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Background The unprecedented rapid re-deployment of health care workers from different care pathways into newly created and fluid COVID-19 teams provides a unique opportunity to examine the interaction of many of the established non-technical factors for successful delivery of clinical care and teamwork in healthcare settings. This research paper therefore aims to address these gaps by qualitatively exploring the impact of COVID work throughout the pandemic on permanent and deployed personnel’s experiences, their ability to effectively work together, and effect of social dynamics (e.g., cohesion, social support) on teamwork and mental health. Methods Seventy-five interviews were conducted across the UK between March and December 2021 during wave 2 and 3 of COVID-19 with 75 health care workers who were either permanent staff, or who had been rapidly deployed to Intensive Care/High Dependency Units or other COVID-19 wards, or had managed such wards. Work Life Balance was measured using the WLB Scale. Interview transcripts were qualitatively coded and thematic codes were compared using network graph modelling. Results Four thematic clusters were found, (1) Teamwork, (2) Organisational Support & Management, (3) Cohesion & Social Support, and (4) Psychological Strain. The study has three main findings. First, the importance of social factors for teamwork and mental health, whereby team identity may influence perceptions of prepareness, collaboration and communication, and impact on the collective appraisal of stressful events and work stressors. Secondly, it demonstrates the positive and negative impact of professional roles and skills on the development of teamwork and team identity. Lastly the study identifies the more pronounced negative impact of COVID work on deployed personnel’s workload, mental health and career intentions, exacerbated by reduced levels of social support during, and after, their deployment. Conclusions The thematic analysis using graph modelling was able to highlight the interactive and interdependent role of social dynamics on teamwork, suggesting that besides technical skills and preparedness, group membership and perception of professional category may play a bigger role for teamwork than previously stated. It also highlights the potentially protective impact of team-membership on participants experience of their pandemic work, especially in light of the length of the recent pandemic.

Contains fulltext : 291657.pdf (Publisher’s version ) (Open Access) BACKGROUND: Anti-TNF drugs, such as infliximab, are associated with attenuated antibody responses after SARS-CoV-2 vaccination. We aimed to determine how the anti-TNF drug infliximab and the anti-integrin drug vedolizumab affect vaccine-induced neutralising antibodies against highly transmissible omicron (B.1.1.529) BA.1, and BA.4 and BA.5 (hereafter BA.4/5) SARS-CoV-2 variants, which possess the ability to evade host immunity and, together with emerging sublineages, are now the dominating variants causing current waves of infection. METHODS: CLARITY IBD is a prospective, multicentre, observational cohort study investigating the effect of infliximab and vedolizumab on SARS-CoV-2 infection and vaccination in patients with inflammatory bowel disease (IBD). Patients aged 5 years and older with a diagnosis of IBD and being treated with infliximab or vedolizumab for 6 weeks or longer were recruited from infusion units at 92 hospitals in the UK. In this analysis, we included participants who had received uninterrupted biological therapy since recruitment and without a previous SARS-CoV-2 infection. The primary outcome was neutralising antibody responses against SARS-CoV-2 wild-type and omicron subvariants BA.1 and BA.4/5 after three doses of SARS-CoV-2 vaccine. We constructed Cox proportional hazards models to investigate the risk of breakthrough infection in relation to neutralising antibody titres. The study is registered with the ISRCTN registry, ISRCTN45176516, and is closed to accrual. FINDINGS: Between Sept 22 and Dec 23, 2020, 7224 patients with IBD were recruited to the CLARITY IBD study, of whom 1288 had no previous SARS-CoV-2 infection after three doses of SARS-CoV-2 vaccine and were established on either infliximab (n=871) or vedolizumab (n=417) and included in this study (median age was 46·1 years [IQR 33·6-58·2], 610 [47·4%] were female, 671 [52·1%] were male, 1209 [93·9%] were White, and 46 [3·6%] were Asian). After three doses of SARS-CoV-2 vaccine, 50% neutralising titres (NT50s) were significantly lower in patients treated with infliximab than in those treated with vedolizumab, against wild-type (geometric mean 2062 [95% CI 1720-2473] vs 3440 [2939-4026]; p

Objectives: Qualitative studies can improve understanding of patient safety culture (PSC), which has been relatively neglected by researchers in the Gulf Cooperation Council context. This study employed a qualitative approach to explore healthcare staff and patients’ perceptions of PSC and how it can be improved. Methods: This qualitative study was conducted in a public hospital in Kuwait. Individual face-to-face interviews were used to understand the experience of healthcare staff and patients concerning PSC. After obtaining the required ethical approvals, maximum variation sampling was used. Interviews were recorded and transcribed. The analysis was inductive and thematic. Results: A total of 51 participants were included in this study (35 healthcare professionals and 16 patients). Data analysis revealed four overarching themes relevant to the research question: (1) workload; (2) communication; (3) environmental constraints; and (4) incident reporting. These issues were interrelated in practice. Kuwaiti and non-Kuwaiti participants held different views, particularly about the response to errors and expatriate staff members’ clinical skills. Conclusion: This study revealed multiple factors related to workload, communication, healthcare environment and incident reporting, which hindered the promotion of positive PSC in the included department. The presence of numerous constraints suggests that multiple interventions which target both individual and organisational levels should be implemented. KEYWORDS Health Services Research; Patient Safety; Safety Culture; Kuwait.

Objective: There is a wide range of strategies that could help in minimizing medication errors during healthcare delivery. We undertook a qualitative study to identify recommended solutions to minimize medication errors in an adult oncology department in Saudi Arabia from the perspectives of healthcare professionals. Methods: This was a qualitative study conducted in an adult oncology department in Saudi Arabia. After obtaining the required ethical approvals and written consents from the participants, seven focus group discussions were carried out for data collection. A stratified purposive sampling strategy was used to recruit medical doctors, pharmacists, and nurses. NVivo Pro version 11 was used for data analyses. Inductive content analysis was adopted in the coding of collected data. Result: Our study showed that improving organizational support, staff education, and communication could help in minimizing medication errors in the adult oncology department. Conclusion: The adoption of multiple strategies is required to improve the safety of the medication process in the adult oncology department. We argue that the availability of supportive leadership should be prioritized as it plays a crucial role in determining the effectiveness and efficiency of both staff education and communication. Keywords: Medication errors, Adult Oncology, Saudi Arabia, Solutions, Qualitative study

Background Ambulance services have a vital role in the shift towards the delivery of health care outside hospitals, when this is better for patients, by offering alternatives to transfer to the emergency department. The introduction of information technology in ambulance services to electronically capture, interpret, store and transfer patient data can support out-of-hospital care. Objective We aimed to understand how electronic health records can be most effectively implemented in a pre-hospital context in order to support a safe and effective shift from acute to community-based care, and how their potential benefits can be maximised. Design and setting We carried out a study using multiple methods and with four work packages: (1) a rapid literature review; (2) a telephone survey of all 13 freestanding UK ambulance services; (3) detailed case studies examining electronic health record use through qualitative methods and analysis of routine data in four selected sites consisting of UK ambulance services and their associated health economies; and (4) a knowledge-sharing workshop. Results We found limited literature on electronic health records. Only half of the UK ambulance services had electronic health records in use at the time of data collection, with considerable variation in hardware and software and some reversion to use of paper records as services transitioned between systems. The case studies found that the ambulance services’ electronic health records were in a state of change. Not all patient contacts resulted in the generation of electronic health records. Ambulance clinicians were dealing with partial or unclear information, which may not fit comfortably with the electronic health records. Ambulance clinicians continued to use indirect data input approaches (such as first writing on a glove) even when using electronic health records. The primary function of electronic health records in all services seemed to be as a store for patient data. There was, as yet, limited evidence of electronic health records’ full potential being realised to transfer information, support decision-making or change patient care. Limitations Limitations included the difficulty of obtaining sets of matching routine data for analysis, difficulties of attributing any change in practice to electronic health records within a complex system and the rapidly changing environment, which means that some of our observations may no longer reflect reality. Conclusions Realising all the benefits of electronic health records requires engagement with other parts of the local health economy and dealing with variations between providers and the challenges of interoperability. Clinicians and data managers, and those working in different parts of the health economy, are likely to want very different things from a data set and need to be presented with only the information that they need. Future work There is scope for future work analysing ambulance service routine data sets, qualitative work to examine transfer of information at the emergency department and patients’ perspectives on record-keeping, and to develop and evaluate feedback to clinicians based on patient records. Study registration This study is registered as Health and Care Research Wales Clinical Research Portfolio 34166. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 10. See the NIHR Journals Library website for further project information.

Background:\ud An understanding of stakeholders’ views is key to the successful development and operation of a rural trauma system. Scotland, which has large remote and rural areas, is currently implementing a national trauma system. The aim of this study was to identify key barriers and enablers to the development of an effective trauma system from the perspective of rural healthcare professionals.\ud \ud Methods:\ud This is a qualitative study, which was conducted in rural general hospitals (RGH) in Scotland, from April to June 2017. We used an opportunistic sampling strategy to include hospital providers of rural trauma care across the region. Semi-structured interviews were conducted, recorded, and transcribed. Thematic analysis was used to identify and group participant perspectives on key barriers and enablers to the development of the new trauma system.\ud \ud Results:\ud We conducted 15 interviews with 18 participants in six RGHs. Study participants described barriers and enablers across three themes: 1) quality of care, 2) interfaces within the system and 3) interfaces with the wider healthcare system. For quality of care, enablers included confidence in basic trauma management, whilst a perceived lack of change from current management was seen as a barrier. The theme of interfaces within the system identified good interaction with other services and a single point of contact for referral as enablers. Perceived barriers included challenges in referring to tertiary care. The final theme of interfaces with the wider healthcare system included an improved transport system, increased audit resource and coordinated clinical training as enablers. Perceived barriers included a rural staffing crisis and problematic patient transfer to further care.\ud \ud Conclusions:\ud This study provides insight into rural professionals’ perceptions regarding the implementation of a trauma system in rural Scotland. Barriers included practical issues, such as retrieval, transfer and referral processes. Importantly, there is a degree of uncertainty, discontent and disengagement towards trauma system development, and concerns regarding staffing levels and governance. These issues are unlikely to be unique to Scotland and warrant further study to inform service planning and the effective delivery of rural trauma systems.

This review aimed to identify methodological aspects of qualitative studies conducted to assess patient safety culture (PSC) in hospital settings. Searches of Google Scholar (Google LLC, Menlo Park, California, USA), MEDLINE® (National Library of Medicine, Bethesda, Maryland, USA), EMBASE (Elsevier, Amsterdam, Netherlands), PsycINFO (American Psychological Association, Washington, District of Columbia, USA) and Web of Science (Clarivate Analytics, Philadelphia, Pennsylvania, USA) databases were used to identify qualitative articles published between 2000 and 2017 that focused on PSC. A total of 22 studies were included in this review and analysis of methodological approaches showed that most researchers adopted purposive sampling, individual interviews, inductive content and thematic analysis. PSC was affected by factors related to staffing, communication, nonhuman resources, organisation and patient-related factors. Most studies lacked theoretical frameworks. However, many commonalities were found across studies. Therefore, it is recommended that future studies adopt a mixed methods approach to gain a better understanding of PSC.Keywords: Patient Safety; Culture; Needs Assessment; Qualitative Research.

BACKGROUND: Acute medical units (AMUs) receive the majority of acute medical patients presenting to hospital as an emergency in the United Kingdom (UK) and in other international settings. They have emerged as a result of local service innovation in the context of a limited evidence base. As such, the AMU model is not well characterised in terms of its boundaries, patient populations and components of care. This makes service optimisation and development through strategic resource planning, quality improvement and research challenging.AIM: This study aims to evaluate a national set of AMUs with the intent of characterising the AMU model.METHODS: Twenty-nine AMUs in Scotland were identified. Data were collected by semi-structured interviews with multidisciplinary healthcare professionals working in each AMU. A draft report was produced for each unit and verified by a unit representative. The unit reports were then analysed to develop a conceptual framework of key components of AMUs and a service definition of the boundaries of acute medical care.RESULTS: Acute medical care in Scotland can be described as being delivered in "acute medical services" rather than geographically distinct AMUs. Twelve key components of AMU care were identified: care areas, functions, populations, patient flow, support services, communication, nurse care, allied healthcare professional care, non-consultant medical care, consultant care, patient assessment and specialty care.DISCUSSION: This empirically derived characterisation of the AMU model is likely to be of utility to practitioners, managers, policy makers and researchers: it is relevant on an operational level, will aid quality improvement and is a foundation to needed further research into how best to deliver care in AMUs. This is important given the central role AMUs play in the journey of the majority of patients presenting to hospital acutely in Scotland, the UK and internationally.

Objective: Adverse events which result from medication errors are considered to be one of the most frequently encountered patient safety issues in clinical settings. We undertook a qualitative investigation to identify and explore factors relating to medication error in an adult oncology department in Saudi Arabia from the perspective of healthcare professionals. Methods: This was a qualitative study conducted in an adult oncology department in Saudi Arabia. After obtaining required ethical approvals and written consents from the participants, semi-structured interviews and focus group discussions were carried out for data collection. A stratified purposive sampling strategy was used to recruit medical doctors, pharmacists, and nurses. NVivo Pro version 11 was used for data analyses. Inductive thematic analysis was adopted in the primary coding of data while secondary coding of data was carried out deductively applying the Hospital Survey of Patient Safety Culture (HSOPSC) framework. Result: The total number of participants were 38. Majority of the participants were nurses (n = 24), females (n = 30), and not of Saudi nationality (n = 31) with an average age of 36 years old. Causes of medication errors were categorized into 6 themes. These causes were related teamwork across units, staffing, handover of medication related information, accepted behavioural norms, frequency of events reported, and non-punitive response to error. Conclusion: There were numerous causes for medication errors in the adult oncology department. This means substantive improvement in medication safety is likely to require multiple, inter-relating, complex interventions. More research should be conducted to examine context-specific interventions that may have the potential to improve medication safety in this and similar departments. Keywords: Medication errors, Adult oncology, Saudi Arabia, Healthcare professionals, Qualitative study

Aim Electronic Records in Ambulances (ERA) is a two-year study examining the opportunities and challenges of prehospital implementation of electronic patient clinical records (ePCR) in the UK. National policy encourages digitisation of health services, 1 but this transition may not be straightforward. 2 Method A telephone survey of progress implementing ePCR in all 13 UK ambulance services explored systems, implementation processes, perceived value and future plans. Interviews with information managers were thematically analysed. Case studies in four UK ambulance services involved observing clinical work, focus groups with ambulance clinicians, interviews with key stakeholders and analysis of routine data. Results Baseline survey: 7/13 services were using ePCR, with mixed compliance from staff. Reported benefits concerned improved data access for audit. Of the 6/13 services currently using paper records, four had previously adopted ePCR, but reverted. Case studies: Initial findings suggest some common themes: Constant change: 3/4 services were already undertaking or considering transition to a second generation system; 1/4 was undertaking a phased rollout of ePCR. Digital diversity: no standard hardware or software in use. Indirect input: patient data was still sometimes transferred to the ePCR from another source (eg writing on a glove) or entered retrospectively. Data dump: ePCRs acted mainly as a store, rather than transferring information to other care providers or supporting decision making. Conclusion Although ePCRs offer opportunities to support prehospital care, the transition to the new technology is neither linear nor co-ordinated, with full benefits not yet realised in terms of integration and data sharing. References . Wachter RM. Making IT work: Harnessing the power of health information technology to improve care in England 2016. Report of the National Advisory Group on Health Information Technology in England. . Greenhalgh, Potts H, Wong G, Bark P, Swinglehurst D. Tensions and paradoxes in electronic patient record research: A systematic literature review using the meta-narrative method. Milbank Quarterly2009;87(4):729–788. Conflict of interest None Funding UK National Institute for Health Research.

الملخص: أهداف البحث: يعتبر خلق ثقافة سلامة المرضى الإيجابية أساسا لتحسين نتائج سلامة المرضى. تهدف هذه الدراسة لإجراء التقييم الأول لثقافة سلامة المرضى في محيط الرعاية الثانوية في الكويت. طرق البحث: أجريت هده الدراسة الاستطلاعية –المقطعية في القسم الطبي في مستشفى عام في الكويت باستخدام مسح لثقافة سلامة المرضى في المستشفى. وتم عمل تحليل الانحدار الخطي المتعدد لتحديد توقعات ثقافة سلامة المرضى. تم استخدام كلا من اختبار أنوفا وكروسكال واليس لتقييم الاختلافات بين مجموع الدرجات والدرجات التي تم تحقيقها في كل بُعدٍ حسب ترتيب الجنسيات. النتائج: تم استلام ١٠٠٨ استبانة مكتملة، بمعدل استجابة ٧٥.٢٪. وجدنا ثلاثة أبعاد لثقافة سلامة المرضى لتكون مجالات ذات أولوية للتحسين: استجابة غير- عقابية للأخطاء، والتوظيف، وانفتاح التواصل. تم تحديد العمل الجماعي داخل الوحدات والتعليم التنظيمي مع التحسين المستمر كمجالات للقوة. كان لدى الذين استجابوا من الكويت⁄ دول الخليج إيجابية أقل لثقافة سلامة المرضى بالمقارنة بالمستجيبين الآسيويين. وأظهر تحليل الانحدار للمستجيبين أن” بلد المنشأ “، والمهنة، والعمر والحضور لدورات ⁄ محاضرات ثقافة سلامة المرضى كانت مرتبطة ارتباطا كبيرا لإدراك ثقافة سلامة المرضى. الاستنتاجات: أظهرت هذه الدراسة أن سلامة المرضى ينظر إليها بشكل مختلف بين الطاقم الطبي من مختلف بلدان المنشأ، والمجموعات المهنية، والفئات العمرية. يجب الإقرار بهذه المتغيرات ومعالجتها عند تخطيط وتقييم مبادرات سلامة المرضى. Abstract: Objectives: To improve patient safety outcomes, it is considered essential to create a positive culture of patient safety. This study carried out an initial evaluation of the patient safety culture in a secondary care setting in Kuwait. Methods: This cross-sectional questionnaire study was conducted in a general hospital medical department in Kuwait, using the Hospital Survey on Patient Safety Culture (HSPSC). Multiple linear regression analyses were used to identify patient safety culture predictors. Both an ANOVA and a Kruskal Wallis test were carried out to assess the differences between participants' total scores and the scores they achieved in each dimension, categorized by nationality. Results: A total of 1008 completed questionnaires were received, yielding a response rate of 75.2%. Three dimensions of patient safety culture were found to be priority areas for improvement: non-punitive responses to errors, staffing, and communication openness. Teamwork within units and organizational learning with continuous improvement were identified as areas of strength. Respondents from Kuwait and the Gulf State countries had a less positive perception of the hospital's patient safety culture than did Asian respondents. A regression analysis showed that the respondents' countries of origin, professions, age, and patient safety course/lecture attendance were significantly correlated with their perceptions of the hospital's patient safety culture. Conclusion: This study demonstrates that patient safety is perceived differently by medical staff members from different countries of origin, professional groups, and age groups. These variables must be acknowledged and addressed when planning or evaluating patient safety initiatives. الكلمات المفتاحية: بلد المنشأ, الكويت, الخدمات الطبية, ثقافة سلامة المرضى, Keywords: Country of origin, Kuwait, Medical services, Patient safety culture

Objective To understand the evolving market of commercial off-the-shelf Computerized Physician Order Entry (CPOE) and Computerized Decision Support (CDS) applications and its effects on their uptake and implementation in English hospitals. Methods Although CPOE and CDS vendors have been quick to enter the English market, uptake has been slow and uneven. To investigate this, the authors undertook qualitative ethnography of vendors and adopters of hospital CPOE/CDS systems in England. The authors collected data from semi-structured interviews with 11 individuals from 4 vendors, including the 2 most entrenched suppliers, and 6 adopter hospitals, and 21 h of ethnographic observation of 2 user groups, and 1 vendor event. The research and analysis was informed by insights from studies of the evolution of technology fields and the emergence of generic COTS enterprise solutions. Results Four key themes emerged: (1) adoption of systems that had been developed outside of England, (2) vendors’ configuration and customization strategies, (3) localized adopter practices vs generic systems, and (4) unrealistic adopter demands. Evidence for our over-arching finding concerning the current immaturity of the market was derived from vendors’ strategies, adopters’ reactions to the technology, and policy makers’ incomplete insights. Conclusions The CPOE/CDS market in England is still in an emergent phase. The rapid entrance of diverse products, triggered by federal policy initiatives, has resulted in premature adoption of systems that do not yet adequately meet the needs of hospitals. Vendors and adopters lacked understanding of how to design and implement generic solutions to meet diverse user needs.

The majority of medical patients presenting to hospital in the UK are cared for in acute medical units (AMUs). Such units are also increasingly present internationally. Care delivery varies across units: this review aims to examine the evidence for how best to deliver AMU care.\ud \ud Six electronic databases and grey literature were searched. Inclusion criteria comprised interventions applied to undifferentiated patients in AMU settings. All studies were quality assessed. A narrative approach was undertaken.\ud \ud Nine studies, all conducted in the UK or Ireland, evaluated 1.3 million episodes, 3617 patients and 49 staff. There was single study evidence for beneficial effects of: enhanced pharmacy care, a dedicated occupational therapy service, an all-inclusive consultant work pattern, a rapid-access medical clinic and formalized handovers. Two studies found increased consultant presence was associated with reduced mortality; one of these studies found an association with a reduction in 28-day readmissions; and the other found an association with an increased proportion of patients discharged on the day they were admitted. Three studies provide evidence of the beneficial effects of multiple interventions developed from local service reviews.\ud \ud Overall, the quality of the evidence was limited. This review has identified operationally relevant evidence that increased consultant presence is associated with improved outcomes of care; has highlighted the potential to improve outcomes locally through service reviews; and has demonstrated an important knowledge gap of how best to deliver AMU care. These findings have importance given the challenges acute services currently face.

The UK National Health Service is making major efforts to implement Hospital Electronic Prescribing and Medicine Administration (HEPMA) to improve patient safety and quality of care. Substantial public investments have attracted a wide range of UK and overseas suppliers offering Commercial-Off –The-Shelf (COTS) solutions. A lack of (UK) implementation experience and weak supplier-user relationships are reflected in systems with limited configurability, poorly matched to the needs and practices of English hospitals. This situation echoes the history of comparable corporate information infrastructures - Enterprise Resource Planning systems - in the 1980s/1990s. UK government intervention prompted a similar swarming of immature, often unfinished, products into the market. This resulted, in both cases, in protracted and difficult implementation processes as vendors and adopters struggled to get the systems to work and match the circumstances of the adopting organisations. An analysis of the influence of the Installed Base on Information Infrastructures should explore how the evolution of COTS solutions is conditioned by the structure of adopter and vendor ‘communities’.

Background Although the collection of patient ethnicity data is a requirement of publicly funded healthcare providers in the UK, recording of ethnicity is sub-optimal for reasons that remain poorly understood.Aims and objectives We sought to understand enablers and barriers to the collection and utilisation of ethnicity data within electronic health records, how these practices have developed and what benefit this information provides to different stakeholder groups.Methods We undertook an in-depth, qualitative case study drawing on interviews and documents obtained from participants working as academics, managers and administrators within the UK.Results Information regarding patient ethnicity was collected and coded as administrative patient data, and/or in narrative form within clinical records. We identified disparities in the classification of ethnicity, approaches to coding and levels of completeness due to differing local, regional and national policies and processes. Most participants could not identify any clinical value of ethnicity information and many did not know if and when data were shared between services or used to support quality of care and research.Conclusions Findings highlighted substantial variations in data classification, and practical challenges in data collection and usage that undermine the integrity of data collected. Future work needs to focus on explaining the uses of these data to frontline clinicians, identifying resources that can support busy professionals to collect standardised data and then, once collected, maximising the utility of these data.

BackgroundThe introduction of information technology (IT) in emergency ambulance services to electronically capture, interpret and store patient data can support out of hospital care. Although electronic health records (EHR) in ambulances and other digital technology are encouraged by national policy across the UK, there is considerable variation across services in terms of implementation. We aimed to understand how electronic records can be most effectively implemented in a pre-hospital context, in order to support a safe and effective shift from acute to community-based care.MethodsWe conducted a mixed-methods study with four work packages (WPs): a rapid literature review, a telephone survey of all 13 freestanding UK ambulance services, detailed case studies in four selected sites, and a knowledge sharing workshop.ResultsWe found considerable variation in hardware and software. Services were in a state of constant change, with services transitioning from one system to another, reverting to paper, or upgrading. Ambulance clinicians were dealing with partial or unclear information, which may not fit comfortably with the EHR. Clinicians continued to use indirect data input approaches such as first writing on a glove. The primary function of EHR in all services seemed to be as a store for patient data. There was, as yet, limited evidence of their full potential being realised to transfer information, support decision making or change patient care.ConclusionsRealising the full benefits of EHR requires engagement with other parts of the local health economy, dealing with the challenges of interoperability. Clinicians and data managers are likely to want very different things from a data set, and need to be presented with only the information that they need.

BackgroundThe roll-out of electronic Patient Clinical Records (ePCR) across UK ambulance services has been an important aspect of modernisation. Electronic Records in Ambulances (ERA) is a two-year study which aims to describe the opportunities and challenges of implementing ePCR and associated technology in emergency ambulances.Our study includes a baseline survey of progress implementing ePCR in all UK ambulance services providing a snapshot of current usage.MethodsWe carried out semi-structured telephone interviews with information managers in each ambulance service in the UK. We asked them about the systems in use, the process and current stage of implementation and explored the perceived value of using ePCR. If services did not use ePCR we asked about plans for future introduction.The interviews were transcribed and thematically analysed, by three members of the research team.ResultsWe completed interviews with 22 managers from 13 services. Implementation varied across the UK. Seven services were using electronic records. Four services had adopted electronic records but, at the time of interview, had reverted to paper with the intention of implementing a new ePCR. Two services still used paper but hoped to move to ePCR in the future. Those who had fully implemented ePCR reported mixed success in terms of staff compliance, and in realising the potential benefits offered by ePCR to link with primary and secondary care.Reported benefits of ePCR were largely associated with improved data management for audit and record keeping. Potential improvements to patient care were discussed, but tended to be associated with future planned developments.ImplicationsImplementation of ePCR has proved challenging with wide variation in use between ambulance services. Progress has been erratic, rather than linear, demonstrated by difficulties that services experienced putting ePCR into practice. There is potential for ambulance services in the earlier stages of implementation to learn from the experiences of others.

Objective: \ud We aimed to explore stakeholder views, attitudes, needs, and expectations regarding likely benefits and risks resulting from increased structuring and coding of clinical information within electronic health records (EHRs).\ud \ud Materials and methods: \ud Qualitative investigation in primary and secondary care and research settings throughout the UK. Data were derived from interviews, expert discussion groups, observations, and relevant documents. Participants (n=70) included patients, healthcare professionals, health service commissioners, policy makers, managers, administrators, systems developers, researchers, and academics.\ud \ud Results: \ud Four main themes arose from our data: variations in documentation practice; patient care benefits; secondary uses of information; and informing and involving patients. We observed a lack of guidelines, co-ordination, and dissemination of best practice relating to the design and use of information structures. While we identified immediate benefits for direct care and secondary analysis, many healthcare professionals did not see the relevance of structured and/or coded data to clinical practice. The potential for structured information to increase patient understanding of their diagnosis and treatment contrasted with concerns regarding the appropriateness of coded information for patients.\ud \ud Conclusions: \ud The design and development of EHRs requires the capture of narrative information to reflect patient/clinician communication and computable data for administration and research purposes. Increased structuring and/or coding of EHRs therefore offers both benefits and risks. Documentation standards within clinical guidelines are likely to encourage comprehensive, accurate processing of data. As data structures may impact upon clinician/patient interactions, new models of documentation may be necessary if EHRs are to be read and authored by patients.

Hospital electronic prescribing (or ePrescribing) systems have the potential to reduce drug-related morbidity and mortality. However, their implementation and adoption has been slow to date, despite the considerable service interest in implementing systems and the long-standing policy drive towards computerization. The underlying reasons may include the demise of the National Programme for Information Technology; a lack of change management expertise and capacity in the National Health Service (NHS); the relatively immature and fragmented market; limited standards guiding procurement, functional specifications and expected benefits; and lack of resources.

Purpose:\ud To evaluate the evidence for the effectiveness of acute medical units (AMUs) compared with other models of care and compare the components of AMU models.\ud \ud Data sources:\ud Six electronic databases and grey literature sources searched between 1990 and 2014.\ud \ud Study selection:\ud Studies reporting on AMUs as an intervention for unplanned medical presentations to hospital with the inclusion of all outcome measures/study designs/comparators.\ud \ud Data extraction:\ud Data on study characteristics/outcomes/AMU components were extracted by one author and confirmed by a second.\ud \ud Data synthesis:\ud Seventeen studies of 12 AMUs across five countries were included. The AMU model was associated with a reduction in-hospital length of stay (LOS) in all analyses ranging from 0.3 to 2.6 days; and a reduction in mortality in 12 of the 14 analyses with the change ranging from a 0.1% increase to a 8.8% reduction. Evidence relating to readmissions and patient/staff satisfaction was less conclusive. There was variation in the following components of AMUs: admission criteria, entry sources, functions and consultant work patterns.\ud \ud Conclusion:\ud This review provides evidence that AMUs are associated with reductions in-hospital LOS and, less convincingly, mortality compared with other models of care when implemented in European and Australasian settings. Reported estimates may be affected by residual confounding. This review reports heterogeneity in components of the AMU model. Further work to identify what constitutes the key components of an AMU is needed to improve the quality and effectiveness of acute medical care. This is of particular importance given the escalating demand on acute services.

Background Patient histories in electronic health records currently exist mainly in free text format thereby limiting the possibility that decision support technology may contribute to the accuracy and timeliness of clinical diagnoses. Structuring and/or coding make patient histories potentially computable. Methods A systematic review was undertaken of the benefits and risks of structuring and/or coding patient history by searching nine international databases for published and unpublished studies over the period 1990–2010. The focus was on the current patient history, defined as information reported by a patient or the patient's caregiver about the patient's present health situation and health status. Findings were synthesised through a theoretically based textural analysis. Findings Of the 9207 potentially eligible papers identified, 10 studies satisfied the eligibility criteria. There was evidence of a modest number of benefits associated with structuring the current patient history, including obtaining more complete clinical histories, improved accuracy of patient self-documented histories, and better associated decision-making by professionals. However, no studies demonstrated any resulting improvements in patient care or outcomes. When more detailed records were obtained through the use of a structured format no attempt was made to confirm if this additional information was clinically useful. No studies investigated possible risks associated with structuring the patient history. No studies examined coding of the patient history. Conclusions There is an insufficient evidence base for sound policy making on the benefits and risks of structuring and/or coding patient history. The authors suggest this field of enquiry warrants further investigation given the interest in use of decision support technology to aid diagnoses.

Background The absence of meaningful end user engagement has repeatedly been highlighted as a key factor contributing to 'failed' implementations of electronic health records (EHRs), but achieving this is particularly challenging in the context of national scale initiatives. In 2002, the National Health Service (NHS) embarked on a so-called 'top-down' national implementation strategy aimed at introducing commercial, centrally procured, EHRs into hospitals throughout England. Objective We aimed to examine approaches to, and experiences of, user engagement in the context of a large-scale EHR implementation across purposefully selected hospital care providers implementing early versions of nationally procured software. Methods We conducted a qualitative, case-study based, socio-technically informed, longitudinal investigation, purposefully sampling and collecting data from four hospitals. Our data comprised a total of 123 semi-structured interviews with users and managers, 15 interviews with additional stakeholders, 43 hours of non-participant observations of meetings and system use, and relevant organisation- specific documents from each case study site. Analysis was thematic, building on an existing model of user engagement that was originally developed in the context of studying the implementation of relatively simple technologies in commercial settings. NVivo8 software was used to facilitate coding. Results Despite an enduring commitment to the vision of shared EHRs and an appreciation of their potential benefits, meaningful end user engagement was never achieved. Hospital staff were not consulted in systems choice, leading to frustration; they were then further alienated by the implementation of systems that they perceived as inadequately customised. Various efforts to achieve local engagement were attempted, but these were in effect risk mitigation strategies. We found the role of clinical champions to be important in these engagement efforts, but progress was hampered by the hierarchical structures within healthcare teams. As a result, engagement efforts focused mainly on clinical staff with inadequate consideration of management and administrative staff. Conclusions This work has allowed us to further develop an existing model of user engagement from the commercial sector and adapt it to inform user engagement in the context of large-scale eHealth implementations. By identifying key points of possible engagement, disengagement and re-engagement, this model will we hope both help those planning similar large-scale EHR implementation efforts and act as a much needed catalyst to further research in this neglected field of enquiry.

Purpose – The paper aims to present and discuss research into the relationship between influencing behaviour and impact, including gender and seniority differences.Design/methodology/approach – The paper builds on previous articles considering influencing behaviour in the workplace. These articles present a model of interpersonal influence and describe how individual influencing behaviour varies in different contexts. They identified the need for further investigation into the effectiveness of such behaviours in those contexts. This research utilises 360‐degree performance assessments as an indicator of the “effectiveness” or impact of workplace influencing behaviours.Findings – The findings extend previous work supporting the idea that there are few, if any, influencing behaviours that apply to all situations and highlight the role of expectancies in work place assessments of influencing behaviours.Research limitations/implications – The research highlights ways in which the relationship between influenc...

PurposeThis article aims to present some further research findings that explore the relationship between influencing behaviour and team role behaviour.Design/methodology/approachThe research is based upon data collected by the authors during training and development activities that they carried out and/or were involved in.FindingsThe main conclusion is specifically related to the revised model of team roles put forward by Manning et al. This was developed in response to perceived limitations in Belbin's original formulation of team role theory. It builds on and develops the idea that there is a significant social dimension to team roles.Originality/valueThe research is based upon data collected by the authors during training and development activities that they carried out and/or were involved in. Information collected comes from a work‐based sample of men and women, at all organizational levels, in a variety of mainly public sector organizations in the UK.

PurposeThe purpose of this paper is to present findings, and discuss the relevance of those findings, with regard to research undertaken about interpersonal influence in the workplace.Design/methodology/approachThis paper is the second part of a three‐part paper considering influencing behaviour in the workplace, the ways in which people at work go about getting their way with others. This part of the paper is divided into two main sections. The first section presents the research findings. The second section discusses the relevance of the findings. In particular, it considers how the observed relationships may provide guidelines for action, suggesting the circumstances in which particular influencing strategies and styles may be appropriate and inappropriate.FindingsThe findings support the idea that influencing behaviour is related to the characteristics of the person, their work role and their orientation to that work role.Research limitations/implicationsThere is clearly a need for further research. For example, the findings presented in this paper tell us nothing about whether patterns of influencing behaviour are actually effective in particular contexts. This raises further questions about how we might assess “effectiveness”. One possible approach is to look at the relationship between behaviour and assessments of effectiveness by other people, including 360 degree assessments. This approach has the merit of being consistent with the model of interpersonal influence described in the paper, that includes explicit reference to expectancies and has feedback loops between behaviour, responses and expectancies.Originality/valueThis paper is of value in presenting research findings that shine light on the nature of the relationship between influencing behaviour and both personality and contextual variables.

PurposeThe purpose of this paper is to model the relationship between influencing behaviour, personality traits, work roles and role orientation. It builds on previous research into team roles, highlighting the relationship between influencing behaviour and team role behaviour.Design/methodology/approachStatistical analysis on questionnaire data from a mixed, work‐based, UK sample is used to assess relationships between influencing behaviour, role expectations, role orientation and team role behaviour.FindingsThe paper argues that team roles access different types of power and influencing behaviours depending on role and role orientation. Findings establish a link between influencing behaviour and team role behaviour, as well as personality traits, developing the idea that there is a significant social dimension to team roles.Research limitations/implicationsThe research does not consider specific influence attempts, nor does it present evidence regarding the effectiveness of patterns of influencing behaviour in particular contexts.Practical implicationsThe paper highlights the relationship between influencing behaviour and personality and contextual variables. Considering “when” different strategies and styles are used may offer guidelines for action. Findings reinforce the significance of the social dimension of team roles and indicate a need for further research to consider the success of influencing behaviour in different contexts.Originality/valuePrevious research into influencing behaviour has focused on its relationship to either situational variables or personality traits and, where personality variable have been studied, they have been specific traits. This research considers both sets of variables simultaneously and covers the whole personality domain. This is the first study of the relationship between team role behaviour and influencing behaviour.

INTRODUCTION:Increasingly, ambulance services offer alternatives to transfer to the emergency department (ED), when this is better for patients. The introduction of electronic health records (EHR) in ambulance services is encouraged by national policy across the United Kingdom (UK) but roll-out has been variable and complex.Electronic Records in Ambulances (ERA) is a two-year study which aims to investigate and describe the opportunities and challenges of implementing EHR and associated technology in ambulances to support a safe and effective shift to out of hospital care, including the implications for workforce in terms of training, role and clinical decision-making skills.METHODS:Our study includes a scoping review of relevant issues and a baseline assessment of progress in all UK ambulance services in implementing EHR. These will inform four in-depth case studies of services at different stages of implementation, assessing current usage, and examining context.RESULTS:The scoping review identified themes including: there are many perceived potential benefits of EHR, such as improved safety and remote diagnostics, but as yet little evidence of them; technical challenges to implementation may inhibit uptake and lead to increased workload in the short term; staff implementing EHR may do so selectively or devise workarounds; and EHR may be perceived as a tool of staff surveillance.CONCLUSIONS:Our scoping review identified some complex issues around the implementation of EHR and the relevant challenges, opportunities and workforce implications. These will help to inform our fieldwork and subsequent data analysis in the case study sites, to begin early in 2017. Lessons learned from the experience of implementing EHR so far should inform future development of information technology in ambulance services, and help service providers to understand how best to maximize the opportunities offered by EHR to redesign care.