Exploring the influence of health system factors on adaptive capacity in diverse hospital teams in Norway: a multiple case study approach.

OBJECTIVES: Understanding flexibility and adaptive capacities in complex healthcare systems is a cornerstone of resilient healthcare. Health systems provide structures in the form of standards, rules and regulation to healthcare providers in defined settings such as hospitals. There is little knowledge of how hospital teams are affected by the rules and regulations imposed by multiple governmental bodies, and how health system factors influence adaptive capacity in hospital teams. The aim of this study is to explore the extent to which health system factors enable or constrain adaptive capacity in hospital teams. DESIGN: A qualitative multiple case study using observation and semistructured interviews was conducted between November 2020 and June 2021. Data were analysed through qualitative content analysis with a combined inductive and deductive approach. SETTING: Two hospitals situated in the same health region in Norway. PARTICIPANTS: Members from 8 different hospital teams were observed during their workday (115 hours) and were subsequently interviewed about their work (n=30). The teams were categorised as structural, hybrid, coordinating and responsive teams. RESULTS: Two main health system factors were found to enable adaptive capacity in the teams: (1) organisation according to regulatory requirements to ensure adaptive capacity, and (2) negotiation of various resources provided by the governing authorities to ensure adaptive capacity. Our results show that aligning to local context of these health system factors affected the team's adaptive capacity. CONCLUSIONS: Health system factors should create conditions for careful and safe care to emerge and provide conditions that allow for teams to develop both their professional expertise and systems and guidelines that are robust yet sufficiently flexible to fit their everyday work context.

Decoding healthcare teamwork: a typology of hospital teams.

The effectiveness of healthcare depends on successful teamwork. Current understanding of teamwork in healthcare is limited due to the complexity of the context, variety of team structures, and unique demands of healthcare work. This qualitative study aimed to identify different types of healthcare teams based on their structure, membership, and function. The study used an ethnographic approach to observe five teams in an English hospital. Data were analyzed using a combined inductive-deductive approach based on the Temporal Observational Analysis of Teamwork framework. A typology was developed, consisting of five team types: structural, hybrid, satellite, responsive, and coordinating. Teams were challenged to varying degrees with staffing, membership instability, equipment shortages, and other elements of the healthcare environment. Teams varied in their ability to respond to these challenges depending on their characteristics, such as their teamworking style, location, and membership. The typology developed in this study can help healthcare organizations to better understand and design effective teams for different healthcare contexts. It can also guide future research on healthcare teams and provide a framework for comparing teams across settings. To improve teamwork, healthcare organizations should consider the unique needs of different team types and design effective training programs accordingly.

External inspection approaches and involvement of stakeholders' views in inspection following serious incidents - a qualitative mixed methods study from the perspectives of regulatory inspectors.

OBJECTIVE: The objective was to gain knowledge about how external inspections following serious incidents are played out in a Norwegian hospital context from the perspective of the inspectors, and whether stakeholders' views are involved in the inspection. METHODS: Based on a qualitative mixed methods design, 10 government bureaucrats and inspectors situated at the National Board of Health Supervision and three County Governors in Norway, were strategically recruited, and individual semi-structured interviews were conducted. Key official government documents were selected, collected, and thematically analyzed along with the interview data. RESULTS: Our findings overall demonstrate two overarching themes: Theme (1) Perspectives on different external inspection approaches of responding and involving stakeholders in external inspection following serious incidents, Theme (2) Inspectors' internal work practices versus external expectations. Documents and all participants reported a development towards new approaches in external inspection, with more policies and regulatory attention to sensible involvement of stakeholders. Involvement and interaction with patients and informal caregivers could potentially inform the case complexity and the inspector's decision-making process. However, stakeholder involvement was sometimes complex and challenging due to e.g., difficult communication and interaction with patients and/or informal caregivers, due to resource demands and/or the inspector's lack of experience and/or relevant competence, different perceptions of the principle of sound professional practice, quality, and safety. The inspectors considered balancing the formal objectives and expectations, with the expectations of the public and different stakeholders (i.e. hospitals, patients and/or informal caregivers) a challenging part of their job. This balance was seen as an important part of the continuous development of ensuring public trust and legitimacy in external inspection processes. CONCLUSIONS AND IMPLICATIONS: Our study suggests that the regulatory system of external inspection and its available approaches of responding to a serious incident in the Norwegian setting is currently not designed to accommodate the complexity of needs from stakeholders at the levels of hospital organizations, patients, and informal caregivers altogether. Further studies should direct attention to how the wider system of accountability structures may support the internal work practices in the regulatory system, to better algin its formal objectives with expectations of the public.

Improving the quality of written communication at patient discharge: triangulation of qualitative analyses and intervention co-design.

BACKGROUND: Poor handovers between hospital and primary care threaten safe discharges, with elderly and frail patients most at risk of harm. Using Behavioural Science we explored influences and identified relevant behaviour change techniques (BCTs) to improve written handovers and safety during discharge. METHODS: We conducted two qualitative studies: (1) ethnographic observations (>80 h) collected by five researchers in five purposively sampled clinical areas of a London teaching hospital, investigating routine work and interactions of hospital staff involved in discharges; and (2) 12 semi-structured interviews with hospital staff involved in discharge exploring influences on preparations of written handovers. Written consent was sought from clinical leads for ethnographic observations and from interview participants. Ethnographic fieldnotes and interview transcripts were thematically analysed using inductive and deductive approaches, respectively. Study findings were triangulated to identify key influences, mapped onto the Theoretical Domains Framework (TDF). We identified appropriate BCTs to address observed influences within each TDF domain using the Theory and Techniques Tool. Health-care workers (n=15), patients (n=2) and carers (n=2) selected and designed an intervention to improve written handovers in two workshops. Hospital workshop participants were involved with preparing written discharge handovers. Public participants had either recently been discharged from hospital or cared for someone recently discharged, including patients from groups especially vulnerable during discharge. FINDINGS: Triangulation of study findings generated 11 key influences on preparations of written handovers within five TDF domains: knowledge (eg, lack of awareness of guidelines), skills (staff experience), social or professional role and identity (effective communication), environmental context and resources (working patterns), and social influences (lack of feedback). 14 BCTs were identified to address these influences, including behavioural rehearsal or practice, instruction on how to perform a behaviour, and social support (practical). Workshop participants selected and designed a multifaceted educational intervention to improve written handovers. INTERPRETATION: The quality of handover documentation prepared by hospital staff for primary care teams is affected by influences from multiple domains, requiring a multifaceted approach to improve handovers. Although only based on findings from one hospital, the designed intervention should be tested in clinical settings with key stakeholders, including primary care staff, to evaluate impact on quality of written handovers and patient safety. FUNDING: National Institute for Health and Care Research (NIHR) Imperial Patient Safety Translational Research Centre.

Transient conformations in the unliganded FK506 binding domain of FKBP51 correspond to two distinct inhibitor-bound states.

Members of the FK506-binding protein (FKBP) family regulate a range of important physiological processes. Unfortunately, current therapeutics such as FK506 and rapamycin exhibit only modest selectivity among these functionally distinct proteins. Recent progress in developing selective inhibitors has been reported for FKBP51 and FKBP52, which act as mutual antagonists in the regulation of steroid hormone signaling. Two structurally similar inhibitors yield distinct protein conformations at the binding site. Localized conformational transition in the binding site of the unliganded FK1 domain of FKBP51 is suppressed by a K58T mutation that also suppresses the binding of these inhibitors. Here, it is shown that the changes in amide hydrogen exchange kinetics arising from this K58T substitution are largely localized to this structural region. Accurate determination of the hydroxide-catalyzed exchange rate constants in both the wildtype and K58T variant proteins impose strong constraints upon the pattern of amide exchange reactivities within either a single or a pair of transient conformations that could give rise to the differences between these two sets of measured rate constants. Poisson-Boltzmann continuum dielectric calculations provide moderately accurate predictions of the structure-dependent hydrogen exchange reactivity for solvent-exposed protein backbone amides. Applying such calculations to the local protein conformations observed in the two inhibitor-bound FKBP51 domains demonstrated that the experimentally determined exchange rate constants for the wildtype domain are robustly predicted by a population-weighted sum of the experimental hydrogen exchange reactivity of the K58T variant and the predicted exchange reactivities in model conformations derived from the two inhibitor-bound protein structures.

No size fits all - a qualitative study of factors that enable adaptive capacity in diverse hospital teams.

Introduction: Resilient healthcare research studies how healthcare systems and stakeholders adapt and cope with challenges and changes to enable high quality care. By examining how performance emerges in everyday work in different healthcare settings, the research seeks to receive knowledge of the enablers for adaptive capacity. Hospitals are defined as complex organizations with a large number of actors collaborating on increasingly complexity tasks. Consequently, most of today's work in hospitals is team based. The study aims to explore and describe what kind of team factors enable adaptive capacity in hospital teams. Methods: The article reports from a multiple embedded case study in two Norwegian hospitals. A case was defined as one hospital containing four different types of teams in a hospital setting. Data collection used triangulation of observation (115 h) and interviews (30), followed by a combined deductive and inductive analysis of the material. Results: The study identified four main themes of team related factors for enabling adaptive capacity; (1) technology and tools, (2) roles, procedures, and organization of work, (3) competence, experience, knowledge, and learning, (4) team culture and relations. Discussion: Investigating adaptive capacity in four different types of teams allowed for consideration of a range of team types within healthcare and how the team factors vary within and across these teams. All of the four identified team factors are of importance in enabling adaptive capacity, the various attributes of the respective team types prompt differences in the significance of the different factors and indicates that different types of teams could need diverse types of training, structural and relational emphasis in team composition, leadership, and non-technical skills in order to optimize everyday functionality and adaptive capacity.

Subsequent COVID-19 Prophylaxis in COVID-19 Associated Glomerulopathies.

Successful vaccination has been the decisive factor in the overall decline of SARS-CoV2 infection related morbidity and mortality. However, global effects of the COVID-19 pandemic are ongoing, with reports of glomerular disease occurring in relation to both infection and vaccination. A particular rise in anti-GBM disease has been identified. Information is still emerging regarding the optimal management of such cases. We reviewed anti-GBM antibody detection rates at our test center over the past 5 years. We followed three patients with biopsy confirmed glomerular disease temporally related to COVID-19 vaccination. Each patient proceeded to receive subsequent COVID-19 vaccination as per immunologist recommendations. Further assessment included COVID-19 antibody testing in each case. A three-fold increase in significant anti-GBM antibody results noted at our center was associated with COVID infection in 10% of cases, and COVID vaccination in 25% of cases. We demonstrated that subsequent vaccination did not appear to lead to adverse effects including relapse in our three cases of COVID-19 vaccine-associated GN. We also identified positive COVID-19 antibody levels in two out of three cases, despite immunosuppression. We report a rise in anti-GBM antibody disease incidence. Our small study suggests that COVID-19 antibody testing can help determine COVID prophylaxis requirements, and subsequent vaccination with an alternative vaccine type appears safe.

An integrated assessment of the 1,4-dioxane cancer mode of action and threshold response in rodents.

1,4-Dioxane is an environmental contaminant that has been shown to cause cancer in rodents after chronic high dose exposures. We reviewed and integrated information from recently published studies to update our understanding of the cancer mode of action of 1,4-dioxane. Tumor development in rodents from exposure to high doses of 1,4-dioxane is preceded by pre-neoplastic events including increased hepatic genomic signaling activity related to mitogenesis, elevation of Cyp2E1 activity and oxidative stress leading to genotoxicity and cytotoxicity. These events are followed by regenerative repair and proliferation and eventual development of tumors. Importantly, these events occur at doses that exceed the metabolic clearance of absorbed 1,4-dioxane in rats and mice resulting in elevated systemic levels of parent 1,4-dioxane. Consistent with previous reviews, we found no evidence of direct mutagenicity from exposure to 1,4-dioxane. We also found no evidence of CAR/PXR, AhR or PPARα activation resulting from exposure to 1,4-dioxane. This integrated assessment supports a cancer mode of action that is dependent on exceeding the metabolic clearance of absorbed 1,4-dioxane, direct mitogenesis, elevation of Cyp2E1 activity and oxidative stress leading to genotoxicity and cytotoxicity followed by sustained proliferation driven by regenerative repair and progression of heritable lesions to tumor development.

Weight of evidence evaluation for chemical-induced immunotoxicity for PFOA and PFOS: findings from an independent panel of experts.

Immunotoxicity is the critical endpoint used by some regulatory agencies to establish toxicity values for perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS). However, the hypothesis that exposure to certain per- and polyfluoroalkyl substances (PFAS) causes immune dysregulation is subject to much debate. An independent, international expert panel was engaged utilizing methods to reduce bias and "groupthink". The panel concluded there is moderate evidence that PFOS and PFOA are immunotoxic, based primarily on evidence from animal data. However, species concordance and human relevance cannot be well established due to data limitations. The panel recommended additional testing that includes longer-term exposures, evaluates both genders, includes other species of animals, tests lower dose levels, assesses more complete measures of immune responses, and elucidates the mechanism of action. Panel members agreed that the Faroe Islands cohort data should not be used as the primary basis for deriving PFAS risk assessment values. The panel agreed that vaccine antibody titer is not useful as a stand-alone metric for risk assessment. Instead, PFOA and PFOS toxicity values should rely on multiple high-quality studies, which are currently not available for immune suppression. The panel concluded that the available PFAS immune epidemiology studies suffer from weaknesses in study design that preclude their use, whereas available animal toxicity studies provide comprehensive dataset to derive points of departure (PODs) for non-immune endpoints. The panel recommends accounting for potential PFAS immunotoxicity by applying a database uncertainty factor to POD values derived from animal studies for other more robustly supported critical effects.

Interventions to enhance pre-pregnancy care for women with type 2 diabetes: A systematic review of the literature.

AIMS: The aim of the study was to examine the content and impact of interventions that have been used to increase the uptake of pre-pregnancy care for women with type 2 diabetes, and their impact on maternal and fetal outcomes. METHODS: A systematic search of multiple databases was conducted in November 2021, and updated July 2022, to identify studies assessing interventions to enhance pre-pregnancy care for women with type 2 diabetes. Over 10% of articles were screened by two reviewers at title and abstract phase, after which all selected full-text articles were screened by two reviewers. Quality assessment was conducted using the Critical Appraisal Skills Programme checklist for cohort studies. Meta-analysis was not possible due to study heterogeneity; therefore, narrative synthesis was conducted. RESULTS: Four eligible cohort studies were identified. The conclusions able to be drawn by this review were limited as women with type 2 diabetes (n = 800) were in the minority in all four studies (35%-40%) and none of the interventions were exclusively tailored for them. The uptake of pre-pregnancy care was lower in women with type 2 diabetes (8%-10%) compared with other participant groups in the studies. Pregnancy preparation indicators generally improved among all groups exposed to pre-pregnancy care, with varying impact on pregnancy outcomes. CONCLUSIONS: This review demonstrates that previous interventions have had a limited impact on pre-pregnancy care uptake in women with type 2 diabetes. Future studies should focus on tailored interventions for improving pre-pregnancy care for women with type 2 diabetes, particularly those from ethnic minorities and living in poorer communities.

Shifts in the composition and distribution of Pacific Arctic larval fish assemblages in response to rapid ecosystem change.

The Pacific Arctic marine ecosystem has undergone rapid changes in recent years due to ocean warming, sea ice loss, and increased northward transport of Pacific-origin waters into the Arctic. These climate-mediated changes have been linked to range shifts of juvenile and adult subarctic (boreal) and Arctic fish populations, though it is unclear whether distributional changes are also occurring during the early life stages. We analyzed larval fish abundance and distribution data sampled in late summer from 2010 to 2019 in two interconnected Pacific Arctic ecosystems: the northern Bering Sea and Chukchi Sea, to determine whether recent warming and loss of sea ice has restricted habitat for Arctic species and altered larval fish assemblage composition from Arctic- to boreal-associated taxa. Multivariate analyses revealed the presence of three distinct multi-species assemblages across all years: (1) a boreal assemblage dominated by yellowfin sole (Limanda aspera), capelin (Mallotus catervarius), and walleye pollock (Gadus chalcogrammus); (2) an Arctic assemblage composed of Arctic cod (Boreogadus saida) and other common Arctic species; and (3) a mixed assemblage composed of the dominant species from the other two assemblages. We found that the wind- and current-driven northward advection of warmer, subarctic waters and the unprecedented low-ice conditions observed in the northern Bering and Chukchi seas beginning in 2017 and persisting into 2018 and 2019 have precipitated community-wide shifts, with the boreal larval fish assemblage expanding northward and offshore and the Arctic assemblage retreating poleward. We conclude that Arctic warming is most significantly driving changes in abundance at the leading and trailing edges of the Chukchi Sea larval fish community as boreal species increase in abundance and Arctic species decline. Our analyses document how quickly larval fish assemblages respond to environmental change and reveal that the impacts of Arctic borealization on fish community composition spans multiple life stages over large spatial scales.

The impact of COVID-19 on nurses (ICON) survey: Nurses' accounts of what would have helped to improve their working lives.

AIMS: To use nurses' descriptions of what would have improved their working lives during the first peak of the COVID-19 pandemic in the UK. DESIGN: Analysis of free-text responses from a cross-sectional survey of the UK nursing and midwifery workforce. METHODS: Between 2 and 14 April 2020, 3299 nurses and midwives completed an online survey, as part of the 'Impact of COVID-19 on Nurses' (ICON) study. 2205 (67%) gave answers to a question asking for the top three things that the government or their employer could do to improve their working lives. Each participants' response was coded using thematic and content analysis. Multiple response analysis quantified the frequency of different issues and themes and examined variation by employer. RESULTS: Most (77%) were employed by the National Health Service (77%) and worked at staff or senior staff nurse levels (55%). 5938 codable responses were generated. Personal protective equipment/staff safety (60.0%), support to workforce (28.6%) and better communication (21.9%) were the most cited themes. Within 'personal protective equipment', responses focussed most on available supply. Only 2.8% stated that nothing further could be done. Patterns were similar in both NHS and non-NHS settings. CONCLUSIONS: The analysis provided valuable insight into key changes required to improve the work lives of nurses during a pandemic. Urgent improvements in provision and quality of personal protective equipment were needed for the safety of both workforce and patients. IMPACT: Failure to meet nurses needs to be safe at work appears to have damaged morale in this vital workforce. We identified key strategies that, if implemented by the Government and employers, could have improved the working lives of the nursing and midwifery workforce during the early stages of the COVID-19 pandemic and could prevent the pandemic from having a longer-term negative impact on the retention of this vital workforce. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution, due to the COVID-19 Pandemic, urgency of the work and the target population being health and social care staff.

A qualitative study of organisational resilience in care homes in Scotland.

Providing care for the dependent older person is complex and there have been persistent concerns about care quality as well as a growing recognition of the need for systems approaches to improvement. The I-SCOPE (Improving Systems of Care for the Older person) project employed Resilient Healthcare (RHC) theory and the CARE (Concepts for Applying Resilience) Model to study how care organisations adapt to complexity in everyday work, with the aim of exploring how to support resilient performance. The project was an in-depth qualitative study across multiple sites over 24 months. There were: 68 hours of non-participant observation, shadowing care staff at work and starting broad before narrowing to observe care domains of interest; n = 33 recorded one-to-one interviews (32 care staff and one senior inspector); three focus groups (n = 19; two with inspectors and one multi-disciplinary group); and five round table discussions on emergent results at a final project workshop (n = 31). All interviews and discussion groups were recorded and transcribed verbatim. Resident and family interviews (n = 8) were facilitated through use of emotional touchpoints. Analysis using QSR NVivo 12.0 focused on a) capturing everyday work in terms of the interplay between demand and capacity, adaptations and intended and unintended outcomes and b) a higher-level thematic description (care planning and use of information; coordination of everyday care activity; providing person-centred care) which gives an overview of resilient performance and how it might be enhanced. This gives important new insight for improvement. Conclusions are that resilience can be supported through more efficient use of information, supporting flexible adaptation, coordination across care domains, design of the physical environment, and family involvement based on realistic conversations about quality of life.

What are nurses' roles in modern healthcare? A qualitative interview study using interpretive description.

Aim: Nursing work has historically been difficult to specify. This has led to difficulties in determining safe staffing requirements and adequately supporting safe patient care. The aim of this qualitative interview study was to explore how nurses understand their work. Design: Qualitative interview study, using the interpretive description methodology. Methods: Twenty registered nurses and nursing students completed semi-structured interviews about their work. The researcher drew on the interpretive description methodology to analyse interview data and create a model that interprets participants' experiences of their nursing work. Results: Nurses understand their work by its role in the healthcare system, rather than by the tasks or activities they complete. This understanding is significant because nurses adapt their work constantly, and rigid definitions of working would not support safe adaptation. Nurses report working across three broad roles: clinical work, which is patient-facing; managing work, which sustains the care environment; and enabling work, which provides supports like research and education that make nursing a profession. Conclusions: Clinical, managing and enabling work have different aims, but all serve the purpose of supporting safe patient care and sustaining healthcare systems. Adaptation is a constant feature of each of these roles. This model may be useful for nurses in structuring and explaining their work and informing nursing workforce policy.

Understanding complex work using an extension of the resilience CARE model: an ethnographic study.

BACKGROUND: Resilient Healthcare research centres on understanding and improving quality and safety in healthcare. The Concepts for Applying Resilience Engineering (CARE) model highlights the relationships between demand, capacity, work-as-done, work-as-imagined, and outcomes, all of which are central aspects of Resilient Healthcare theory. However, detailed descriptions of the nature of misalignments and the mechanisms used to adapt to them are still unknown. OBJECTIVE: The objectives were to identify and classify types of misalignments between demand and capacity and types of adaptations that were made in response to misalignments. METHODS: The study involved 88.5 hours of non-participant ethnographic observations in a large, teaching hospital in central London. The wards included in the study were: two surgical wards, an older adult ward, a critical care unit, and the Acute Assessment Unit (AAU), an extension unit created to expedite patient flow out of the Emergency Department. Data were collected via observations of routine clinical work and ethnographic interviews with healthcare professionals during the observations. Field notes were transcribed and thematically analysed using a combined deductive-inductive approach based on the CARE model. RESULTS: A total of 365 instances of demand-capacity misalignment were identified across the five wards included in the study. Of these, 212 had at least one observed corresponding work adaptation. Misalignments identified include equipment, staffing, process, communication, workflow, and space. Adaptations identified include process, resource redistribution, and extra-role performance. For all misalignment types observed across the five in-patient settings, process adaptations were the most frequently used adaptations. The exception to this was for staffing misalignments, which were most frequently responded to with extra-role performance adaptations. Of the three process adaptations, hospital workers most often adapted by changing how the process was done. CONCLUSIONS: This study contributes a new version of the CARE model that includes types of misalignments and corresponding adaptations, which can be used to better understand work-as-done. This affords insight into the complexity of the system and how it might be improved by reducing misalignments via work system redesign or by enhancing adaptive capacity.

Theorising Health System Resilience and the Role of Government Policy- Challenges and Future Directions Comment on "Government Actions and Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada".

Resilient healthcare (RHC) emphasises the importance of adaptive capacity to respond to unanticipated crises such as the global coronavirus disease 2019 (COVID-19) pandemic but there are few examples of RHC research focusing on the decisions taken by macro level policy makers. The Smaggus et al paper analyses the actions of two governments in Canada and Australia as described in media releases from a resilience perspective. The paper clearly articulates the need for conceptual clarity when analysing system resilience, and integrates three theoretical perspectives to understand the types of government responses and how they were related to resilience. The paper makes a valuable contribution to the developing RHC evidence base, but challenges remain in identifying conceptual frameworks, researching macro level resilience, including identifying and accessing reliable macro level data sources, analysing interactions between macro, meso and micro system levels, and understanding how resilience manifests at different temporal and spatial scales.

Is Mixtures' Additivity Supported by Empirical Data? A Case Study of Developmental Toxicity of PFOS and 6:2 FTS in Wildtype Zebrafish Embryos.

Per- and polyfluoroalkyl substances (PFASs) are a major priority for many federal and state regulatory agencies charged with monitoring levels of emerging contaminants in environmental media and setting health-protective benchmarks to guide risk assessments. While screening levels and toxicity reference values have been developed for numerous individual PFAS compounds, there remain important data gaps regarding the mode of action for toxicity of PFAS mixtures. The present study aims to contribute whole-mixture toxicity data and advance the methods for evaluating mixtures of two key components of aqueous film-forming foams: perfluorooctanesulfonic acid (PFOS), and 6:2 fluorotelomer sulfonic acid (6:2 FTS). Wildtype (AB) zebrafish embryos were exposed to PFOS and 6:2 FTS, both as individual components and as binary mixtures, from 2 to 122 h post-fertilization. Five treatment levels were selected to encompass environmentally relevant exposure levels. Experimental endpoints consisted of mortality, hatching, and developmental endpoints, including swim bladder inflation, yolk sac area, and larval body length. Results from dose-response analysis indicate that the assumption of additivity using conventional points of departure (e.g., NOAEL, LOAEL) is not supported for critical effect endpoints with these PFAS mixtures, and that the interactions vary as a function of the dose range. Alternative methods for quantifying relative potency are proposed, and recommendations for additional investigations are provided to further advance assessments of the toxicity of PFAS mixtures to aquatic organisms.

Exploring the role of leaders in enabling adaptive capacity in hospital teams - a multiple case study.

BACKGROUND: Resilient healthcare research studies how healthcare systems and stakeholders adapt and cope with challenges and changes to enable high quality care. Team leaders are seen as central in coordinating clinical care, but research detailing their contributions in supporting adaptive capacity has been limited. This study aims to explore and describe how leaders enable adaptive capacity in hospital teams. METHODS: This article reports from a multiple embedded case study in two Norwegian hospitals. A case was defined as one hospital containing four different types of teams in a hospital setting. Data collection used triangulation of observation and interviews with leaders, followed by a qualitative content analysis. RESULTS: Leaders contribute in several ways to enhance their teams' adaptive capacity. This study identified four key enablers; (1) building sufficient competence in the teams; (2) balancing workload, risk, and staff needs; (3) relational leadership; and (4) emphasising situational understanding and awareness through timely and relevant information. CONCLUSION: Team leaders are key actors in everyday healthcare systems and facilitate organisational resilience by supporting adaptive capacity in hospital teams. We have developed a new framework of key leadership enablers that need to be integrated into leadership activities and approaches along with a strong relational and contextual understanding.