Search

The executive nurse director role is complex and there is significant variation in the expectations and responsibilities placed on it. The main function of the role is to deliver the nursing agenda and ensure that safety and quality remain the focus of the executive board. However, it is unclear what evidence exists regarding the challenges and opportunities experienced by executive nurse directors. This scoping review, undertaken as part of the Stronger Study, explores the literature published from 2009 onwards on the challenges and opportunities affecting executive nurse directors' ability to deliver the nursing agenda in the UK. Findings from the review suggest that the importance attached to the executive nurse director role is not matched by the amount of research available. Strengthening the executive nurse director role requires a stronger evidence base and an awareness of the benefits of the role.

As a member of NATO, Norway supports efforts to enhance deterrence, crisis management and regional security in the North Atlantic and High North — including Scandinavia and northern Russia, as well as the waters of the Arctic Ocean, Barents Sea and North Sea. To inform ongoing strategy and policy development, Norway commissioned RAND to gather insights into other NATO Allies' perspectives on strategic opportunities and challenges in the region.

While the affordances of the digital age certainly enable more diverse students to access higher education, higher education assessment is often underpinned by notions of equality rather than equity. Drawing together key literature and data from interviews with 53 first year undergraduate students from low socio-economic status backgrounds, this chapter identifies three potential causes of assessment inequity which appear to persist into the digital age: student assessment self-efficacy, prior preparation, and external pressures. It then identifies how the affordances of modern technology can be used to help combat these challenges.

This study sought to: understand the strategic defence and security implications of climate change on UK MOD activities; develop a conceptual framework to help decision makers map a range of impacts of climate change in relation to the UK Ministry of Defence (MOD)'s strategic objectives; and produce recommendations to support the UK MOD in mitigating risks and adapting the challenges and opportunities presented by climate change.

This study challenges the traditional relationships between the UK's military, government and people. It examines the relevance of the construct for the 21st Century and what this evolving relationship means for the nature of the utility of force.

Regulation 2017/821 requires EU importers to ensure that minerals with which they work originate from responsible sources and that businesses comply with and report on supply chain due diligence obligations with special focus on so-called conflict-affected and high-risk areas (CAHRAs). This report presents the methodology proposed by RAND Europe to produce an indicative, non-exhaustive, regularly updated list of CAHRAs under Regulation 2017/821.

Compulsory distance education has always sought to be inclusive, providing educational opportunities for K-12 students unable to attend mainstream, face-to-face schools for medical, geographical, or personal reasons. However, how to effectively engage these diverse learners has remained a perpetual challenge, with a need for further investigation into the nature of student engagement with compulsory school distance contexts and how teachers can best support it. This qualitative study used focus groups (n = 2 groups, n = 16 participants) to examine teacher definitions and student engagement strategies within eKindy-12 distance education in Queensland, Australia. Categorical analysis was conducted using a priori codes for definitions, focusing on four previously established engagement types (i.e. behavioural, emotional, cognitive, and agentic engagement), and in vivo codes for strategies. Teacher definitions focused strongly on behavioural engagement, but most also contained elements of emotional and cognitive engagement; agentic engagement was only occasionally evidenced via practice descriptions. Teachers described engaging students by: building relationships, creating a safe classroom environment through differentiation, using inclusive technological tools to facilitate interaction and monitor progress, making learning fun and relevant, drawing on school-wide pedagogical frameworks and teaching strategies, and encourage self-regulation. Findings suggest distance education teachers face unique challenges around evidencing engagement and supporting student agency.

Most ex-Service personnel transition effectively into civilian life, but some face challenges that hinder a successful transition. This can lead to some individuals committing crimes and finding themselves within the criminal justice system. RAND Europe was commissioned to evaluate the Ex-Service Personnel in the CJS Programme, to understand how projects have helped reduce reoffending and provide support to ex-Service personnel in the CJS.

Data walls, used to display student data within schools, are a growing phenomenon internationally. Drawing on a conceptual model of data use, this systematic review examined 32 empirical sources from compulsory education settings to evaluate claims about the impact of data walls on teaching and learning. The review found details regarding goals for data walls and the displayed information, but there was limited evidence of how data analysis was used to guide improvement action and evaluation of impact. The review concluded that there is currently insufficient empirical research evidence to substantiate or refute claims about their educational effects.

Background Compassion is integral to professional nursing practice worldwide and a fundamental value in healthcare. Following serious care failures at a healthcare provider in the United Kingdom, a government commissioned report (the Francis Report) made several recommendations for strengthening compassion in nursing care and consequently ‘intentional rounding’ was incorporated into nursing practice in the United Kingdom. Intentional rounding is a structured process implemented primarily in the United Kingdom, North America and Australia, whereby nurses conduct 1–2 hourly checks on every patient using a standardised protocol and documentation. Objectives To examine the role of intentional rounding in the delivery of compassionate nursing care in England from multiple perspectives. Methods This paper reports qualitative findings from one phase of a realist evaluation of intentional rounding which used a mixed-methods approach. Individual, semi-structured interviews were undertaken with 33 nursing staff, 17 senior nurse managers, 34 patients and 28 family carers from three geographically spread case study hospital sites in England. Interviews elicited detailed reflections on the contexts, mechanisms and outcomes of intentional rounding and how it impacted the interviewee and those around them. Results This study found little evidence that intentional rounding ensures the comfort, safety or dignity of patients or increases the delivery of compassionate care. The systematised approach of intentional rounding emphasises transactional care delivery in the utilisation of prescribed methods of recording or tick boxes rather than relational, individualised patient care. It has the potential to reduce the scope of nursing care to a minimum standard, leading to a focus on the fundamentals as well as the prevention of adverse events. Its documentation is primarily valued by nursing staff as a means of protecting themselves through written proof or ‘evidence’ of care delivered, rather than as a means of increasing compassionate care. Conclusions This large-scale, theoretically-driven study of intentional rounding – the first of its kind – demonstrates that intentional rounding prioritises data collection through tick boxes or a prescriptive and structured recording of care. Thus, intentional rounding neither improves the delivery of compassionate nursing care nor addresses the policy imperative it was intended to target. This study raises questions about the role, contribution and outcomes from intentional rounding and suggests a need for a wider, international debate within the nursing profession about its future use. If an intervention to increase compassionate nursing care is required, it may be better to start afresh, rather than attempting to adapt the system currently implemented.

Background Clinically assisted hydration (CAH) at end of life is a contentious issue (Cabanero-Martinez et al, 2016) There is disagreement as to its benefits and this can lead to a lack of concordance between medical and nursing opinions, with nurses feeling unable to challenge doctors (Churchman, 2010; Van Der Riet, 2008; Mayashita, 2007). Prior to introducing a feasibility study on CAH (Davies, 2018) on one hospice site, an unpublished survey of nursing staff revealed widespread dissatisfaction with the standard practice of not routinely offering CAH. Following completion of the study a staff survey was undertaken to see if attitudes had changed. Aims To determine if nurses feel coerced into accepting the current hospice policy on CAH. To examine how nurses interacted with families when asked about CAH. To explore staff engagement with research on CAH. Method A semi-structured questionnaire sent to all nursing staff including HCA’s, with closed and open-ended questions. The responses were analysed using descriptive statistics and thematic analysis. Results The responses indicated that; The majority accept standard care without feeling coerced (68%). Nurses felt they could challenge accepted practice (62%). An overwhelming majority felt the hospice should be engaged in research on CAH (80%). Nursing staff expressed the following; Nurses wanted to be more involved in decision making around CAH. Many felt that a standard practice should be replaced with individual patient decisions. Staff were frequently asked about CAH and felt able to discuss the risks and benefits with families. Conclusions Overall, nurses accepted hospice standard practice on CAH and did not feel coerced. A few opposed further research, most welcomed it to establish an evidence base.

Background: There is growing attention in the UK and internationally to the representation of black and minority ethnic groups in healthcare education and the workplace. Although the NHS workforce is very diverse, ethnic minorities are unevenly spread across occupations, and considerably underrepresented in senior positions. Previous research has highlighted that this inequality also exists at junior levels with newly qualified nurses from non-White/British ethnic groups being less likely to get a job at graduation than their White/British colleagues. Although there is better national data on the scale of inequalities in the healthcare workforce, there is a gap in our understanding about the experience of job seeking, and the factors that influence disadvantage in nursing and other professions such as physiotherapy. Aim: This qualitative study seeks to fill that gap and explores the experience of student nurses (n=12) and physiotherapists (n=6) throughout their education and during the first 6-months post qualification to identify key experiences and milestones relating to successful employment particularly focusing on the perspectives from different ethnic groups. Participants: Participants were purposively sampled from one university to ensure diversity in ethnic group, age and gender. Methods: Using a phenomenological approach, in-depth semi-structured interviews were conducted at course completion and 6 months later. Results: Two main themes were identified. The ‘proactive self’ (‘It’s up to me’) theme included perceptions of employment success being due to student proactivity and resilience; qualities valued by employers. The second theme described the need to ‘fit in’ with organisational culture. Graduates described accommodating strategies where they modified aspects of their identity (clothing, cultural markers) to fit in. At one extreme, rather than fitting in, participants from minority ethnic backgrounds avoided applying to certain hospitals due to perceptions of discriminatory cultures, ‘I wouldn’t apply there ‘cos you know, it’s not really an ethnic hospital’. In contrast, some participants recognised that other graduates (usually white) did not need to change and aspects of their identity brought unsolicited rewards 'if your face fits then the barriers are reduced'. Conclusions: The findings indicate that success in getting work is perceived as determined by individual factors, and fitting in is enabled by strategies adopted by the individual rather than the workplace. Demands for change are more acute for graduates from black and minority ethnic backgrounds. This is an issue for healthcare organisations seeking to be inclusive and challenges employers and educators to acknowledge inequalities and take action to address them. Keywords: ethnicity; employability; nurses; physiotherapists; job seeking activities; equality of employment

Learning professional skills through exposure to real-world contexts demands sophisticated assessment practices. However, complex and often novel genres can be daunting for undergraduate students. This study examined student perspectives as they engaged in Portfolio assessment for the first time within a core undergraduate engineering unit. 42 students were surveyed (27%) with 11 participating in a follow-up telephone interview. Students rated content derived from their contributions to team projects as the most valuable component of their portfolio in terms of demonstrating the unit learning outcomes and developing the skills and dispositions needed in professional practice. The team structure of many learning opportunities encouraged students to collaborate and to draw on each other as instructional resources. The data indicated it is highly worthwhile for instructors to develop static resources that reduce students' need to contact instructors with trivial questions, though lecturer contact was deemed essential and effective for comprehending more complex tasks.

While online courses provide opportunities for a range of assessment tools and resources, little is known about how lecturers might best provide assessment cues to support diverse cohorts. This study explored how lecturers communicate messages about assessment expectations to first-year students in two courses at an Australian regional university (Nursing, n = 323; Engineering, n = 153), and how students accessed the assessment resources. A comparative case study methodology was used. Data included interviews with course coordinators to identify the assessment cues provided, course online content related to assessment and data recording student access of assessment resources. Diverse messaging systems were observed and verbal and written cues were abundant and embedded throughout both courses; however, not all students accessed all cues. What remains unclear is how students might bring together these cues in a productive way. Further research must explore the extent to which students can be better supported to improve their learning.

Objective Older people resident in care homes often rely on staff for support relating to their activities of daily living, including intimate care such as continence care. Managing fecal incontinence can be challenging for both residents and care staff. We conducted this review to describe the prevalence, incidence, and correlates of fecal incontinence among care home residents. Design Systematic literature review. Setting and participants Older care home residents (both nursing and residential care) aged 60 years and older. Measures We defined double incontinence as the presence of fecal plus urinary incontinence, isolated fecal incontinence as fecal incontinence with no urinary incontinence, and all fecal incontinence as anyone with fecal incontinence (whether isolated or double). The CINAHL and MEDLINE databases were searched up to December 31, 2017, to retrieve all studies reporting the prevalence and/or incidence and correlates of fecal incontinence. Results We identified 278 citations after removing duplicates, and 23 articles met the inclusion criteria. There were 12 high-quality studies, 5 medium-quality studies, and 6 low-quality studies. The medians for prevalence (as reported by the studies) of isolated fecal incontinence, double incontinence, and all fecal incontinence were 3.5% [interquartile range (IQR) = 2.8%], 47.1% (IQR = 32.1%), and 42.8% (IQR = 21.1%), respectively. The most frequently reported correlates of fecal incontinence were cognitive impairment, limited functional capacity, urinary incontinence, reduced mobility, advanced age, and diarrhea. Conclusions/Implications Fecal incontinence is prevalent among older people living in care homes. Correlates included impaired ability to undertake activities of daily living, reduced mobility, laxative use, and altered stool consistency (eg, constipation or diarrhea) which are potentially amenable to interventions to improve fecal incontinence. (C) 2019 AMDAeThe Society for Post-Acute and Long-Term Care Medicine. This is an open access articleunder the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects of interventions for treating or managing faecal incontinence (FI) in older people living in care homes; and to critically appraise and summarise current evidence on the associated resource use, costs and cost‐effectiveness. Note: we are covering treatment (interventions aiming to cure or improve symptoms) and management (interventions aiming to contain symptoms, such as pads or anal plugs, or reduce effects of symptoms, such as skin protection) of FI. Prevention of FI in those who do not currently have the symptom is beyond the scope of this review.

In December 1890, a 22-year-old woman named Gabrielle Bompard was accused of complicity in the brutal murder and robbery of a Parisian bailiff. The audacious view that Bompard had been completely unconscious of her acts was advanced by Jules Liegeois, Professor of Administrative Law at Nancy and the most outspoken disciple of the psychiatrist Hippolyte Bernheim. Liegeois expounded most volubly on the extra-medical realm of hypnosis as early as 1884 when he presented a memoir on its medico-legal implications to the Academie des Sciences Morales et Politiques before an audience of philosophers, publicists, social reformers, and medical men. The fact that the Parisians laboured to have the defendant condemned with a vehemence which matched the prosecution’s tends to suggest that moral and social issues outside the realm of medical doctrine alone influenced the position they upheld so rigidly in the courtroom.

This work analyses Albert Schweitzer's complex relationship to Africa, and places him within the context of medical missionizing. Although he worked in Africa for over fifty years, Schweitzer was strangely indifferent to the continent's culture. Unlike his fellow missionaries, he never learned native languages, and his service was primarily grounded in a Nietzschean rejection of European conventionalities and a desire to develop his unique ‘ethical personality’. Schweitzer's self-belief enabled him to create a village-hospital where the sick could come with their families for treatment and refuge, and contributed to his idea of the ‘reverence for life’, a secularized ethics of compassion and environmental protection that made him famous in the West. The village-hospital enabled him to tend the sick more effectively, but after the First World War it became more hierarchical and de-personalized. Schweitzer's missionary experiment in Lambaréné was simultaneously radical and conformist, daring and self-protectively conservative. His desire to serve was as profound as any of his clerical colleagues, but it was built, as will be seen, upon rebellious ethical foundations. Schweitzer stands out not so much for his therapeutic innovations (though these were important), as for his later formulation of a neo-Christian ecologism that assured his fame in Europe and America.

AIM: To investigate the views of senior nurse and human resource managers of strategies to retain hospital nurses in a metropolitan area.BACKGROUND: Against a global shortage, retaining nurses is a management imperative for the quality of hospital services.METHOD: Semi-structured interviews, thematically analysed.RESULTS: Metropolitan areas have many health organisations in geographical proximity, offering nurses choices in employer and employment. Senior nurse and human resource managers recognised the complexity of factors influencing nurse turnover, including those that 'pulled' nurses out of their jobs to other posts and factors that 'pushed' nurses to leave. Four themes emerged in retaining nurses: strategy and leadership, including analysis of workforce and leavers' data, remuneration, the type of nursing work and career development and the immediate work environment.CONCLUSIONS: In contexts where multiple organisations compete for nurses, addressing retention through strategic leadership is likely to be important in paying due attention and apportioning resources to effective strategies.IMPLICATIONS FOR NURSING MANAGEMENT: Aside from good human resource management practices for all, strategies tailored to different segments of the nursing workforce are likely to be important. This metropolitan study suggests attention should be paid to strategies that address remuneration, progressing nursing careers and the immediate work environment.

In order for nurses and other health care professionals to make important contributions to the literature, there must be an awareness of the many areas where unintentional ethical conflicts can arise. Leading ethical concerns include plagiarism, duplicate submission, authorship standards, bias, and conflicts of interest. Although many sources are available on the variety of ethical concerns, this article takes the position to identify the area of concern and describe why it is an ethical violation. Solutions are posed for resolving the conflict, including why medical librarians can help in the publishing process.

The value and importance of UK nursing research was given a resounding endorsement in a recent assessment of research quality, the Research Excellence Framework 2014 (REF2014). The overview report by the main panel A (MPA) of the REF2014 considered that diversity and quality of research submitted to the sub-panel unit of assessment (UOA) 3 (Allied Health Professions, Dentistry, Nursing and Pharmacy) to be strong. They concluded

OBJECTIVES: to evaluate accuracy, sensitivity, specificity and inter-rater agreement of AVPU (Alert, Voice, Pain, Unresponsive) when used by non-specialist nursing staff assessing consciousness, and to investigate users' views. METHODS: Video-recorded simulations of assessments of consciousness were developed and verified by an expert panel. Participants scored simulations using AVPU and completed questionnaires eliciting views on the scale. AVPU scores were compared with functional levels agreed by the panel. SETTING: A large urban teaching hospital. RESULTS: Fifty-one participants scored 255 simulations. Overall accuracy was 82.4% (95% CI=77.7-87.1%), sensitivity 0.94 (95% CI=0.90-0.98), specificity 0.74 (95% CI=0.66-0.82) and inter-rater agreement (un-weighted kappa) 0.782. Accuracy was low for simulations depicting an orientated patient whose eyes open to speech (49% correct) and a confused patient with spontaneous eye opening (61.5% correct). Sensitivity and agreement for levels corresponding to "Alert" and "Voice" were 0.81 (95% CI=0.69-0.93) and kappa=0.506. Participants expressed uncertainty about aspects of AVPU's use. CONCLUSIONS: AVPU had low rates of accuracy, sensitivity and agreement in distinguishing between "Alert" and "Voice", and low specificity overall, suggesting it may be unsuitable for early warning scoring. Participants expressed doubts about the use of AVPU.

Peer- and self-assessment (PASA) can lead to increased student self-regulation and achievement. However, few studies have examined the content of the feedback students in primary and secondary schools provide themselves and their peers. This study used Hattie and Timperley’s task, process, self-regulation and self feedback categories from their Review of Educational Research article ‘The power of feedback’ to (1) examine the content of a sample of naturally occurring student-written PASA comments (n = 471 utterances) and (2) explore the feasibility of using this model with student-generated feedback. Students provided primarily task feedback to both themselves and their peers, with self-regulation feedback only found in self-assessment. Students in higher grades tended to provide more task and process feedback, while giving less self feedback during self-assessment and more during peer assessment. More refinement of the model is recommended for both research and professional development purposes to better capture the quality and complexity of student-led feedback comments.

Background Co-production is defined as the voluntary or involuntary involvement of users in the design, management, delivery and/or evaluation of services. Interest in co-production as an intervention for improving healthcare quality is increasing. In the acute healthcare context, co-production is promoted as harnessing the knowledge of patients, carers and staff to make changes about which they care most. However, little is known regarding the impact of co-production on patient, staff or organisational outcomes in these settings.\ud \ud \ud Aims To identify and appraise reported outcomes of co-production as an intervention to improve quality of services in acute healthcare settings.\ud \ud \ud Design Rapid evidence synthesis.\ud \ud \ud Data sources Medline, Cinahl, Web of Science, Embase, HMIC, Cochrane Database of Systematic Reviews, SCIE, Proquest Dissertation and Theses, EThOS, OpenGrey; CoDesign; The Design Journal; Design Issues.\ud \ud \ud Study selection Studies reporting patient, staff or organisational outcomes associated with using co-production in an acute healthcare setting.\ud \ud \ud Findings 712 titles and abstracts were screened; 24 papers underwent full-text review, and 11 papers were included in the evidence synthesis. One study was a feasibility randomised controlled trial, three were process evaluations and seven used descriptive qualitative approaches. Reported outcomes related to (a) the value of patient and staff involvement in co-production processes; (b) the generation of ideas for changes to processes, practices and clinical environments; and (c) tangible service changes and impacts on patient experiences. Only one study included cost analysis; none reported an economic evaluation. No studies assessed the sustainability of any changes made.\ud \ud \ud Conclusions Despite increasing interest in and advocacy for co-production, there is a lack of rigorous evaluation in acute healthcare settings. Future studies should evaluate clinical and service outcomes as well as the cost-effectiveness of co-production relative to other forms of quality improvement. Potentially broader impacts on the values and behaviours of participants should also be considered.

Background: Nurse turnover is an issue of concern in health care systems internationally. Understanding which interventions are effective to reduce turnover rates is important to managers and health care organisations. Despite a plethora of reviews of such interventions, strength of evidence is hard to determine. Objective: We aimed to review literature on interventions to reduce turnover in nurses working in the adult health care services in developed economies. Method: We conducted an overview (systematic review of systematic reviews) using the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, Applied Social Sciences Index and Abstracts, CINAHL plus and SCOPUS and forward searching. We included reviews published between 1990 and January 2015 in English. We carried out parallel blinded selection, extraction of data and assessment of bias, using the Assessment of Multiple Systematic Reviews. We carried out a narrative synthesis. Results: Despite the large body of published reviews, only seven reviews met the inclusion criteria. These provide moderate quality review evidence, albeit from poorly controlled primary studies. They provide evidence of effect of a small number of interventions which decrease turnover or increase retention of nurses, these being preceptorship of new graduates and leadership for group cohesion. Conclusion: We highlight that a large body of reviews does not equate with a large body of high quality evidence. Agreement as to the measures and terminology to be used together with well-designed, funded primary research to provide robust evidence for nurse and human resource managers to base their nurse retention strategies on is urgently required.

INTRODUCTION: \ud \ud Intentional rounding (IR) is a structured process whereby nurses in hospitals carry out regular checks, usually hourly, with individual patients using a standardised protocol to address issues of positioning, pain, personal needs and placement of items. The widespread implementation of IR across the UK has been driven by the recommendations of the Francis Inquiry although empirical evidence of its effectiveness is poor. This paper presents a protocol of a multimethod study using a realist evaluation approach to investigate the impact and effectiveness of IR in hospital wards on the organisation, delivery and experience of care from the perspective of patients, their family members and staff.\ud \ud METHODS AND ANALYSIS: \ud \ud The study will be conducted in four phases. Phase 1: theory development using realist synthesis to generate hypotheses about what the mechanisms of IR may be, what particular groups may benefit most or least and what contextual factors might be important to its success or failure which will be tested in subsequent phases of the study. Phase 2: a national survey of all NHS acute trusts to explore how IR is implemented and supported across England. Phase 3: case studies to explore how IR is implemented 'on the ground', including individual interviews with patients, family members and staff, non-participant observation, retrieval of routinely collected patient outcomes and cost analysis. Phase 4: accumulative data analysis across the phases to scrutinise data for patterns of congruence and discordance and develop an overall evaluation of what aspects of IR work, for whom and in what circumstances.\ud \ud ETHICS AND DISSEMINATION: \ud \ud The study has been approved by NHS South East Coast-Surrey Research Ethics Committee. Findings will be published in a wide range of outputs targeted at key audiences, including patient and carer organisations, nursing staff and healthcare managers.

Realist synthesis offers a novel and innovative way to interrogate the large literature on interprofessional teamwork in health and social care teams. This article introduces realist synthesis and its approach to identifying and testing the underpinning processes (or "mechanisms") that make an intervention work, the contexts that trigger those mechanisms and their subsequent outcomes. A realist synthesis of the evidence on interprofessional teamwork is described. Thirteen mechanisms were identified in the synthesis and findings for one mechanism, called "Support and value" are presented in this paper. The evidence for the other twelve mechanisms ("collaboration and coordination", "pooling of resources", "individual learning", "role blurring", "efficient, open and equitable communication", "tactical communication", "shared responsibility and influence", "team behavioural norms", "shared responsibility and influence", "critically reviewing performance and decisions", "generating and implementing new ideas" and "leadership") are reported in a further three papers in this series. The "support and value" mechanism referred to the ways in which team members supported one another, respected other's skills and abilities and valued each other's contributions. "Support and value" was present in some, but far from all, teams and a number of contexts that explained this variation were identified. The article concludes with a discussion of the challenges and benefits of undertaking this realist synthesis.

This article is the third in a series reporting the process and findings of a realist synthesis of interprofessional teamwork in health and social care. The synthesis articulated and tested four "mechanisms" (processes) of teamwork related to communication and found variable evidence to support them. Evidence was strongest for "efficient, open and equitable communication" and "tactical communication", but lacking for the shared responsibility element of the "shared responsibility and influence" mechanism. Little evidence was found to support or oppose the mechanism, "team behavioural norms", so its status as a mechanism of interprofessional teamwork is unclear. A striking finding for all the mechanisms was the dearth of information on how they affected patient clinical outcomes and experiences.

Realist synthesis is a theory-driven approach for evaluating complex interventions using empirical evidence, which seeks an explanatory analysis of who a complex intervention works for, how, why, and in what circumstances. Interprofessional teamworking in healthcare is one such complex intervention, as teams are influenced by social and organizational factors, which makes them highly variable and context dependent. This article concludes a series of four articles that report on a realist synthesis of interprofessional teamworking. The synthesis identified 13 mechanisms that are reported in the literature to be the underlying processes through which interprofessional teamworking produces its effects. This article explores four of these mechanisms: a shared purpose; critical reflection; innovation; and leadership. These mechanisms together explain how a team sets and maintains its focus and direction. This article highlights that whilst many assumptions are made within the healthcare literature about how these mechanisms operate within teams, these assumptions are not always founded upon strong empirical evidence.

SummaryIn the early 1950s, Albert Schweitzer was a heroic figure, arguably second only to Albert Einstein in renown. Today, many have scarcely heard of him and know nothing of his work as a medical missionary in Equatorial Africa, or of his receipt of the 1952 Nobel Peace Prize. Schweitzer's genius flourished when he felt he was able to operate between cultures. Convinced that he was uniquely able to mediate between opposites, whether it was between France and Germany, Jews and Christians, or Western and Eastern spirituality, Schweitzer was a tantalising figure, hovering on the verge of what we would today call ‘cross-cultural’ dialogue. Here I will examine his intellectual and ethical trajectory, and explore how his reaction to Africa produced an early liberation that stalled due to his inability to engage deeply with Africans and their culture. As the decades passed, he was increasingly cut adrift both from Europe and from changing currents within Africa, and became strangely absorbed in Indian thought,...