The impact of strike action on healthcare delivery: A scoping review.

BACKGROUND: Strike action carried out by healthcare workers raises a range of ethical issues. Most fundamentally, as a strike is designed to disrupt, it has the potential to impact patient outcomes and healthcare delivery. This paper synthesises and analyses the empirical literature that details the impact of strike action on healthcare delivery. METHODS: A systematic scoping review was utilised to examine the extent, range and nature of research activity. Embase, Medline, CINAHL, Bioethicsline, EconLit and Web of Science were searched, yielding 5644 results. Papers were included if they examined the impact that strike action had on healthcare delivery (i.e., admissions, presentations, waiting time). After screening, 43 papers met inclusion criteria. RESULTS: Nineteen studies explored presentations to emergency or admissions to hospital. Both dropped dramatically when comparing non-strike to strike periods. Ten studies examined length of stay in hospital and waiting times. No clear relationship was found with strike action, with some studies showing that wait times decreased. Nine studies examined the impact of strike action in facilities that were not on strike, but were impacted by nearby strike action along with the impact that strike action had on treatment seeking. Hospitals dealing with these upstream impacts often saw increase in presentations at hospitals, but results relates to treatment seeking during strike action were mixed. CONCLUSION: Strike action can have a substantial impact on the delivery of healthcare, but this impact is not felt uniformly across services. While many services are disrupted, a number are not, with several studies reporting increased efficiency.

A last resort? A scoping review of patient and healthcare worker attitudes toward strike action.

While strike action has been common since the industrial revolution, it often invokes a passionate and polarising response, from the strikers themselves, from employers, governments and the general public. Support or lack thereof from health workers and the general public is an important consideration in the justification of strike action. This systematic review sought to examine the impact of strike action on patient and clinician attitudes, specifically to explore (1) patient and health worker support for strike action and (2) the predictors for supporting strike action and the reasons given for engaging in strike action. A systematic scoping review was employed to identify all relevant literature, followed by a textual narrative synthesis. A total of 34 studies met inclusion criteria. Support for strike action was largely context-dependent. A range of factors impact support for strike action; broader cultural and structural factors, such as unionisation and general acceptance of strike action; systemic factors, such as the nature of the healthcare system, including infrastructure and work conditions; the strike itself and a range of individual factors, the most notable of which was being a student or in an early career stage. There were also some surprising results, for example, during doctors strike, nurses were provided with the opportunity to expand their role, which led to greater professional autonomy and job satisfaction.

Clinical research nurses, perspectives on recruitment challenges and lessons learnt from a large multi-site observational study.

Background: Recruitment of large numbers of study participants within a designated time frame for multi-site clinical research studies is a significant challenge faced by researchers. If a study does not manage to recruit targeted number of participants, it could have a significant impact on the statistical significance of the research. Purpose: This paper highlights the challenges of recruitment for a large multi-site UK-based tuberculosis observational study 'PREDICT'. Methods: It uses a case-study analysis from the research nurses, perspective, and descriptive information retrieved from non-recruitment log forms to understand reasons for potential recruits not participating. Results: Some of the main challenges to recruitment included patients not attending their clinic appointments, time required to obtain site-specific permissions and courier timings for blood sample collection. This paper also outlines key reasons for potential recruits who did not participate. Some of the common barriers to participation for non-recruited participants were work and family commitments, additional blood tests and language barriers. Conclusion: Successful strategies which were implemented to overcome some of the challenges during the study are presented. This paper, therefore, aims to present the challenges faced, lessons learnt and successful strategies implemented to inform the planning of similar longitudinal studies of this scale in future.

The impact of health care strikes on patient mortality: A systematic review and meta-analysis of observational studies.

OBJECTIVE: This study sought to evaluate the impact of health care strike action on patient mortality. DATA SOURCES: EMBASE, PubMed CINAHL, BIOETHICSLINE, EconLit, WEB OF SCIENCE, and grey literature were searched up to December 2021. STUDY DESIGN: A systematic review and meta-analysis were utilized. DATA COLLECTION/EXTRACTION: Random-effects meta-analysis was used to compare mortality rate during strike versus pre- or post-strike, with meta-regression employed to identify factors that might influence the potential impact of strike action. Studies were included if they were observational studies that examined in-hospital/clinic or population mortality during a strike period compared with a control period where there was no strike action. PRINCIPAL FINDINGS: Seventeen studies examined mortality: 14 examined in-hospital mortality and three examined population mortality. In-hospital studies represented 768,918 admissions and 7191 deaths during strike action and 1,034,437 admissions and 12,676 deaths during control periods. The pooled relative risk (RR) of in-hospital mortality did not significantly differ during strike action versus non-strike periods (RR = 0.91, 95% confidence interval 0.63, 1.31, p = 0.598). Meta-regression also showed that mortality RR was not significantly impacted by country (p = 0.98), profession on strike (p = 0.32 for multiple professions, p = 0.80 for nurses), the duration of the strike (p = 0.26), or whether multiple facilities were on strike (p = 0.55). Only three studies that examined population mortality met the inclusion criteria; therefore, further analysis was not conducted. However, it is noteworthy that none of these studies reported a significant increase in population mortality attributable to strike action. CONCLUSIONS: Based on the data available, this review did not find any evidence that strike action has any significant impact on in-hospital patient mortality.

The justification for strike action in healthcare: A systematic critical interpretive synthesis.

Strike action in healthcare has been a common global phenomenon. As such action is designed to be disruptive, it creates substantial ethical tension, the most cited of which relates to patient harm, that is, a strike may not only disrupt an employer, but it could also have serious implications for the delivery of care. This article systematically reviewed the literature on strike action in healthcare with the aim of providing an overview of the major justifications for strike action, identifying relative strengths and shortcomings of this literature and providing direction for future discussions, and theoretical and empirical research. Three major themes emerged related to (1) the relationship between healthcare workers, patients and society; (2) the consequences of strike action; and (3) the conduct of strike action. Those who argue against strike action generally cite the harms of such action, particularly as it relates to patients. Many also argue that healthcare workers, because of their skills and position in society, have a special obligation to their patients and society more generally. Those who see this action as not only permissible but also, in some cases, necessary have advanced several points in response, arguing that healthcare workers do not necessarily have any special obligation to their patients or society, and even if so, this obligation is not absolute. Overwhelmingly, when talking about the potential risks of strike action, authors have focused on patient welfare and the impact that a strike could have. Several directions for future work are identified, including greater explorations into how structural and systemic issues impact strike action, the need for greater consideration about the contextual factors that influence the risks and characteristics of strike action and finally the need to tie this literature to existing empirical evidence.

The impact of strike action on patient morbidity: A systematic literature review.

Strike action in healthcare has been common over the last several decades. The overarching aim of this systematic review was to synthesise and analyse the empirical literature that examines the impact of strike action on patient morbidity, that is, all patient outcomes except mortality. After conducting a search and apply eligibility criteria, 15 studies were included in this review. These articles included a variety of outcomes from hypertension control to rates of chlamydia. Strikes ranged from 13 to 118 days, with a mean strike length of 56 days. A textual narrative synthesis was employed to arrange studies by whether they had a positive, mixed or neutral or negative impact on patient morbidity. Results suggest that strike action has little impact on patient morbidity. The majority of studies reported that strike action had a neutral or mixed impact of strike action on patient morbidity. One study reported positive outcomes and three studies reported negative outcomes, however in both cases, the impact that the strike had was marginal.

Relative effectiveness of non-surgical interventions for pain management in knee osteoarthritis: a protocol for a component network meta-analysis of randomised controlled trials.

INTRODUCTION: Knee osteoarthritis is a chronic degenerative disease associated with significant chronic pain, disability and impaired quality of life and is the most common form of osteoarthritis. There is no cure for knee osteoarthritis, and the main therapeutic goals are pain management and improving quality of life. The objective of this study is to evaluate the relative efficacy and acceptability of available interventions using network meta-analysis (NMA) to provide a comprehensive evidence base to inform future treatment guidelines. METHODS AND ANALYSIS: A comprehensive literature search of major electronic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) and clinical trial registries will identify randomised control trials (RCTs) of interventions listed in NICE guidelines for the treatment of knee osteoarthritis in adults. We will perform an NMA to estimate relative intervention effects across the whole treatment network. If any studies use multicomponent intervention packages, we will employ a component NMA model to estimate the contribution of individual components. The quality of evidence will be assessed using the Confidence in Network Meta-Analysis approach, which is based on the traditional GRADE framework adapted for NMA. Risk of bias (RoB) will be assessed using the revised Cochrane RoB 2.0 tool for RCTs. ETHICS AND DISSEMINATION: This study does not require ethical approval. Findings will be submitted to a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42020184192.

An integrative review of the factors influencing older nurses' timing of retirement.

AIMS: To summarize the international empirical literature to provide a comprehensive understanding of older nurses' decision-making surrounding the timing of their retirement. BACKGROUND: The global nursing shortage is increasing. Among some countries it has become an economic imperative to consider raising the state pension age and to extend working lives. DESIGN: An integrative literature review using an integrated design. DATA SOURCES: MEDLINE, CINAHL and Business Source Premier databases were searched for studies between January 2007 - October 2019. REVIEW METHODS: Quality appraisal of the studies was conducted. Findings were summarized, grouped into categories and themes extracted. Two models were developed for data representation. RESULTS: A total of 132 studies were identified by the search strategy. Of these, 27 articles were included for appraisal and synthesis. Sixteen papers were quantitative, seven qualitative, and four mixed methods. The research took place in 13 different geographical locations. Most studies were of a questionnaire design, followed by interviews and focus groups. The total participant sample was 35,460. Through a synthesis of the studies, four themes were identified: Health, Well-being, and Family factors; Employer factors; Professional factors; and Financial factors. CONCLUSION: This review not only revealed the heterogeneity of studies on this subject and confirmed previous findings but also established a ranking of criteria that influences nurses' decision-making: age, followed by personal and organizational factors. Four extracted themes of push and pull factors map onto these factors. No 'one-size-fits-all' strategy exists to ensure the extension of older nurses' working lives. Organizations need to foster an environment where older nurses feel respected and heard and where personal and professional needs are addressed. IMPACT: Organizations need to implement HR policies addressing nurses' personal well-being and retirement preparation. Older nurses are more likely to extend their working lives if they feel committed to their organization and when professional standards are maintained.

The Effect of Diabetes-Specific Enteral Nutrition Formula on Cardiometabolic Parameters in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomised Controlled Trials.

BACKGROUND: The prevalence of diabetes is on the increase in the UK and worldwide, partly due to unhealthy lifestyles, including poor dietary regimes. Patients with diabetes and other co-morbidities such as stroke, which may affect swallowing ability and lead to malnutrition, could benefit from enteral nutrition, including the standard formula (SF) and diabetes-specific formulas (DSF). However, enteral nutrition presents its challenges due to its effect on glycaemic control and lipid profile. AIM: The aim of this review was to evaluate the effectiveness of diabetes-specific enteral nutrition formula versus SF in managing cardiometabolic parameters in patients with type 2 diabetes. METHOD: This review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses. Three databases (Pubmed, EMBASE, PSYCInfo) and Google scholar were searched for relevant articles from inception to 2 January 2019 based on Population, Intervention, Comparator, Outcomes and Study designs (PICOS) framework. Key words, Medical Subject Heading (MeSH) terms, and Boolean operators (AND/OR) formed part of the search strategy. Articles were evaluated for quality and risks of bias. RESULTS: Fourteen articles were included in the systematic review and five articles were selected for the meta-analysis. Based on the findings of the review and meta-analysis, two distinct areas were evident: the effect of DSF on blood glucose parameters and the effect of DSF on lipid profile. All fourteen studies included in the systematic review showed that DSF was effective in lowering blood glucose parameters in patients with type 2 diabetes compared with SF. The results of the meta-analysis confirmed the findings of the systematic review with respect to the fasting blood glucose, which was significantly lower (p = 0.01) in the DSF group compared to SF, with a mean difference of -1.15 (95% CI -2.07, -0.23) and glycated haemoglobin, which was significantly lower (p = 0.005) in the DSF group compared to the SF group following meta-analysis and sensitivity analysis. However, in relation to the sensitivity analysis for the fasting blood glucose, differences were not significant between the two groups when some of the studies were removed. Based on the systematic review, the outcomes of the studies selected to evaluate the effect of DSF on lipid profile were variable. Following the meta-analysis, no significant differences (p > 0.05) were found between the DSF and SF groups with respect to total cholesterol, LDL cholesterol and triglyceride. The level of the HDL cholesterol was significantly higher (p = 0.04) in the DSF group compared to the SF group after the intervention, with a mean difference of 0.09 (95% CI, 0.00, 0.18), although this was not consistent based on the sensitivity analysis. The presence of low glycaemic index (GI) carbohydrate, the lower amount of carbohydrate and the higher protein, the presence of mono-unsaturated fatty acids and the different amounts and types of fibre in the DSF compared with SF may be responsible for the observed differences in cardiometabolic parameters in both groups. CONCLUSION: The results provide evidence to suggest that DSF is effective in controlling fasting blood glucose and glycated haemoglobin and in increasing HDL cholesterol, but has no significant effect on other lipid parameters. However, our confidence in these findings would be increased by additional data from further studies.

A Surgical Team Simulation to Improve Teamwork and Communication across Two Continents: ViSIOT Proof-of-Concept Study.

BACKGROUND: Team communication in operating rooms is problematic worldwide, and can negatively impact patient safety. Although initiatives such as the World Health Organization's Surgical Safety Checklist have been introduced to improve communication, patient safety continues to be compromised globally, warranting the development of new interventions. Video-based social science methods have contributed to the study of communication in UK ORs through actual observations of surgical teams in practice. Drawing on this, the authors have developed a surgical team simulation-training model [Video-Supported Simulation of Interactions in the Operating Theatre (ViSIOT)]. A proof-of-concept study was conducted in the UK and USA to assess if the ViSIOT simulation-training has applicability and acceptability beyond the UK. METHODS: ViSIOT training was conducted at two simulation centers in the UK and USA over a 10-month period. All surgical team participants completed a questionnaire (that assessed design, education, satisfaction, and self-confidence in relation to the training). Descriptive and inferential statistics were performed for the quantitative data and thematic analysis was conducted for the qualitative data. RESULTS: There was strong agreement from all participants in terms of their perception of the course across all sub-sections measured. Nine themes from the qualitative data were identified. The two countries shared most themes, however, some emerged that were unique to each country. CONCLUSIONS: Practical developments in the course design, technology, and recruitment were identified. Evidence of the course applicability in the USA provides further affirmation of the universal need for team communication training within ORs. Further studies are required to assess its effectiveness in improving communication in OR practice.

A new approach to multi-professional end of life care training using a sequential simulation (SqS Simulation™) design: A mixed methods study.

BACKGROUND: A need for improved education and training for hospital staff caring for patients in the last year of life was identified at an urban UK hospital. Sequential Simulation (SqS Simulation™) is a type of simulation that recreates a patient's journey, considering the longitudinal element of care and how this might impact on the patient's experiences, wishes and needs. OBJECTIVES: The aim of this study was to investigate a new end of life care training intervention for multi-professional hospital staff, and its effect on their confidence in managing patients at the end of their life. SETTING/PARTICIPANTS: Based on the results of a formal Training Needs Analysis, four SqS Simulation™ specialty-based courses were designed for general medical and surgical multidisciplinary teams in an acute UK hospital. METHODS: Over three months, seven SqS Simulation™ sessions were attended by fifty-seven multidisciplinary healthcare professionals. A quasi-experimental mixed-methods study was conducted using open and closed-ended questionnaires, pre and post-intervention. Changes in course attendees' confidence levels were analysed and qualitative data from free-text answers informed potential reasons for any differences identified. RESULTS: Confidence improved for all professional cohorts (p < 0.001). The differences were found to be highly significant for 'doctors' (p < 0.001), significant for 'therapists' (p = 0.02) and not significant for the 'nurses' cohort (p = 0.238). This was explored further using a qualitative explanatory framework. Categories included: Communicating with Families; Teamwork; Goal Planning; Do Not Attempt Cardiopulmonary Resuscitation; Course Usefulness; Prior Training; and Clinical Experience. CONCLUSION: This study has shown an overall improvement in confidence across disciplines after attending a SqS Simulation™ course. The differences in quantitative results between disciplines were explored through the qualitative data and revealed a difference in what the professionals gained from it. Further studies are required to assess its effectiveness in maintaining confidence of end of life care in practice, as well as its benefit to patient outcomes.

Sequential simulation used as a novel educational tool aimed at healthcare managers: a patient-centred approach.

Background: A new challenge for healthcare managers is to improve the patient experience. Simulation is often used for clinical assessment and rarely for those operating outside of direct clinical care. Sequential simulation (SqS) is a form of simulation that re-creates care pathways, widening its potential use. Local problem: Numbers, outcome measures and system profiling are used to inform healthcare decisions. However, none of these captures the personal subtleties of a patient's experience. Intervention: 56 students attended a teaching module using SqS and facilitated workshops as part of their induction week on an MSc International Health Management course. The workshop was voluntary and was offered as an opportunity for the students to gain an insight into the UK health system through the medium of simulation. Methods: An evaluation survey incorporating quantitative and qualitative student feedback was conducted. Descriptive statistics were generated from the quantitative data, and thematic analysis was undertaken for the qualitative data. Results: There was strong agreement for the acceptability of the workshop approach in relation to the aims and objectives. Likert scale (1--5) mean total=4.49. Participants responded enthusiastically (revealed through the qualitative data) with ideas related to perspectives sharing, understanding healthcare management and processes and the consideration of feasibility and practicalities. They also suggested other applications that SqS could be used for. Conclusion: The SqS approach has demonstrated that simulation has a wider potential than for clinical assessment alone. Further studies are required to determine its potential uses and affordances beyond its current format.

Sequential simulation of a patient journey.

OBJECTIVES: To develop an intervention for educating pharmacists (community and hospital) about integrated care and their role in implementing it. METHODS: We developed a sequential simulation derived from a patient's journey, with the key scenario featuring a community pharmacist. The scenarios were designed with input from pharmacists and patients, and emphasised the point that operating in silos can have an affect on the patient. Operating in silos can have an affect on the patient EVALUATION: Evaluation was by questionnaire, field notes and analysis of video material. Of the 37 participants in total, 21 (56.7%) responded to the questionnaire, and 19 of the 21 expressed that they felt the event was a good or excellent educational experience, had improved their confidence in their capability to improve patient care, and said that their knowledge and understanding of integrated care had been enhanced. The sequential simulation was appreciated as a way of visualising integrated care, with 19/21 describing it as good or excellent. Further themes were identified through video analysis and field-note analysis. CONCLUSION: Sequential simulation is a novel and practical approach to present current care pathways, aiming to generate a mutual focus, create participant empathy and bring the conventionalities of integrated care to life. We consider this approach helpful in preparing frontline staff to participate in integrated care.

Sequential simulation (SqS) of clinical pathways: a tool for public and patient engagement in point-of-care diagnostics.

OBJECTIVES: Public and patient engagement (PPE) is fundamental to healthcare research. To facilitate effective engagement in novel point-of-care tests (POCTs), the test and downstream consequences of the result need to be considered. Sequential simulation (SqS) is a tool to represent patient journeys and the effects of intervention at each and subsequent stages. This case study presents a process evaluation of SqS as a tool for PPE in the development of a volatile organic compound-based breath test POCT for the diagnosis of oesophagogastric (OG) cancer. SETTING: Three 3-hour workshops in central London. PARTICIPANTS: 38 members of public attended a workshop, 26 (68%) had no prior experience of the OG cancer diagnostic pathway. INTERVENTIONS: Clinical pathway SqS was developed from a storyboard of a patient, played by an actor, noticing symptoms of oesophageal cancer and following a typical diagnostic pathway. The proposed breath testing strategy was then introduced and incorporated into a second SqS to demonstrate pathway impact. Facilitated group discussions followed each SqS. PRIMARY AND SECONDARY OUTCOME MEASURES: Evaluation was conducted through pre-event and postevent questionnaires, field notes and analysis of audiovisual recordings. RESULTS: 38 participants attended a workshop. All participants agreed they were able to contribute to discussions and like the idea of an OG cancer breath test. Five themes emerged related to the proposed new breath test including awareness of OG cancer, barriers to testing and diagnosis, design of new test device, new clinical pathway and placement of test device. 3 themes emerged related to the use of SqS: participatory engagement, simulation and empathetic engagement, and why participants attended. CONCLUSIONS: SqS facilitated a shared immersive experience for participants and researchers that led to the coconstruction of knowledge that will guide future research activities and be of value to stakeholders concerned with the invention and adoption of POCT.

Unsettled teamwork: communication and learning in the operating theatres of an urban hospital.

AIM: To explore the unsettling effects of increased mobility of nurses, surgeons and other healthcare professionals on communication and learning in the operating theatre. BACKGROUND: Increasingly, healthcare professionals step in and out of newly formed transient teams and work with colleagues they have not met before, unsettling previously relatively stable team work based on shared, local knowledge accumulated over significant periods of close collaboration. DESIGN: An ethnographic case study was conducted of the operating theatre department of a major teaching hospital in London. METHOD: Video recordings were made of 20 operations, involving different teams. The recordings were systematically reviewed and coded. Instances where difficulties arose in the communication between scrub nurse and surgeons were identified and subjected to detailed, interactional analysis. FINDINGS: Instrument requests frequently prompted clarification from the scrub nurse (e.g. 'Sorry, what did you want?'). Such requests were either followed by a relatively elaborate clarification, designed to maximize learning opportunities, or a by a relatively minimal clarification, designed to achieve the immediate task at hand. CONCLUSIONS: Significant variation exists in the degree of support given to scrub nurses requesting clarification. Some surgeons experience such requests as disruptions, while others treat them as opportunities to build shared knowledge.

A Video Analysis of Intra- and Interprofessional Leadership Behaviors Within "The Burns Suite": Identifying Key Leadership Models.

OBJECTIVE: Leadership is particularly important in complex highly interprofessional health care contexts involving a number of staff, some from the same specialty (intraprofessional), and others from different specialties (interprofessional). The authors recently published the concept of "The Burns Suite" (TBS) as a novel simulation tool to deliver interprofessional and teamwork training. It is unclear which leadership behaviors are the most important in an interprofessional burns resuscitation scenario, and whether they can be modeled on to current leadership theory. The purpose of this study was to perform a comprehensive video analysis of leadership behaviors within TBS. METHODS: A total of 3 burns resuscitation simulations within TBS were recorded. The video analysis was grounded-theory inspired. Using predefined criteria, actions/interactions deemed as leadership behaviors were identified. Using an inductive iterative process, 8 main leadership behaviors were identified. Cohen's κ coefficient was used to measure inter-rater agreement and calculated as κ = 0.7 (substantial agreement). Each video was watched 4 times, focusing on 1 of the 4 team members per viewing (senior surgeon, senior nurse, trainee surgeon, and trainee nurse). The frequency and types of leadership behavior of each of the 4 team members were recorded. Statistical significance to assess any differences was assessed using analysis of variance, whereby a p < 0.05 was taken to be significant. Leadership behaviors were triangulated with verbal cues and actions from the videos. RESULTS: All 3 scenarios were successfully completed. The mean scenario length was 22 minutes. A total of 362 leadership behaviors were recorded from the 12 participants. The most evident leadership behaviors of all team members were adhering to guidelines (which effectively equates to following Advanced Trauma and Life Support/Emergency Management of Severe Burns resuscitation guidelines and hence "maintaining standards"), followed by making decisions. Although in terms of total frequency the senior surgeon engaged in more leadership behaviors compared with the entire team, statistically there was no significant difference between all 4 members within the 8 leadership categories. This analysis highlights that "distributed leadership" was predominant, whereby leadership was "distributed" or "shared" among team members. The leadership behaviors within TBS also seemed to fall in line with the "direction, alignment, and commitment" ontology. CONCLUSIONS: Effective leadership is essential for successful functioning of work teams and accomplishment of task goals. As the resuscitation of a patient with major burns is a dynamic event, team leaders require flexibility in their leadership behaviors to effectively adapt to changing situations. Understanding leadership behaviors of different team members within an authentic simulation can identify important behaviors required to optimize nontechnical skills in a major resuscitation. Furthermore, attempting to map these behaviors on to leadership models can help further our understanding of leadership theory. Collectively this can aid the development of refined simulation scenarios for team members, and can be extrapolated into other areas of simulation-based team training and interprofessional education.

Engaging patients and clinicians through simulation: rebalancing the dynamics of care.

This paper proposes simulation-based enactment of care as an innovative and fruitful means of engaging patients and clinicians to create collaborative solutions to healthcare issues. This use of simulation is a radical departure from traditional transmission models of education and training. Instead, we frame simulation as co-development, through which professionals, patients and publics share their equally (though differently) expert perspectives. The paper argues that a process of participatory design can bring about new insights and that simulation offers understandings that cannot easily be expressed in words. Drawing on more than a decade of our group's research on simulation and engagement, the paper summarises findings from studies relating to clinician-patient collaboration and proposes a novel approach to address the current need. The paper outlines a mechanism whereby pathways of care are jointly created, shaped, tested and refined by professionals, patients, carers and others who are affected and concerned by clinical care.