Dr Carin Magnusson

Objectives: Despite widespread advocacy of a feedback culture in healthcare, paramedics receive little feedback on their clinical performance. Provision of 'outcome feedback', or information concerning health-related patient outcomes following incidents that paramedics have attended, is proposed, to provide paramedics with a means of assessing and developing their diagnostic and decision-making skills. To inform the design of feedback mechanisms, this study aimed to explore the perceptions of paramedics concerning current feedback provision and to discover their attitudes towards formal provision of patient outcome feedback.Methods: Convenience sampling from a single ambulance station in the United Kingdom (UK) resulted in eight paramedics participating in semi-structured interviews. Interpretative phenomenological analysis was employed to generate descriptive and interpretative themes related to both current and potential feedback provision.Results: The perception that only exceptional incidents initiate feedback, and that often the required depth of information supplied is lacking, resulted in some participants describing an isolation of their daily practice. Barriers and limitations of the informal processes currently employed to access feedback were also highlighted. Formal provision of outcome feedback was anticipated by participants to benefit the integration and progression of the paramedic profession as a whole, in addition to facilitating the continued development and well-being of the individual clinician. Participants anticipated feedback to be delivered electronically to minimise resource demands, with delivery initiated by the individual clinician. However, a level of support or supervision may also be required to minimise the potential for harmful consequences.Conclusions: Establishing a just feedback culture within paramedic practice may reduce a perceived isolation of clinical practice, enabling both individual development and progression of the profession. Carefully designed formal outcome feedback mechanisms should be initiated and subsequently evaluated to establish resultant benefits and costs.

Background Clinical feedback provision to health professionals is advocated to benefit both clinical development and work engagement. Aim This literature review aims to develop recommendations for effective clinical feedback provision by examining mechanisms that exist specifically for ambulance clinicians. Method: A systematic search of contemporary literature identified 15 research papers and four articles, which were included for review and narrative synthesis. Findings The initial identification of practice that requires improvement, together with an understanding of the practitioners' baseline attitudes, is important. While minimising resource demands will improve sustainability, repeated interaction with clinicians will benefit effectiveness. Provision should be balanced and timely, and who delivers feedback is significant. Clinical outcome feedback not restricted to specific conditions requires further consideration of which incidents will initiate feedback and what information will be supplied. Conclusion Feedback has been shown to improve clinical performance but demonstrating subsequent benefits to patient outcomes has proved more difficult.

'Organisational governance'--the systems, processes, behaviours and cultures by which an organisation leads and controls its functions to achieve its objectives--is seen as an important influence on patient safety. The features of 'good' governance remain to be established, partly because the relationship between governance and safety requires more investigation.

BACKGROUND: Little is known about how newly qualified nurses delegate to health care assistants when delivering bedside care. AIM: To explore newly qualified nurses' experiences of delegating to, and supervising, health care assistants. DESIGN: Ethnographic case studies. SETTINGS: In-patient wards in three English National Health Service (NHS) acute hospitals. PARTICIPANTS: 33 newly qualified nurses were observed, 10 health care assistants and 12 ward managers. METHODS: Participant observation and in-depth interviews. FINDINGS: We suggest that newly qualified nurses learn to delegate to, and supervise, health care assistants through re-working (`recontextualising') knowledge; and that this process occurs within a transitional (`liminal') space. CONCLUSIONS: Conceptualising learning in this way allows an understanding of the shift from student to newly qualified nurse and the associated interaction of people, space and experience. Using ethnographic case studies allows the experiences of those undergoing these transitions to be vocalised by the key people involved.

The aim was to assess both nurses’ attitudes about in-service education, and the impact had by attending in-service education on nurses’ management and knowledge of deteriorating patients. In-service education cannot reach its best potential outcomes without strong leadership. Nurse managers are in a position of adopting leadership styles and creating conditions for enhancing the in-service education outcomes. We conducted a comparative cross-sectional study between British and Finnish nurses (N = 180; United Kingdom: n = 86; Finland: n = 94). A modified “Rapid Response Team Survey” was used in data collection. A sample of medical and surgical registered nurses were recruited from acute care hospitals. Self-reporting, self-reflection, and case-scenarios were used to assess nurses’ attitudes, practice, and knowledge. Data were analyzed by Mann-Whitney-U and Chi-square tests. Nurses’ views on education programs were positive; however, low confidence, delays caused by hospital culture, and fear of criticism remained barriers to post education management of deteriorating patients. Nurses’ self-reflection on their management of deteriorating patients indicates that 20–25% of deteriorating patients are missed. Nurse managers should promote a no-blame culture, mitigate unnecessary hospital culture and routines, and facilitate in-service education focusing on identification and management of deteriorating patients, simultaneously improving nurses’ confidence. •In-service education is crucial for improving nurses’ competence in acute hospitals.•Nurses should actively improve their competence to prevent missed RRS-activation incidents.•Nurse managers are clinical leaders who can translate the evidence-based changes.•Nurse managers should promote a no-blame culture to improve nurses’ confidence.•Nurse managers should mitigate unnecessary hospital culture and routines.

In this article, the authors illuminate some of the hidden aspects of the mentor role, which often go unnoticed in challenging clinical settings. Four key areas have been selected for the purpose of stimulating thought and debate on current mentorship issues: preparedness for the mentor role; management of students' clinical learning and skills development; processes of practice assessment and support for the mentoring role. The findings demonstrate the need for increased funding to enhance the clinical curriculum. This includes formal protection of time for mentors to provide quality learning experiences. Investment in the mentor/student dyad is essential as successful mentoring can literally be a 'gift' to student midwives.

Failure or delay in using rapid response system is associated with adverse patient outcomes. To assess nurses’ ability to timely activate the rapid response system in case scenarios and to assess nurses’ perceptions of the rapid response system. A comparative cross-sectional study was conducted using a modified rapid response team survey. A sample of medical/surgical registered nurses were recruited from one acute tertiary care hospital in Finland and one National Health Service acute care hospital in United Kingdom (N = 180; UK: n = 86; Finland: n = 94). The results demonstrated that in half of the case scenarios, nurses failed to activate the rapid response system on time, with no significant difference between countries. Nurses did not perceive doctor’s disagreement with activation of the rapid response system to be a strong barrier for activating the rapid response system. Finnish nurses found doctor’s disagreement in activating the rapid response system less important compared to British nurses. The study identified gaps in nurses’ knowledge in management of deteriorating patients. Nurses’ management of the case scenarios was suboptimal. The findings suggest that nurses need education for timely activation of the rapid response system. Case scenarios could be beneficial for nurses’ training.

This paper describes how the use of methodological triangulation can enrich the research process. The first section of the paper provides a brief outline of a national research project that studied 'pairs' of student midwives and their mentors in practice, and discusses the strengths and weaknesses of the approach. It then moves on to describe the combination of methods chosen for one aspect of the project before providing illustrative examples from the data that show how the triangulation of methods gave depth to the analysis

The invisibility of nursing work has been discussed in the international literature but not in relation to learning clinical skills. Evans and Guile’s (Practice-based education: Perspectives and strategies, Rotterdam: Sense, 2012) theory of recontextualisation is used to explore the ways in which invisible or unplanned and unrecognised learning takes place as newly qualified nurses learn to delegate to and supervise the work of the healthcare assistant. In the British context, delegation and supervision are thought of as skills which are learnt “on the job.” We suggest that learning “on-the- job” is the invisible construction of knowledge in clinical practice and that delegation is a particularly telling area of nursing practice which illustrates invisible learning. Using an ethnographic case study approach in three hospital sites in England from 2011 to 2014, we undertook participant observation, interviews with newly qualified nurses, ward managers and healthcare assistants. We discuss the invisible ways newly qualified nurses learn in the practice environment and present the invisible steps to learning which encompass the embodied, affective and social, as much as the cognitive components to learning. We argue that there is a need for greater understanding of the “invisible learning” which occurs as newly qualified nurses learn to delegate and supervise.

Introduction Accurate and timely dispatch of emergency medical services (EMS) is vital due to limited resources and patients’ risk of mortality and morbidity increasing with time. Currently, most UK emergency operations centres (EOCs) rely on audio calls and accurate descriptions of the incident and patients’ injuries from lay 999 callers. If dispatchers in the EOCs could see the scene via live video streaming from the caller’s smartphone, this may enhance their decision making and enable quicker and more accurate dispatch of EMS. The main aim of this feasibility randomised controlled trial (RCT) is to assess the feasibility of conducting a definitive RCT to assess the clinical and cost effectiveness of using live streaming to improve targeting of EMS.Methods and analysisThe SEE-IT Trial is a feasibility RCT with a nested process evaluation. The study also has two observational substudies: (1) in an EOC that routinely uses live streaming to assess the acceptability and feasibility of live streaming in a diverse inner-city population and (2) in an EOC that does not currently use live streaming to act as a comparator site regarding the psychological well-being of EOC staff using versus not using live streaming.Ethics and disseminationThe study was approved by the Health Research Authority on 23 March 2022 (ref: 21/LO/0912), which included NHS Confidentiality Advisory Group approval received on 22 March 2022 (ref: 22/CAG/0003). This manuscript refers to V.0.8 of the protocol (7 November 2022). The trial is registered with the ISRCTN (ISRCTN11449333). The first participant was recruited on 18 June 2022.The main output of this feasibility trial will be the knowledge gained to help inform the development of a large multicentre RCT to evaluate the clinical and cost effectiveness of the use of live streaming to aid EMS dispatch for trauma incidents.Trial registration numberISRCTN11449333.

Background The role of medical emergency team (MET) in managing deteriorating patients and enhancing patient safety is greatly affected by teamwork. Aims To identify teamwork-related needs of the MET from MET nurses' perspectives. To assess the associations between MET nurses' perceptions of teamwork and their work experience and education. Study design A quantitative, descriptive correlational design. Methods Registered intensive care unit (ICU) nurses (n = 50) who were members of the MET in an acute tertiary care hospital answered a modified version of the team assessment questionnaire in 2017. Data were analysed using descriptive statistics, the Kruskal-Wallis test, and the univariate analysis of variance method. The reporting of this study adheres to the strengthening the reporting of observational studies (STROBE) guidelines. Results Participants showed least agreement with the items presenting leadership skills (mean = 2.6, SD = 0.68). Approximately 50% nurses disagreed that the MET had adequate resources, training, and skills. The majority of nurses (80%) felt that their responsibilities as a MET member interfered with taking care of their own ICU patients. Many nurses (64%) felt that they did not have a voice in MET's decision-making process. Approximately 50% nurses felt that they were not recognized for their individual contribution, and they were uncertain regarding MET's policies for dealing with conflicts. The amounts of MET nurses' work experience and education were associated with MET skills and function, respectively. Conclusion Key teamwork elements of the MET that need improvements include decision-making and conflict resolution skills, valuing team members, and team leadership. Practicing shared mental models, implementing the TeamSTEPPS curricula at hospitals for training ICU nurses, and simulation-based team-training programmes may be beneficial in improving teamwork of MET members. Relevance to clinical practice This study revealed key teamwork elements of the MET that need improvements. Our findings may contribute to improve teamwork, thereby optimizing MET function, and enhancing patient outcomes.

Background Timely dispatch of appropriate emergency medical services (EMS) resources to the scene of medical incidents, and/or provision of treatment at the scene by bystanders and medical emergency lay callers (referred to as ‘callers’ in this review) can improve patient outcomes. Currently, in dispatch systems worldwide, prioritisation of dispatch relies mostly on verbal telephone information from callers, but advances in mobile phone technology provide means for sharing video footage. This scoping review aimed to map and identify current uses, opportunities, and challenges for using video livestreaming from callers’ smartphones to emergency medical dispatch centres. Methods A scoping review of relevant published literature between 2007 and 2023 in the English language, searched within MEDLINE; CINAHL and PsycINFO, was descriptively synthesised, adhering to the PRISMA extension for scoping reviews. Results Twenty-four articles remained from the initial search of 1,565 articles. Most studies were simulation-based and focused on emergency medical dispatchers’ (referred to as ‘dispatcher/s’ in this review) assisted video cardiopulmonary resuscitation (CPR), predominantly concerned with measuring how video impacts CPR performance. Nine studies were based on real-life practice. Few studies specifically explored experiences of dispatchers or callers. Only three articles explored the impact that using video had on the dispatch of resources. Opportunities offered by video livestreaming included it being: perceived to be useful; easy to use; reassuring for both dispatchers and callers; and informing dispatcher decision-making. Challenges included the potential emotional impact for dispatchers and callers. There were also concerns about potential misuse of video, although there was no evidence that this was occurring. Evidence suggests a need for appropriate training of dispatchers and video-specific dispatch protocols. Conclusion Research is sparse in the context of video livestreaming. Few studies have focussed on the use of video livestreaming outside CPR provision, such as for trauma incidents, which are by their nature time-critical where visual information may offer significant benefit. Further investigation into acceptability and experience of the use of video livestreaming is warranted, to understand the potential psychological impact on dispatchers and callers.

Background: Many specialist paramedics are moving from the ambulance service to primary care. There is a lack of empirical literature regarding this transition. Aims: This study aims to improve support for specialist paramedics undertaking the transition by ascertaining factors that may hinder or facilitate the process. Methods: The study used semi-structured interviews with eight specialist paramedics working in primary care in England. An interpretative phenomenological analysis approach was used to analyse data, and this was informed by a review of theoretical and empirical literature. Findings: Facilitators and barriers to transition were found, along with information regarding the transition. Five facilitators were identified: previous clinical experience; mentorship; support; clear role parameters; and opportunity to develop. Four barriers were identified: role misunderstanding; changing scope of clinical practice; time pressures; and gaps in education and knowledge. Conclusion: This study contributes to a limited field of research by highlighting barriers and facilitators to the transition of specialist paramedics to primary care. Practical steps can be taken to smooth this transition.

Background Use of bystander video livestreaming from scene to Emergency Medical Services (EMS) is becoming increasingly common to aid decision making about the resources required. Possible benefits include earlier, more appropriate dispatch and clinical and financial gains, but evidence is sparse. Methods A feasibility randomised controlled trial with an embedded process evaluation and exploratory economic evaluation where working shifts during six trial weeks were randomised 1:1 to use video livestreaming during eligible trauma incidents (using GoodSAM Instant-On-Scene) or standard care only. Pre-defined progression criteria were: (1) ≥70% callers (bystanders) with smartphones agreeing and able to activate live stream; (2) ≥50% requests to activate resulting in footage being viewed; (3) Helicopter Emergency Medical Services (HEMS) stand-down rate reducing by ≥10% as a result of live footage; (4) no evidence of psychological harm in callers or staff/dispatchers. Observational sub-studies included (i) an inner-city EMS who routinely use video livestreaming to explore acceptability in a diverse population; and (ii) staff wellbeing in an EMS not using video livestreaming for comparison to the trial site. Results Sixty-two shifts were randomised, including 240 incidents (132 control; 108 intervention). Livestreaming was successful in 53 incidents in the intervention arm. Patient recruitment (to determine appropriateness of dispatch), and caller recruitment (to measure potential harm) were low (58/269, 22% of patients; 4/244, 2% of callers). Two progression criteria were met: (1) 86% of callers with smartphones agreed and were able to activate livestreaming; (2) 85% of requests to activate livestreaming resulted in footage being obtained; and two were indeterminate due to insufficient data: (3) 2/6 (33%) HEMS stand down due to livestreaming; (4) no evidence of psychological harm from survey, observations or interviews, but insufficient survey data from callers or comparison EMS site to be confident. Language barriers and older age were reported in interviews as potential challenges to video livestreaming by dispatchers in the inner-city EMS. Conclusions Progression to a definitive RCT is supported by these findings. Bystander video livestreaming from scene is feasible to implement, acceptable to both 999 callers and dispatchers, and may aid dispatch decision-making. Further assessment of unintended consequences, benefits and harm is required. Trial registration Trial registration: ISRCTN 11449333 (22 March 2022). https://www.isrctn.com/ISRCTN11449333

Qualified and student nurses remain at the forefront of dealing with, and reporting, patient safety events or incidents. There has been limited exploration of whether and how the patient's perspective is represented by staff or student nurses using formal reporting systems. The overall aim of the study was to explore the student nurses' experiences in practice of patient safety events they were themselves directly or indirectly involved in. This specifically explored the subsequent reporting and inclusion of the patient perspectives that may or may not have taken place. A qualitative approach to this research was selected using the principles of thematic analysis to analyse data gathered from focus groups of student nurses across all year groups. Three universities participated in the study located in the north east, south east and east of England. Student nurses from across the year groups attended focus groups. Following ethical approval and informed consent, participants took part in focus groups within each university setting. Data were transcribed verbatim and analysed using thematic analysis. Three themes were identified: the benefit of reporting and patient involvement, the barriers experienced by the students in reporting and the support needed to ensure they do the right thing in practice. Learning for students from patient safety incidents is important and seeking patients' views and perceptions adds to the learning experience. There are however challenges for the student in practice in both reporting and patient involvement. Resources are needed that follow and feed into the student learning alongside a workforce that see the benefit of learning from those we care for.

Nurses' clinical competence involves an integration of knowledge, skills, attitudes, thinking ability, and values, which strongly affects how deteriorating patients are managed. The aim of the study was to examine nurses' attitudes as part of clinical competence towards the rapid response system in two acute hospitals with different rapid response system models. This is a comparative cross-sectional correlational study. A modified “Nurses' Attitudes Towards the Medical Emergency Team” tool was distributed among 388 medical and surgical registered nurses in one acute hospital in the UK and one in Finland. A total of 179 nurses responded. Statistical analyses, including exploratory factor analysis, Mann–Whitney U tests, Kruskal–Wallis tests, chi-square tests, and univariate and multivariate regression analyses, were used. Generally, nurses had positive attitudes towards rapid response systems. British and Finnish nurses' attitudes towards rapid response system activation were divided when asked about facing a stable (normal vital signs) but worrisome patient. Finnish nurses relied more on intuition and were more likely to activate the rapid response system. Approximately half of the nurses perceived the physician's influence as a barrier to rapid response system activation. The only sociodemographic factor that was associated with nurses activating the rapid response system more freely was work experience ≥10 years. The findings are beneficial in raising awareness of nurses' attitudes and identifying attitudes that could act as facilitators or barriers in rapid response system activation. The study suggests that nurses' attitudes towards physician influence and intuition need to be improved through continuing development of clinical competence. When the system model included “worrisome” as one of the defined parameters for activation, nurses were more likely to activate the rapid response system. Future rapid response system models may need to have clear evidence-based instructions for nurses when they manage stable (normal vital signs) but worrisome patients and should acknowledge nurses’ intuition and clinical judgement.

Background. Despite a focus on user involvement in healthcare services and education in the UK, there is little evidence of women's views of education in midwifery practice. Aim. To identify women's perceptions of clinical teaching and learning in midwifery practice, in order to inform the midwifery curriculum. Method. Qualitative structured telephone interviews were conducted with 18 women who had been involved in a larger study that had used non-participant observation visits in hospital and community environments, 12 of whom were primiparae Thematic content analysis of the data was undertaken, based on a framework used in the larger study. Findings. Women described both physical and emotional support as being offered by student midwives. Some talked about student midwives' tentativeness and reduced confidence levels during episodes of care, but most expressed appreciation for the students' presence. Conclusions. More innovative ways to involve service users in the midwifery curriculum are needed, alongside research to evaluate them. More careful consideration needs to be given for student midwives' involvement in maternity care, with better preparation for both students and women. © 2007 The Royal College of Midwives.