession was already under because of austerity, staff shortages and increasingly complex healthcare needs has been worsened by the Covid-19 pandemic. The UK is extending and evaluating the use of blended learning programmes for pre-registration nursing and midwifery students to help address these issues. This study sought to explore relevant nursing and midwifery experiences from outside the UK to help inform future health professional education policy here and elsewhere. DESIGN: Cross-sectional, sequential, mixed methods study PARTICIPANTS/SETTINGS: Nursing/nurse education leaders from across International Council of Nurses regions METHODS: Exploratory online survey (n = 32) and three follow-up case studies (March-May 2021). Participants' knowledge and experiences of blended learning were examined along with any perceived benefits for workforce development and successful strategies for addressing the challenges blended learning presents in this context. Case studies were developed inductively from survey responses and follow up telephone calls to provide more detailed information about reported successes. RESULTS: Participants reported flexibility, cost effectiveness, increased student/tutor and student/student communication and interaction as benefits of blended learning. Challenges included the design and use of interactive learning resources, appropriate preparation and support for staff and students, the potential of blended learning to exacerbate otherwise hidden disadvantage and the need for multi-stakeholder cost/benefit evaluation. CONCLUSIONS: Blended learning is used globally in the pre-registration education of nurses, midwives and other healthcare professionals. These results broadly mirror the literature regarding the benefits blended learning offers healthcare students, staff and organisations and the strategies employed to mitigate risk. As the deployment of blended learning nursing and midwifery programmes expands, further work is needed to address gaps in the current evidence base regarding the practice and impact of this approach. These concern adequate preparation and support of students and staff, ensuring access to appropriate equipment and connectivity, exploration of student perceptions that online learning is of lesser value and comprehensive multi-stakeholder, exploratory evaluation to uncover any hidden factors and impact. TWEETABLE ABSTRACT: Blended learning plays an effective part in the education of pre-registration nursing and midwifery students to help tackle global workforce shortages, but further work is needed to address gaps in the current evidence base regarding the practice and impact of this approach.

Identity, positionality and reflexivity: relevance and application to research paramedics.

This article introduces the reader to the concepts of identity, positionality and reflexivity and outlines their relevance to research paramedics. We outline how a researcher's identity and positionality can influence all aspects of research, including the research question, study design, data collection and data analysis. We discuss that the 'insider' position of paramedics conducting research with other paramedics or within their specific clinical setting has considerable benefits to participant access, understanding of data and dissemination, while highlighting the difficulties of role duality and power dynamics. While positionality is concerned with the researcher clearly stating their assumptions relating to the research topic, the research design, context and process, as well as the research participants; reflexivity involves the researcher questioning their assumptions and finding strategies to address these. The researcher must reflect upon the way the research is carried out and explain to the reader how they moved through the research processes to reach certain conclusions, with the aim of producing a trustworthy and honest account of the research. Throughout this article, we provide examples of how these concepts have been considered and applied by a research paramedic while conducting their PhD research studies within a pre-hospital setting, to illustrate how they can be applied practically.

The role of feedback in emergency ambulance services: a qualitative interview study.

BACKGROUND: Several international studies suggest that the feedback that emergency ambulance service (EMS) personnel receive on the care they have delivered lacks structure, relevance, credibility and routine implementation. Feedback in this context can relate to performance or patient outcomes, can come from a variety of sources and can be sought or imposed. Evidence from health services research and implementation science, suggests that feedback can change professional behavior, improve clinical outcomes and positively influence staff mental health. The current study aimed to explore the experience of EMS professionals regarding current feedback provision and their views on how feedback impacts on patient care, patient safety and staff wellbeing. METHODS: This qualitative study was conducted as part of a wider study of work-related wellbeing in EMS professionals. We used purposive sampling to select 24 frontline EMS professionals from one ambulance service in the United Kingdom and conducted semi-structured interviews. The data was analyzed in iterative cycles of inductive and deductive reasoning using Abductive Thematic Network Analysis. The analysis was informed by psychological theory, as well as models from the wider feedback effectiveness and feedback-seeking behavior literature. RESULTS: Participants viewed current feedback provision as inadequate and consistently expressed a desire for increased feedback. Reported types of prehospital feedback included patient outcome feedback, patient-experience feedback, peer-to-peer feedback, performance feedback, feedforward: on-scene advice, debriefing and investigations and coroners' reports. Participants raised concerns that inadequate feedback could negatively impact on patient safety by preventing learning from mistakes. Enhancing feedback provision was thought to improve patient care and staff wellbeing by supporting personal and professional development. CONCLUSIONS: In line with previous research in this area, this study highlights EMS professionals' strong desire for feedback. The study advances the literature by suggesting a typology of prehospital feedback and presenting a unique insight into the motives for feedback-seeking using psychological theory. A logic model for prehospital feedback interventions was developed to inform future research and development into prehospital feedback.

Multiple meanings of resilience: Health professionals' experiences of a dual element training intervention designed to help them prepare for coping with error.

RATIONALE, AIMS AND OBJECTIVES: Consistent data demonstrates negative psychological effects of caregiving on front-line health professionals. Evidence that psychological resilience factors can help minimize distress and the potential for low-cost interventions have created interest in resilience-based development programmes; yet evidence of perceived value amongst health professionals is lacking. This study explored health professionals' experiences and perceptions of a novel, resilience-based intervention designed to pro-actively prepare staff for coping with error; to investigate their perceptions of what resilience meant to them, the relevance of the intervention, and impact of participation on ability to cope with error. METHODS: Semi-structured interviews 4-6 weeks post intervention with 23 randomly selected participants from seven cohorts (midwives, paediatricians, obstetricians/gynaecologists, paramedics) and trainees (physician associates, mammographers, sonographers). Thematic analysis of interview data. FINDINGS: Participants reported various interpretations of, and a shift in perception regarding what the concept of psychological resilience meant to them and their practice. These included for example, resilience as a positive or negative concept and their awareness and response to a range of personal, organizational and system factors influencing personal resilience. They valued the prophylactic, clinically relevant, interactive and applied nature of the intervention; having developed and applied valuable skills beyond the context of involvement in error, noting that individuals needed to be willing to explore their own coping mechanisms and human fallibility to gain maximum benefit. There was also consensus that whilst proactively developing individual level psychological resilience is important, so too is addressing the organizational and system factors that affect staff resilience which are outside individual staff control. CONCLUSION: Enhancing resilience appears to be considered useful in supporting staff to prepare for coping with error and the wider emotional burden of clinical work, but such interventions require integration into wider system approaches to reduce the burden of clinical work for health professionals.

The Association Between Health Care Staff Engagement and Patient Safety Outcomes: A Systematic Review and Meta-Analysis.

OBJECTIVES: Despite decades of research, improving health care safety remains a global priority. Individual studies have demonstrated links between staff engagement and care quality, but until now, any relationship between engagement and patient safety outcomes has been more speculative. This systematic review and meta-analysis therefore assessed this relationship and explored if the way these variables were defined and measured had any differential effect. METHODS: After systematic searches of Medline, CINAHL, PsycInfo, Embase, Cochrane Library, and National Institute for Health Research Journals databases, narrative and random-effects meta-analyses were completed, with pooled effect sizes expressed as Pearson r. RESULTS: Fourteen studies met the inclusion criteria, 11 of which were suitable for meta-analysis. Meta-analyses indicated a small but consistent, statistically significant relationship between staff engagement and patient safety (all outcomes; 11 studies; r = 0.22; 95% confidence interval [CI], 0.07 to 0.36; n = 30,490) and 2 patient safety outcome categories: patient safety culture (7 studies; r = 0.22; 95% CI, 0.01 to 0.41; n = 27,857) and errors/adverse events (4 studies; r = -0.20; 95% CI, -0.26 to -0.13; n = 2633). The specific approach to conceptualizing engagement did not affect the strength of the findings. CONCLUSIONS: This is the first review to demonstrate a significant relationship between engagement and both safety culture scores and errors/adverse events. Despite a limited and evolving evidence base, we cautiously conclude that increasing staff engagement could be an effective means of enhancing patient safety. Further research is needed to determine causality and clarify the nature of the staff engagement/patient safety relationship at individual and unit/workgroup levels.

Can we prepare healthcare professionals and students for involvement in stressful healthcare events? A mixed-methods evaluation of a resilience training intervention.

BACKGROUND: Healthcare professionals are experiencing unprecedented levels of occupational stress and burnout. Higher stress and burnout in health professionals is linked with the delivery of poorer quality, less safe patient care across healthcare settings. In order to understand how we can better support healthcare professionals in the workplace, this study evaluated a tailored resilience coaching intervention comprising a workshop and one-to-one coaching session addressing the intrinsic challenges of healthcare work in health professionals and students. METHODS: The evaluation used an uncontrolled before-and-after design with four data-collection time points: baseline (T1); after the workshop (T2); after the coaching session (T3) and four-to-six weeks post-baseline (T4). Quantitative outcome measures were Confidence in Coping with Adverse Events ('Confidence'), a Knowledge assessment ('Knowledge') and Resilience. At T4, qualitative interviews were also conducted with a subset of participants exploring participant experiences and perceptions of the intervention. RESULTS: We recruited 66 participants, retaining 62 (93.9%) at T2, 47 (71.2%) at T3, and 33 (50%) at T4. Compared with baseline, Confidence was significantly higher post-intervention: T2 (unadj. ß = 2.43, 95% CI 2.08-2.79, d = 1.55, p < .001), T3 (unadj. ß = 2.81, 95% CI 2.42-3.21, d = 1.71, p < .001) and T4 (unadj. ß = 2.75, 95% CI 2.31-3.19, d = 1.52, p < .001). Knowledge increased significantly post-intervention (T2 unadj. ß = 1.14, 95% CI 0.82-1.46, d = 0.86, p < .001). Compared with baseline, resilience was also higher post-intervention (T3 unadj. ß = 2.77, 95% CI 1.82-3.73, d = 0.90, p < .001 and T4 unadj. ß = 2.54, 95% CI 1.45-3.62, d = 0.65, p < .001). The qualitative findings identified four themes. The first addressed the 'tension between mandatory and voluntary delivery', suggesting that resilience is a mandatory skillset but it may not be effective to make the training a mandatory requirement. The second, the 'importance of experience and reference points for learning', suggested the intervention was more appropriate for qualified staff than students. The third suggested participants valued the 'peer learning and engagement' they gained in the interactive group workshop. The fourth, 'opportunities to tailor learning', suggested the coaching session was an opportunity to personalise the workshop material. CONCLUSIONS: We found preliminary evidence that the intervention was well received and effective, but further research using a randomised controlled design will be necessary to confirm this.

Screaming silences: lessons from the application of a new research framework.

BACKGROUND: The Silences Framework ( Serrant-Green 2011 ) originated from research exploring ethnicity, gender and sexual health decision-making, and provides a useful tool for researching underrepresented groups and topics. AIM: To present the lessons learned from the application of the Silences Framework in the context of a qualitative study exploring the experiences of people under the age of 60 recovering from a fragility hip fracture. DISCUSSION: The authors explore current conceptions of marginalisation in healthcare with reference to nursing research and provide practical tips for others interested in applying and further testing the framework. CONCLUSION: The framework is likely to be attractive to nurses as it is underpinned by core nursing values, such as advocacy-based action. It places participant and public voices at the centre of the research and resembles the familiar nursing process. The structure and flexibility it offers also makes it relevant for new and experienced researchers in a variety of contexts. IMPLICATIONS FOR PRACTICE: Critical analysis of the initial application of the Silences Framework in a different setting to the one in which it was developed indicates it offers a beneficial addition to the research toolkit. Its limited use to date means its relevance for nursing and potential for further development have not yet been fully established. It should be tested more widely and in other contexts.

Silent slips, trips and broken hips in the under 60s: A review of the literature.

This critical review of the literature regarding the recovery experiences and healthcare needs of people under 60 following a fragility hip fracture seeks to identify the associated implications for nursing practice and inform care delivery. Forty papers were included following a structured database, citation and grey literature search and filtering of results in line with specified inclusion criteria. Hip fracture is a common, serious and complex injury and an important cause of morbidity, mortality and rising healthcare costs worldwide. This review indicates that although commonly associated with the elderly, incidence and impact in the under 60s has been under-explored. Current health policy, professional and social norms almost exclusively focus on the elderly, surgical interventions and short-term outcomes, rendering the under 60s an inadvertently marginalised, relatively 'silent' sub-set of the hip fracture population. Nurses must be aware, however, of the different recovery needs of this younger group. The limited evidence available indicates these include work related needs and long term physical and psychosocial limitations in this socially and economically active group. Priorities are identified for research to inform policy and practice. Meanwhile, nurses can address the needs of this group by listening to and involving them and their families as healthcare partners.

Introducing service improvement to the initial training of clinical staff.

BACKGROUND: It is well recognised in healthcare settings that clinical staff have a major influence over change in how services are provided. If a culture of systematic service improvement is to be established, it is essential that clinical staff have an understanding of what is required and their role in its application. METHODS: This paper describes the development of short educational interventions (a module of 6-8 contact hours or a longer module of 18-30 h) for inclusion in the initial training of future clinical staff (nursing, medicine, physiotherapy, occupational therapy, dietetics, social work, operating department practice, public health and clinical psychology) and presents the results of an evaluation of their introduction. Each module included teaching on process/systems thinking, initiating and sustaining change, personal and organisational development, and public and patient involvement. RESULTS: Over 90% of students considered the modules relevant to their career. Nearly 90% of students felt that they could put their learning into practice, although the actual rate of implementation of changes during the pilot period was much lower. The barriers to implementation most commonly cited were blocks presented by existing staff, lack of time and lack of status of students within the workforce. CONCLUSION: This pilot demonstrates that short educational interventions focused on service improvement are valued by students and that those completing them feel ready to contribute. Nevertheless, the rate of translation into practice is low. While this may reflect the status of students in the health service, further research is needed to understand how this might be enhanced.

Health care improvement and continuing interprofessional education: continuing interprofessional development to improve patient outcomes.

Health care improvement and continuing professional education must be better understood if we are to promote continuous service improvement through interprofessional learning in the workplace. We propose that situating interprofessional working, interprofessional learning, work-based learning, and service improvement within a framework of social learning theory creates a continuum between work-based interprofessional learning and service improvement in which each is integral to the other. This continuum provides a framework for continuing interprofessional development that enables service improvement in the workplace to serve as a vehicle through which individual professionals and teams can continually enhance patient care through working and learning together. The root of this lies in understanding that undertaking improvement and learning about improvement are co-dependent and that health care professionals must recognize their responsibility to improve as well as complete their everyday work. We believe that significant opportunities exist for health care commissioners, service providers, and educational institutions to work together to promote continuing interprofessional development in the workplace to enhance patient outcomes, and we outline some of the opportunities we believe exist.

Addressing the learning needs of multidisciplinary students at a distance using a virtual learning environment (VLE): A novice teacher reflects.

This paper analyses the experience of one individual in the development and delivery of an innovative, undergraduate leadership development module. The module is accessed by practising health care professionals in Malaysia as part of a top-up Honours Degree and is delivered solely using a virtual learning environment (VLE), in this case Blackboard. The aim of this analysis is to contribute to the current body of knowledge regarding the use of VLE technology to facilitate learning at a distance. Of particular relevance is the paper's focus on: the drivers for e-learning; widening participation and increasing access; the experience of designing and delivering learning of relevance for this contemporary student population and evaluating the VLE experience/module. The development and delivery of this module is one result of a rapidly growing area of education. As a novice teacher in her first year in the higher education sector, this experience was a significant and stimulating challenge for a number of reasons and these are explored in greater depth. This is achieved by means of personal reflection using the phases of module development and delivery as a focus.