'It is designed for everybody to find their own level and to improve themselves'; views of older people and instructors of the Falls Management Exercise (FaME) programme.

BACKGROUND: Older adults are at increased risk of falls due to ageing, decreased muscle strength and impaired balance. Clinical trials have demonstrated the efficacy and effectiveness of the Falls Management Exercise (FaME) programme in improving functioning and preventing falls. However, programme completion is often low, impacting the potential benefits of FaME. OBJECTIVE: To explore the barriers and facilitators for participation and completion of the FaME programme from an instructor and participant perspective. METHODS: Semi-structured interviews were conducted with 20 FaME users and seven Postural Stability Instructors from the East Midlands region of England, UK. Interviews were conducted using a topic guide and explored their views of the programme, intended benefits, reasons for participating, instructor's approach and venue facilities. Data were transcribed verbatim and analysed using thematic analysis. Written informed consent was obtained from all participants and instructors. RESULTS: Common themes identified by participants and instructors for adherence related to perceived health benefits, psychological well-being, intervention characteristics, cost, instructors' qualities, opportunity to socialise, venue accessibility and facilities. Further factors such as maintaining independence, discipline, relationship with peers and caring responsibilities influenced participants' engagement with the programme. Instructor factors such as progression were also reported as important predictors. CONCLUSIONS: Instructor and participant factors influence uptake, attendance and adherence of FaME. The findings from this study can inform the development and improvement of additional falls-prevention programmes. It can also guide marketing strategies to promote uptake of exercise-based falls-prevention programmes among older adults.

'You're on show all the time': Moderating emotional labour through space in the emergency department.

AIMS: This is the second of two papers conceptualizing emotional labour in the emergency department (ED). This paper aims to understand the environmental 'moderators' of ED nurses' emotional labour. DESIGN: Ethnography, through an interpretivist philosophy, enabled immersion in the ED setting, gathering the lived experiences and narratives of the ED nurses. METHODS: Observation and semi-structured interviews over a 6-month period. Two hospital sites (one district general and one major trauma centre based in the United Kingdom. RESULTS: Over 200 h of observation plus 18 formal/semi-structured interviews were completed. Environmental, institutional and organizational dynamics of the emergency department instrumented the emotional labour undertaken by the nursing team. Time and space were found to be 'moderators' of ED nurses' emotional labour. This paper focusses on the relevance of space and in particular, 'excessive visibility' with little respite for the nurses from their intense emotional performance. CONCLUSION: Emotional labour is critical to staff well-being and the way in which healthcare spaces are designed has an impact on emotional labour. Understanding how emotional labour is moderated in different clinical settings can inform organizational, environmental and workforce-related decision-making.

A qualitative study exploring the influence of a talent management initiative on registered nurses' retention intentions.

AIM: The aim of this study is to explore the influence of a talent management scheme in an English National Health Service (NHS) Trust on registered nurses' retention intentions. BACKGROUND: The retention of nurses is a global challenge, and talent management initiatives can play a role in improving retention. Talent management in its broadest sense is a way in which an organization recruits and retains the workforce that it needs to optimize the services it delivers. METHODS: In this qualitative study, eight in-depth semi-structured interviews were conducted with registered nurses who had participated in a talent management initiative, at an English acute NHS Trust. Data were collected in July 2019. RESULTS: The talent management initiative influenced positive retention intentions. Retention of nurses was facilitated by the creation of networks and networking. CONCLUSION: Networks and networking can be viewed as a form of social capital, which was a facilitating factor for positive retention intentions for nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Talent management initiatives for nurses should be developed and directed to include the building of networks and networking to enable development of social capital. Although this talent management scheme is within the NHS, the issue of nursing retention is global. Application of learning from this paper to other health care systems is possible.

Discourses of compassion from the margins of health care: the perspectives and experiences of people with a mental health condition.

BACKGROUND: Evidence supports the positive influence of compassion on care experiences and health outcomes. However, there is limited understanding regarding how compassion is identified by people with lived experience of mental health care. AIM: To explore the views and experiences of compassion from people who have lived experience of mental health. METHODS: Participants with a self-reported mental health condition and lived experience of mental health (n = 10) were interviewed in a community setting. Characteristics of compassion were identified using an interpretative description approach. RESULTS: Study participants identified compassion as comprised three key components; 'the compassionate virtues of the healthcare professional', which informs 'compassionate engagement', creating a 'compassionate relational space and the patient's felt-sense response'. When all these elements were in place, enhanced recovery and healing was felt to be possible. Without the experience of compassion, mental health could be adversely affected, exacerbating mental health conditions, and leading to detachment from engaging with health services. CONCLUSIONS: The experience of compassion mobilises hope and promotes recovery. Health care policymakers and organisations must ensure services are structured to provide space and time for compassion to flourish. It is imperative that all staff are provided with training so that compassion can be acquired and developed.

'Real world' effectiveness of the Falls Management Exercise (FaME) programme: an implementation study.

BACKGROUND: Falls incidence increases with age alongside declines in strength and balance. Clinical trials show that the Falls Management Exercise (FaME) programme improves strength and balance, which can reduce falls and improve physical functioning. OBJECTIVE: To determine if the clinical trial efficacy of FaME translates into effectiveness in non-research settings. DESIGN AND SETTING: An implementation study of FaME in 10 local authorities across the East Midlands region of England. SUBJECTS: Adults aged 65 and over enrolled on a FaME programme. METHOD: Anonymised outcome data collected by the FaME providers were compared at baseline, end of programme and 6 months follow-up using univariate and multivariate analyses. RESULTS: For 348 adults enrolled in programmes and analysed, the mean age was 76.8, 73% were female and 143 (41%) completed ≥75% of classes. Overall confidence in balance, fear of falling, functional reach and timed-up-and-go (all P < 0.001), and turn 180° (P = 0.008) improved significantly at programme completion versus baseline, but improvements were not maintained 6 months later. Falls risk (FRAT score) and total minutes of physical activity did not change significantly though minutes of strength and balance activity increased by 55% at programme completion and was maintained at 6 months. The falls incidence rate ratio (IRR) was non-significantly lower at programme completion (IRR 0.76, 95% Confidence Interval (CI) 0.48,1.21) and follow-up (IRR 0.82 95% CI 0.48,1.39) versus baseline. CONCLUSIONS: There is modest translation of FaME efficacy into effectiveness, but not all effects persist after completion. Strategies to aid adherence and exercise maintenance are important to maximise benefits.

Self-reported diseases and their associated risk factors among camp-dwelling conflict-affected internally displaced populations in Nigeria.

Background Conflict in Nigeria displaced millions of people, and some settled in camp-like locations within the country. Evidence on the association between living conditions and health outcomes among these populations are limited. This study investigated the risk factors associated with illnesses among camp-dwelling internally displaced persons (IDPs) in northern Nigeria. Methods A cross-sectional study was conducted in nine camps in 2016. Self-reported data on socio-demography, resource utilization and disease outcomes were collected. Association between health conditions and various factors, including sanitation and healthcare access, was investigated. Results Data from 2253 IDPs showed 81.1% (CI = 79.5-82.7) experienced one or more health conditions; however, over 20% did not access healthcare services. Most common diseases were malaria, fever, typhoid and diarrhoea. Multivariable logistic regression presented as adjusted odds ratios(aOR) and 95% confidence intervals(CIs) showed factors significantly associated with increased likelihood of illnesses included being female (aOR = 1.53;CI = 1.19-1.96), overcrowding (aOR = 1.07;CI = 1.00-1.36), long-term conditions (aOR = 2.72;CI = 1.88-3.94), outdoor defecation (aOR = 2.37;CI = 1.14-4.94) and presence of disease-causing vectors (aOR = 3.71;CI = 1.60-8.60). Conclusion Most diseases in the camps were communicable. Modifiable risk factors such as overcrowding and poor toilet facilities were associated with increased poor health outcomes. This evidence highlights areas of high priority when planning humanitarian public health interventions.

Knowledge sharing to support long-term condition self-management-Patient and health-care professional perspectives.

BACKGROUND: Increased self-management is a suggested solution to the burden on health-care services of long-term conditions (LTCs). This requires effective sharing of knowledge between health-care professionals and patients, and is an underexplored area. OBJECTIVE: To understand how patients and health-care professionals (HCPs) share and utilize knowledge in the social context of health-care interactions within long-term condition management. METHODS: Thematic analysis of 93 hours of observations of health-care interactions and 33 semi-structured interviews involving patients, carers and HCPs. RESULTS: 3 themes were identified: normative social roles, differing professional roles and the value of knowledge. Knowledge sharing was a complex process heavily influenced by social and cultural norms within the health-care context. Not all knowledge was easily shared within routine health-care interactions. DISCUSSION: The social context in which health-care is practised influences what knowledge is shared and how this is achieved. It favours sharing of clinical knowledge from HCPs to patients and disadvantages patients in their ability to share their unique knowledge based on lived experience of illness. The opportunities for patients to be supported in their knowledge, skills and confidence within routine health-care interactions are limited. CONCLUSION: Both patients and HCPs need support to recognize the characteristics of the social context of health care and their understandings of their roles within this in order for them to move beyond accepted behaviours to develop more effective partnership working. PATIENT OR PUBLIC CONTRIBUTION: Patients were involved in initial design of the study, particularly ethics of ethnographic observation.

A study of mapping usual care and unmet need for vocational rehabilitation and psychological support following major trauma in five health districts in the UK.

OBJECTIVE: To identify where and how trauma survivors' rehabilitation needs are met after trauma, to map rehabilitation across five UK major trauma networks, and to compare with recommended pathways. DESIGN: Qualitative study (interviews, focus groups, workshops) using soft-systems methodology to map usual care across trauma networks and explore service gaps. Publicly available documents were consulted. CATWOE (Customers, Actors, Transformation, Worldview, Owners, Environment) was used as an analytic framework to explore the relationship between stakeholders in the pathway. SETTING: Five major trauma networks across the UK. SUBJECTS: 106 key rehabilitation stakeholders (service providers, trauma survivors) were recruited to interviews (n = 46), focus groups (n = 4 groups, 17 participants) and workshops (n = 5 workshops, 43 participants). INTERVENTIONS: None. RESULTS: Mapping of rehabilitation pathways identified several issues: (1) lack of vocational/psychological support particularly for musculoskeletal injuries; (2) inconsistent service provision in areas located further from major trauma centres; (3) lack of communication between acute and community care; (4) long waiting lists (up to 12 months) for community rehabilitation; (5) most well-established pathways were neurologically focused. CONCLUSIONS: The trauma rehabilitation pathway is complex and varies across the UK with few, if any patients following the recommended pathway. Services have developed piecemeal to address specific issues, but rarely meet the needs of individuals with multiple impairments post-trauma, with a lack of vocational rehabilitation and psychological support for this population.

"I don't have any emotions": An ethnography of emotional labour and feeling rules in the emergency department.

AIMS: This study aims to apply Hochschild's theory of emotional labour to emergency care, and uncover the 'specialty-specific' feeling rules driving this labour. Despite the importance of positive nurse well-being, the emotional labour of nursing (a great influencer in wellbeing) remains neglected. DESIGN AND METHODS: Ethnography enabled immersion in the ED setting, gathering the lived experiences and narratives of the ED nursing team. We undertook first-hand observations at one major trauma centre ED and one district general ED including semi-structured interviews (18). A reflexive and interpretive approach towards thematic analysis was used. RESULTS: We unearthed and conceptualized four feeling rules born from this context and offer extensive insights into the emotional labour of emergency nurses. CONCLUSION: Understanding the emotional labour and feeling rules of various nursing specialties offers critical insight into the challenges facing staff - fundamental for nursing well-being and associated retention programs. IMPACT: What problem did the study address? What were the main findings? Where and on whom will the research have impact? Academically, this research expands our understanding - we know little of nurses' feeling rules and how specialties influence them. Clinically, (including service managers and policy makers) there are practical implications for nurse well-being.

PHysical activity Implementation Study In Community-dwelling AduLts (PHISICAL): study protocol.

BACKGROUND: Falls in older people are a leading causes of unintentional injury. Due to an ageing population, injuries are likely to increase unless more is done to reduce older people's falls risk. In clinical trials, the Falls Management Exercise (FaME) programme has reduced the rate of falls and falls-related injuries in community-dwelling older adults. However, the commissioning of FaME is inconsistent across England, potentially due to a lack of evidence that FaME can be delivered effectively in a 'real world' setting. The PHysical activity Implementation Study In Community-dwelling AduLts (PHISICAL) study is designed to study the implementation of FaME in a range of different settings in England. METHODS: The PHISICAL study will use a mixed-methods, triangulation, multilevel design to explore the implementation of FaME. Framework analysis of semistructured interviews with up to 90 stakeholders (exercise programme users, service providers, referrers and commissioners) and observational data from locally led communities of practice will identify the factors that influence FaME's implementation. Quantitative, anonymised, routine service data from up to 650 exercise programme users, including measures of falls and physical activity, will allow assessment of whether the benefits of FaME reported in clinical trials translate to the 'real world' setting. CONCLUSION: The findings from this study will be used to develop a toolkit of resources and guidance to inform the commissioning and delivery of future FaME programmes. This study has the potential to inform public health prevention strategies, and in doing so may reduce the number of falls in the older population while delivering cost savings to health and social care services.

An audit of healthcare provision in internally displaced population camps in Nigeria.

BACKGROUND: Armed conflict in Nigeria resulted in more than 2 million internally displaced persons (IDPs). IDPs live in poor conditions lacking basic resources with variable provision across different locations. This audit aimed to determine the health-related resources available to IDPs in camp-like settings in Nigeria and whether these met international standards. METHODS: Using a cross-sectional study approach, information was collected in nine camps across seven states from camp managers, and direct observation in September-October 2016. The Sphere minimum standards in humanitarian crises were used as the audit standards. FINDINGS: The 5 of 15 assessed standards were met to some extent, including the availability of water and shelter. Sanitation and vaccination were unmet in five camps, with severe overcrowding in five camps, and inadequate waste disposal in all camps. Health programme implementation was uneven, and especially poor in self-settled and dispersed settlements. CONCLUSION: Inequality in distribution of humanitarian support was observed across different settings, which could lead to a higher likelihood of water, food and air-related diseases and thereby, a poorer quality of life for IDPs. Ensuring standardized health assessments could promote a more even distribution of resources across IDP locations.

Resisting big data exploitations in public healthcare: free riding or distributive justice?

We draw on findings from qualitative interviews with health data researchers, GPs and citizens who opted out from NHS England's care.data programme to explore controversies and negotiations around data sharing in the NHS. Drawing on theoretical perspectives from science and technology studies, we show that the new socio-technical, ethical and economic arrangements were resisted not only on the basis of individual autonomy and protection from exploitation, but also as a collective effort to protect NHS services and patient data. We argue that the resulting opt-outs were a call for more personal control over data use. This was not because these citizens placed their personal interests above those of society. It was because they resisted proposed arrangements by networks of stakeholders, not seen as legitimate, to control flows and benefits of NHS patient data. Approaching informed consent this way helps us to explore resistance as a collective action for influencing the direction of such big data programmes towards the preservation of public access to healthcare as well as the distribution of ethical decision-making between independent, trustworthy institutions and individual citizens.

Trialling technologies to reduce hospital in-patient falls: an agential realist analysis.

This paper analyses the 'failure' of a patient safety intervention. Our study was part of a randomised controlled trial (RCT) of bed and bedside chair pressure sensors linked to radio pagers to prevent bedside falls in older people admitted to hospital. We use agential realism within science and technology studies to examine the fall and its prevention as a situated phenomenon of knowledge that is made and unmade through intra-actions between environment, culture, humans and technologies. We show that neither the intervention (the pressure sensor system), nor the outcome (fall prevention) could be disentangled from the broader sociomaterial context of the ward, the patients, the nurses and (especially) their work through the RCT. We argue that the RCT design, by virtue of its unacknowledged assumptions, played a part in creating the negative findings. The study also raises wider questions about the kind of subjectivities, agencies and power relations these entanglements might effect and (re)produce in the hospital ward.

Patient safety culture in care homes for older people: a scoping review.

BACKGROUND: In recent years, there has been an increasing focus on the role of safety culture in preventing incidents such as medication errors and falls. However, research and developments in safety culture has predominantly taken place in hospital settings, with relatively less attention given to establishing a safety culture in care homes. Despite safety culture being accepted as an important quality indicator across all health and social care settings, the understanding of culture within social care settings remains far less developed than within hospitals. It is therefore important that the existing evidence base is gathered and reviewed in order to understand safety culture in care homes. METHODS: A scoping review was undertaken to describe the availability of evidence related to care homes' patient safety culture, what these studies focused on, and identify any knowledge gaps within the existing literature. Included papers were each reviewed by two authors for eligibility and to draw out information relevant to the scoping review. RESULTS: Twenty-four empirical papers and one literature review were included within the scoping review. The collective evidence demonstrated that safety culture research is largely based in the USA, within Nursing Homes rather than Residential Home settings. Moreover, the scoping review revealed that empirical evidence has predominantly used quantitative measures, and therefore the deeper levels of culture have not been captured in the evidence base. CONCLUSIONS: Safety culture in care homes is a topic that has not been extensively researched. The review highlights a number of key gaps in the evidence base, which future research into safety culture in care home should attempt to address.

Market-driven production of biospecimens and the role of NHS hospital-led biobanks.

Biobanks are vital for biospecimen production in research, despite the regulatory, recruitment and commercial difficulties they face. We conducted interviews with clinicians, researchers, volunteers who recruit biobank participants, regulators and NHS managers about the integration of a biobank into an NHS hospital. We show that medical waste collected for biomedical research acquires its socio-ethical and economic value from the level of integration (both technologically and organisationally) of the biobank into the NHS hospital. There is extensive investment in a range of intellectual and commercial relationships and labour among stakeholders involved in the production of biospecimens. It is not only the boundaries of research, clinical care and commercialisation of biospecimens that blur but also those of volunteerism and citizenship. Hospital-led biobanks provide an opportunity to study the intertwining of biomedical innovation and healthcare.

Adherence to precautions for preventing the transmission of microorganisms in primary health care: a qualitative study.

BACKGROUND: Health care associated infections (HAIs) are a source of concern worldwide. No health service in any country can be considered HAI risk-free. However, there is scarcity of data on the risks to which both patients and health workers are subject in non-hospital settings. The aim of this study was to identify issues that determine the adherence of professionals to precautions for preventing transmission of microorganisms in primary health care. METHOD: This was a qualitative study, using focus groups of primary health care staff, in two Brazilian municipalities. The data were analysed using content analysis. RESULTS: Four focus groups were conducted with 20 professionals (11 community health workers, 5 nursing assistants and 4 nurses), and the analysed content was organized into four thematic categories. These categories are: low risk perception, weaknesses in knowledge, insufficient in-service training and infrastructure limitations. Participants expressed their weaknesses in knowledge of standard and transmission based precautions, mainly for hand hygiene and tuberculosis. A lack of appropriate resources and standardization in sharps disposal management was also highlighted by the participants. CONCLUSION: The study points out the need to provide in-service training for professionals on the transmission of microorganisms in primary health care to ensure adequate level of risk perception and knowledge. Further recommendations include investment to improve infrastructure to facilitate adherence to precautions and to minimize the risk of disease transmission for both patients and health care workers.

Tensions within management roles in healthcare organisations.

Aim This article reports the results of a study that gives an insight into ward leaders' perspectives of their leadership role and explores how they deliver leadership at ward level within organisational constraints and processes. Previous studies have been evaluations of clinical leadership in general, or literature reviews of the ward leader role. The aim of this study was to examine the leadership role of ward sisters and to understand how they lead improvements in quality of care on their wards. Methods A qualitative methodology was used, incorporating 19 in-depth interviews with ward leaders and modern matrons. Results Three main themes were identified: empty conformity, authority and autonomy, and visibility and leading by example. Participants aimed to be role models in leading and maintaining standards of care for patients, but this was sometimes constrained by organisational processes, lack of authority and autonomy, and lack of support and preparation. Conclusion Perceived differences between nursing and health service management mean that ward leaders' efforts to lead improvements in quality care are often undermined. Ward leaders must strike a balance between leading high-quality nursing care, in the context of organisational and political performance requirements, and the demands of administrative work, while often lacking autonomy and authority.

Dissenting from care.data: an analysis of opt-out forms.

BACKGROUND: Care.data was a programme of work led by NHS England for the extraction of patient-identifiable and coded information from general practitioner (GP) records for secondary uses. This study analyses the forms (on the websites of GP practices) which enabled patients to opt out. METHODS: Theoretical sampling and summative content analysis were used to collect and analyse dissent forms used by patients to opt out from care. DATA: Domains included basic information about the programme, types of objections and personal details required for identification purposes. RESULTS: One hundred opt-out forms were analysed. Fifty-four forms mentioned that this programme was run by NHS England. 81 forms provided two types of objections to data-sharing, and 15 provided only one objection. Only 26 forms mentioned that direct care would not be affected and 32 that patients maintain their right to opt back anytime. All but one of the opt-out forms we reviewed requested the name of the person wishing to opt out. 94 required a date of birth and 33 an NHS number. 82 required an address, 42 a telephone number and 7 an email address. CONCLUSIONS: Numbers of patients (not) opting out should be treated with caution, because the variability of information provided and the varied options for dissent may have caused confusion among patients. To ensure that dissent is in accordance with individual preferences and moral values, we recommend that well-designed information material and standardised opt-out forms be developed for such data-sharing initiatives.