Developing the Resident Measure of Safety in Care Homes (RMOS): A Delphi and Think Aloud Study.

OBJECTIVE: This study aimed to develop a measure of contributory factors to safety incidents in care homes to be completed by residents and/or their unpaid carers. INTRODUCTION: Care home residents are particularly vulnerable to patient safety incidents, due to higher likelihood of frailty, multimorbidity and cognitive decline. However, despite residents and their carers wanting to be involved in safety initiatives, there are few mechanisms for them to contribute and make meaningful safety improvements to practice. METHODS: We developed 73 evidence-based items from synthesis and existing measures, which we presented to a panel of stakeholders (residents/carers, health/social care professionals and researchers). We used two online rounds of Delphi to generate consensus (80%) on items important to include in the Resident Measure of Safety in Care Homes (RMOS); a consensus meeting was later held. The draft RMOS developed through the Delphi was presented to participants during 'Think Aloud' interviews using cognitive testing techniques. RESULTS: The 29-item RMOS was developed. Forty-three participants completed Delphi round 1, and 27 participants completed round 2, 11 participants attended the consensus meeting and 12 'Think Aloud' interviews were conducted. Of the 73 original items, 42 items that did not meet consensus in Delphi round 1 were presented in round 2. After the consensus meeting, it was agreed that 35 items would comprise the RMOS questionnaire and were presented in the 'Think Aloud' interviews. Participants suggested numerous changes to items mostly to improve comprehension and ability to answer. CONCLUSION: We have a developed an evidence-based RMOS, with good face validity, to assess contributory factors to safety in care homes from a resident/carer perspective. Future work will involve psychometrically testing the items in a pilot and developing a complementary simplified, dementia-friendly version to promote inclusivity. PATIENT OR PUBLIC INVOLVEMENT: Four patient and public contributors worked with researchers to develop the online questionnaires. Patients (residents) and carers participated on the consensus panel. One member of the research team is an expert by lived experience and was involved in design and analysis decisions. The item list and instructions for the questionnaires were reviewed for face validity, understanding and acceptability by a patient and public involvement group and modified.

Establishing evidence to inform culturally competent mental health services: A mixed methods study protocol.

BACKGROUND: COVID-19 has exacerbated the significant and longstanding mental health inequalities for ethnic minorities, who were less likely to access mental health support in primary care but more likely to end up in crisis care compared to the majority ethnic group. Services were poorly offered and accessed to respond to the increased mental health challenges. AIM: To 1) establish evidence on which changes to mental health services provided in response to COVID-19 are beneficial for ethnic minorities who experience mental health difficulties in the North of England, and 2) to inform what and how culturally competent mental health services should be routinely provided. METHODS: A mixed methods approach comprising 1) a rapid review to map services and models of care designed or adjusted for mental health during the pandemic, 2) an observational study of retrospective routine data to assess changes to mental health services and associated outcomes, 3) qualitative interviews to understand experiences of seeking care and factors associated with high-quality service provision, and 4) a Delphi study to establish consensus on key features of culturally competent services. From the selected areas in the North of England, adults from ethnic minorities who experience mental health difficulties will be identified from the primary, community and secondary care services and local ethnic minority communities. DISCUSSION: This study will identify ways to tackle health inequalities and contribute to mental health service recovery post pandemic by providing practice recommendations on equitable and effective services to ensure culturally competent and high-quality care. A list of services and features on what and how mental health services will be provided. Working with study collaborators and public and patient involvement partners, the study findings will be widely disseminated through presentations, conferences and publications and will inform the subsequent funding application for intervention development and evaluation.

Patient safety, self-injection, and B12 deficiency: a UK cross-sectional survey.

BACKGROUND: Individuals with vitamin B12 deficiency (including pernicious anaemia) often report being 'let down' or stigmatised by general practice systems and policy, and choose instead to self-medicate via injection; the association between this and perceptions of safe primary care in this group of people is unknown. AIM: To examine the association between self-medication for vitamin B12 deficiency and patient-reported safety in primary care. DESIGN AND SETTING: A UK cross-sectional online survey. METHOD: The survey consisted of the three components: demographics; the validated Primary Care Patient Measure of Safety; and questions about self-medication for vitamin B12 deficiency. Multivariable logistic regression analyses and thematic synthesis were undertaken. RESULTS: Responses from 1297 participants indicated 508 (39.2%) self-medicated via injection. Perceived primary care safety was low. Those who self-medicated via injection reported a significantly lower level of patient safety in primary care including adverse patient-related factors (odds ratio 0.82, 95% confidence interval = 0.73 to 0.92), and patients >34 years of age were significantly more likely to self-medicate via injection. Many reported that treatment under the guidance of a clinician was preferable to self-medication, but felt they had no other choice to regain quality of life. Almost half felt that the doctor did not always consider what they wanted for their care. CONCLUSION: To the authors' knowledge, this is the largest study to date examining patient safety and vitamin B12 deficiency. It found that four out of 10 patients with B12 deficiency self-medicate via injection. Patients who self-medicated perceived primary care as less safe. Providing patient-centred care and treating these patients with dignity and respect is a policy priority to reduce unsafe health behaviours.

Beyond the control of the care home: A meta-ethnography of qualitative studies of Infection Prevention and Control in residential and nursing homes for older people.

OBJECTIVE: This study aimed to develop interpretive insights concerning Infection Prevention and Control (IPC) in care homes for older people. DESIGN: This study had a meta-ethnography design. DATA SOURCES: Six bibliographic databases were searched from inception to May 2020 to identify the relevant literature. REVIEW METHODS: A meta-ethnography was performed. RESULTS: Searches yielded 652 records; 15 were included. Findings were categorized into groups: The difficulties of enacting IPC measures in the care home environment; workload as an impediment to IPC practice; the tension between IPC and quality of life for care home residents; and problems dealing with medical services located outside the facility including diagnostics, general practice and pharmacy. Infection was revealed as something seen to lie 'outside' the control of the care home, whether according to origins or control measures. This could help explain the reported variability in IPC practice. Facilitators to IPC uptake involved repetitive training and professional development, although such opportunities can be constrained by the ways in which services are organized and delivered. CONCLUSIONS: Significant challenges were revealed in implementing IPC in care homes including staffing skills, education, workloads and work routines. These challenges cannot be properly addressed without resolving the tension between the objectives of maintaining resident quality of life while enacting IPC practice. Repetitive staff training and professional development with parallel organisational improvements have prospects to enhance IPC uptake in residential and nursing homes. PATIENT OR PUBLIC CONTRIBUTION: A carer of an older person joined study team meetings and was involved in writing a lay summary of the study findings.

Exploring Associations between Stressors and Burnout in Trainee Doctors During the COVID-19 Pandemic in the UK.

OBJECTIVE: The authors examined associations between stressors and burnout in trainee doctors during the COVID-19 pandemic. METHODS: An anonymous online questionnaire including 42 questions on general and pandemic-specific stressors, and the Maslach Burnout Inventory-Health Services Survey (MBI-HSS), was sent to 1000 randomly selected trainee doctors in North-West England. Main outcomes were burnout scores that were stratified into Emotional Exhaustion (EE), Depersonalisation (DP), and reduced Personal Accomplishment (PA) and associations between stressors and burnout using stepwise regression analysis. RESULTS: A total of 362 complete responses were received giving a response rate of 37%. Mean scores for EE, DP, and PA derived from the MBI-HSS were 27.7, 9.8, and 34.3 respectively. Twenty-three stressors were found to be associated with burnout dimensions. "Increase in workload and hours due to COVID-19," "Poor leadership and management in the National Health Service," and "Not feeling valued" were found to have strong associations with burnout dimensions. Only "Not confident in own abilities" was found to be associated with all burnout dimensions. CONCLUSIONS: Associations with burnout were found to be identified in a range of work, pandemic, and non-work-related stressors, supporting the need for multi-level interventions to mitigate burnout.

Cross-sectional study exploring the association between stressors and burnout in junior doctors during the COVID-19 pandemic in the United Kingdom.

OBJECTIVES: This study aims to develop a comprehensive list of stressors relevant to junior doctors and will also report findings exploring the associations between burnout and stressors, which include work and non-work-related stressors as well as pandemic-related stressors. METHODS: An anonymous online questionnaire was sent to 1000 randomly selected junior doctors in the North-West of England. The questionnaire included 37 questions on general and pandemic-specific stressors, and the Maslach Burnout Inventory Health Services Survey. The main outcomes of interest were junior doctor ratings of stressors and scores for burnout (emotional exhaustion [EE], depersonalisation [DP], and personal accomplishment [PA]). Stepwise regression analysis was undertaken to assess associations between stressors and burnout. RESULTS: In total, 326 responses were collected (response rate = 33%). Of the top 10 stressors rated by junior doctors, 60% were related to the pandemic. Multiple stressors were found to be associated with the burnout dimensions. Fatigue (ß = .43), pandemic-related workload increase (ß = .33), and feeling isolated (ß = .24) had the strongest associations with EE, whereas fatigue (ß = .21), uncertainty around COVID-19 information (ß = .22) and doing unproductive tasks (ß = .17) had the strongest associations with DP. Working beyond normal scope due to COVID-19 (ß = -.26), not confident in own ability (ß = -.24) and not feeling valued (ß = -.20) were found to have the strongest associations with PA. CONCLUSIONS: Junior doctors experience a combination of general stressors and additional stressors emerging from the pandemic which significantly impact burnout. Monitoring these stressors and targeting them as part of interventions could help mitigating burnout in junior doctors.

Consultation patterns and frequent attenders in UK primary care from 2000 to 2019: a retrospective cohort analysis of consultation events across 845 general practices.

OBJECTIVE: To describe the distribution of consultations at the practice level and examine whether increases are uniform or driven by people who consult more frequently. DESIGN: Retrospective cohort study. SETTING: UK general practice data from the Clinical Practice Research Datalink (CPRD) GOLD database. PARTICIPANTS: 1 699 709 314 consultation events from 12 330 545 patients, in 845 general practices (1 April 2000 to 31 March 2019). METHODS: Consultation information was aggregated by financial year into: all consultations/all staff; all consultations/general practitioners (GPs); face-to-face consultations/all staff; face-to-face consultations/GPs. Patients with a number of consultations above the 90th centile, within each year, were classified as frequent attenders. Negative binomial regressions examined the association between available practice characteristics and consultation distribution. RESULTS: Among frequent attenders, all consultations by GPs increased from a median (25th and 75th centile) of 13 (10 and 16) to 21 (18 and 25) and all consultations by all staff increased from 27 (23-30) to 60 (51-69) over the study period. Approximately four out of ten consultations of any type concerned frequent attenders and the proportion of consultations attributed to them increased over time, particularly for face-to-face consultations with GPs, from a median of 38.0% (35.9%-40.3%) in 2000-2001 to 43.0% (40.6%-46.4%) in 2018-2019. Regression analyses indicated decreasing trends over time for face-to-face consultations and increasing trends for all consultation types, for both GPs and all staff. Frequent attenders consulted approximately five times more than the rest of the practice population, on average, with adjusted incidence rate ratios ranging between 4.992 (95% CI 4.917 to 5.068) for face-to-face consultations with all staff and 5.603 (95% CI 5.560 to 5.647) for all consultations with GPs. CONCLUSIONS: Frequent attenders progressively contributed to increased workload in general practices across the UK from 2000 to 2019. Important knowledge gaps remain in terms of the demographic, social and health characteristics of frequent attenders and how UK general practices can be prepared to meet the needs of these patients.

Contributors to stress and burnout in junior doctors during the COVID-19 pandemic

IntroductionJunior doctors have previously reported high levels of burnout;and additional stressors have likely emerged from the COVID-19 pandemic may further accelerate burnout. There is a need to identify which particular stressors are most likely to lead to burnout in junior doctors in order to develop appropriate interventions. Objectives1) To develop a comprehensive list of stressors that are relevant to junior doctors, which includes general work and non-work related stressors as well as stressors that have specifically emerged with the pandemic. 2) To assess which of these stressors are most strongly associated with burnout.MethodsAn anonymous online questionnaire was sent to 1000 randomly selected junior doctors in the North West of England between 10/07/20 to 04/08/20. It included 37 questions on general and pandemic-specific stressors, and the Maslach Burnout Inventory (MBI) Health Services Survey. Stepwise regression analyses were undertaken to assess associations between stressors and burnout.ResultsIn total, 326 responses were collected (response rate=33%). Of the top 10 stressors rated by junior doctors, 60% were related to the pandemic. Multiple stressors were found to be associated with the burnout dimensions. Fatigue (β=0.43), pandemic-related workload increase (β=0.33) and feeling isolated (β=0.24) had the strongest associations with Emotional Exhaustion, whereas fatigue (β=0.24), uncertainty around COVID-19 information (β=0.22) and doing unproductive tasks (β =0.22) had the strongest associations with Depersonalisation.ConclusionJunior doctors experience a combination of general stressors and additional stressors emerging from the pandemic which significantly to impact on burnout. Monitoring these stressors and targeting them as part of interventions could help mitigating burnout in junior doctors.

Effects of the first COVID-19 lockdown on quality and safety in mental healthcare transitions in England.

BACKGROUND: The COVID-19 pandemic forced the rapid implementation of changes to practice in mental health services, in particular transitions of care. Care transitions pose a particular threat to patient safety. AIMS: This study aimed to understand the perspectives of different stakeholders about the impact of temporary changes in practice and policy of mental health transitions as a result of coronavirus disease 2019 (COVID-19) on perceived healthcare quality and safety. METHOD: Thirty-four participants were interviewed about quality and safety in mental health transitions during May and June 2020 (the end of the first UK national lockdown). Semi-structured remote interviews were conducted to generate in-depth information pertaining to various stakeholders (patients, carers, healthcare professionals and key informants). Results were analysed thematically. RESULTS: The qualitative data highlighted six overarching themes in relation to practice changes: (a) technology-enabled communication; (b) discharge planning and readiness; (c) community support and follow-up; (d) admissions; (e) adapting to new policy and guidelines; (f) health worker safety and well-being. The COVID-19 pandemic exacerbated some quality and safety concerns such as tensions between teams, reduced support in the community and increased threshold for admissions. Also, several improvement interventions previously recommended in the literature, were implemented locally. DISCUSSION: The practice of mental health transitions has transformed during the COVID-19 pandemic, affecting quality and safety. National policies concerning mental health transitions should concentrate on converting the mostly local and temporary positive changes into sustainable service quality improvements and applying systematic corrective policies to prevent exacerbations of previous quality and safety concerns.