'That's how we got around it': a qualitative exploration of healthcare professionals' experiences of care provision for asylum applicants' with limited English proficiency in UK contingency accommodation.

OBJECTIVES: The inadequate provision of language interpretation for people with limited English proficiency (LEP) is a determinant of poor health, yet interpreters are underused. This research explores the experiences of National Health Service (NHS) staff providing primary care for people seeking asylum, housed in contingency accommodation during COVID-19. This group often have LEP and face multiple additional barriers to healthcare access. Language discrimination is used as a theoretical framework. The potential utility of this concept is explored as a way of understanding and addressing inequities in care. DESIGN: Qualitative research using semistructured interviews and inductive thematic analysis. SETTING: An NHS primary care service for people seeking asylum based in contingency accommodation during COVID-19 housing superdiverse residents speaking a wide spectrum of languages. PARTICIPANTS: Ten staff including doctors, nurses, mental health practitioners, healthcare assistants and students participated in semistructured online interviews. Some staff were redeployed to this work due to the pandemic. RESULTS: All interviewees described patients' LEP as significant. Inadequate provision of interpretation services impacted the staff's ability to provide care and compromised patient safety. Discrimination, such as that based on migration status, was recognised and challenged by staff. However, inequity based on language was not articulated as discrimination. Instead, insufficient and substandard interpretation was accepted as the status quo and workarounds used, such as gesticulating or translation phone apps. The theoretical lens of language discrimination shows how this propagates existing social hierarchies and further disadvantages those with LEP. CONCLUSIONS: This research provides empirical evidence of how the inadequate provision of interpreters forces the hand of healthcare staff to use shortcuts. Although this innovative 'tinkering' allows staff to get the job done, it risks normalising structural gaps in care provision for people with LEP. Policy-makers must rethink their approach to interpretation provision which prioritises costs over quality. We assert that the concept of language discrimination is a valuable framework for clinicians to better identify and articulate unfair treatment on the grounds of LEP.

Healthcare resilience: a meta-narrative systematic review and synthesis of reviews.

OBJECTIVES: The COVID-19 pandemic has tested global healthcare resilience. Many countries previously considered 'resilient' have performed poorly. Available organisational and system frameworks tend to be context-dependent and focus heavily on physical capacities. This study aims to explore and synthesise evidence about healthcare resilience and present a unified framework for future resilience-building. DESIGN: Systematic review and synthesis of reviews using a meta-narrative approach. SETTING: Healthcare organisations and systems. PRIMARY AND SECONDARY OUTCOME MEASURES: Definitions, concepts and measures of healthcare resilience. We used thematic analysis across included reviews to summarise evidence on healthcare resilience. RESULTS: The main paradigms within healthcare resilience include global health, disaster risk reduction, emergency management, patient safety and public health. Definitions of healthcare resilience recognise various hierarchical levels: individual (micro), facility or organisation (meso), health system (macro) and planetary or international (meta). There has been a shift from a focus on mainly disasters and crises, to an 'all-hazards' approach to resilience. Attempts to measure resilience have met with limited success. We analysed key concepts to build a framework for healthcare resilience containing pre-event, intra-event, post-event and trans-event domains. Alongside, we synthesise a definition which dovetails with our framework. CONCLUSION: Resilience increasingly takes an all-hazards approach and a process-oriented perspective. There is increasing recognition of the relational aspects of resilience. Few frameworks incorporate these, and they are difficult to capture within measurement systems. We need to understand how resilience works across hierarchical levels, and how competing priorities may affect overall resilience. Understanding these will underpin interdisciplinary, cross-sectoral and multi-level approaches to healthcare resilience for the future. PROSPERO REGISTRATION NUMBER: CRD42022314729.

In critique of moral resilience: UK healthcare professionals' experiences working with asylum applicants housed in contingency accommodation during the COVID-19 pandemic.

This research explores the experiences of UK NHS healthcare professionals working with asylum applicants housed in contingency accommodation during the COVID-19 pandemic. Using a critical understanding of the concept of moral resilience as a theoretical framework, we explore how the difficult circumstances in which they worked were navigated, and the extent to which moral suffering led to moral transformation. Ten staff from a general practice participated in semistructured interviews. Encountering the harms endured by people seeking asylum prior to arrival in the UK and through the UK's 'Hostile Environment' caused healthcare staff moral suffering. They responded to this in several ways, including: (1) feeling grateful for their own fortunes; (2) defining the limitations of their professional obligations; (3) focusing on the rewards of work and (4) going above and beyond usual care. Although moral resilience is reflected in much of the data, some participants described how the work caused ideological transformations and motivated challenges to systems of oppression. We show how current moral resilience theory fails to capture these transformative political and social responses, warning of how, instead, it might encourage healthcare staff to maintain the status quo. We caution against the widespread endorsement of current formulations of moral resilience in contemporary social and political climates, where the hostile and austere systems causing suffering are the result of ideological political decisions. Future work should instead focus on enabling working conditions to support, and developing theory to capture, collective resistance.

Systematic literature search, review and dissemination methodology for the COVID-19 pandemic.

Purpose of the study: SARS-CoV-2 has caused healthcare systems globally to reorganise. A pandemic paradox emerged; while clinicians were desperate for information on a new disease, they had less time to find and evaluate the vast volume of publications at times of significant strain on healthcare systems.A multidisciplinary team undertook a weekly literature search capturing all COVID-19 publications. We also monitored free open access medical education (FOAMed) sources for emerging themes. Title and abstract screening pooled the most relevant papers for emergency medicine. Three summary types were created, a 'Top 5 Flash Update', a journal club and a rapid response to emerging FOAMed themes. From these summaries, three modes of dissemination were used: short written summaries, blogs and podcasts. These were amplified through social media. Study design: A retrospective review was conducted assessing the impact of this knowledge dissemination strategy for the period of March to September 2020. Results: In total, 64 687 papers were identified and screened. Of the papers included in the 'Top 5', 28.3% were on epidemiology, 23.6% treatment, 16.7% diagnostics, 12% prognosis, 8.7% pathophysiology with the remaining 10.7% consisting of PPE, public health, well-being and 'other'. We published 37 blogs, 17 podcasts and 18 Top 5 Flash Updates. The blogs were read 138 343 times, the Top 5 Flash Updates 68 610 times and the podcasts had 72 501 listens. Conclusion: A combination of traditional academic and novel social media approaches can address the pandemic paradox clinicians are facing.