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    Four System Enablers of Large‐System Transformation in Health Care: A Mixed Methods Realist Evaluation

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    Abstract Policy Points The implementation of large-scale health care interventions relies on a shared vision, commitment to change, coordination across sites, and a spanning of siloed knowledge. Enablers of the system should include building an authorizing environment; providing relevant, meaningful, transparent, and timely data; designating and distributing leadership and decision making; and fostering the emergence of a learning culture. Attention to these four enablers can set up a positive feedback loop to foster positive change that can protect against the loss of key staff, the presence of lone disruptors, and the enervating effects of uncertainty. Context Large-scale transformative initiatives have the potential to improve the quality, efficiency, and safety of health care. However, change is expensive, complex, and difficult to implement and sustain. This paper advances system enablers, which will help to guide large-scale transformation in health care systems. Methods A realist study of the implementation of a value-based health care program between 2017 and 2021 was undertaken in every public hospital (n = 221) in New South Wales (NSW), Australia. Four data sources were used to elucidate initial program theories beginning with a set of literature reviews, a program document review, and informal discussions with key stakeholders. Semistructured interviews were then conducted with 56 stakeholders to confirm, refute, or refine the theories. A retroductive analysis produced a series of context-mechanism-outcome (CMO) statements. Next, the CMOs were validated with three health care quality expert panels (n = 51). Synthesized data were interrogated to distill the overarching system enablers. Findings Forty-two CMO statements from the eight initial program theory areas were developed, refined, and validated. Four system enablers were identified: (1) build an authorizing environment; (2) provide relevant, authentic, timely, and meaningful data; (3) designate and distribute leadership and decision making; and (4) support the emergence of a learning culture. The system enablers provide a nuanced understanding of large-system transformation that illustrates when, for whom, and in what circumstances large-system transformation worked well or worked poorly. Conclusions System enablers offer nuanced guidance for the implementation of large-scale health care interventions. The four enablers may be portable to similar contexts and provide the empirical basis for an implementation model of large-system value-based health care initiatives. With concerted application, these findings can pave the way not just for a better understanding of greater or lesser success in intervening in health care settings but ultimately to contribute higher quality, higher value, and safer care

    Nitrogen availability regulates the effects of a simulated marine heatwave on carbon sequestration and phycosphere bacteria of a marine crop

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    Great hope has been pinned on seaweed cultivation as being a potent way of removing CO2 to reduce rates of sea surface warming and acidification. Marine heatwaves and nitrogen pollution in coastal ecosystems are serious current issues that need to be better understood to inform decision making and policy. Here, we investigated the effects of a simulated heatwave and nitrogen pollution on carbon sequestration by an important seaweed crop species and its phycosphere bacteria. Gracilaria lemaneiformis was grown in ambient and high nitrogen conditions (14 and 200 μM L−1). Photosynthetic rate, seaweed biomass and particulate organic carbon accumulation were significantly increased in “high nitrogen-no heatwave” conditions. In “ambient nitrogen heatwave” conditions, the expression of genes related to photosynthesis was down regulated and the seaweeds lost more dissolved organic carbon (DOC) to the surrounding water, resulting in more refractory dissolved organic carbon (RDOC). In “high nitrogen heatwave” conditions, photosynthetic gene expression was upregulated; bacterial abundance was also increased that can explain the reduced DOC and RDOC accumulation. The simulated heatwave reduced bacterial diversity while high nitrogen alleviated this effect. These findings suggest that the economically important alga G. lemaneiformis may lose more DOC and RDOC to nearshore waters during marine heatwave events, enhancing carbon sequestration, while nitrogen enrichment has a counteractive effect

    Re-Imagining Marginalised Tudor Voices: Working Women, Print Culture and the Rejection of Female Silence

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    Though the recent work of historians has begun to reveal the rich and complex lives of working women (Hubbard, 2012, p.1), their narrative potential has mostly been ignored by writers of modern historical fiction. Working women are infrequently protagonists and when they do appear, their domesticity is emphasised; those Tudor women who traversed the gender divide to attain employment in male-dominated fields are almost entirely marginalised. This project seeks to address this gap by offering a novel, Carew, that foregrounds the experiences of a working woman, the fictional Hannah Carew, whose character is inspired by the printer Elisabeth Pickering. It conceptualises how a Tudor woman might have experienced Tudor societal expectations, using the printing press to give physical form to gender boundaries. The novel also seeks to creatively consider notions of ‘history’ and how ‘histories’ are constructed and, in so doing, explore possible reasons why working women’s voices have been marginalised. The inclusion of epigraphs establish history as a contested space, while the composition of the First Examination of Anne Askew, an account of the Tudor martyr’s first trial for heresy, is used to explore how historians make use of literary techniques. The project also seeks to challenge, subvert and resist common representations of working women in historical fiction who are often subordinated by their upper-class counterparts

    We Are Displaced, But We Are More Than That: Using Anarchist Principles to Materialize Capitalism’s Cracks at Sites of Contemporary Forced Displacement in Europe

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    AbstractThis article charts the development of The Made in Migration Collective, a coalition of displaced people, academics, and creative professionals that was developed during a recently completed British Academy postdoctoral fellowship. Following discussion of how archaeology and heritage are under attack globally from far-right nationalism and specifically within the UK, I provide examples of how community archaeology can highlight fissures in capitalism. I follow others in interpreting anarchism as a potential form of care. Two public heritage exhibitions – one digital, one “live”—which were collaboratively produced by The Made in Migration Collective are reflected upon.</jats:p

    Association between interpretation flexibility and emotional health in an anxious sample: The challenge of measuring flexible adoption of multiple perspectives

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    Interpreting ambiguous situations in a rigidly negative manner contributes to emotional disorders. Although negative interpretation biases have been well studied in relation to anxiety and depression, the relationship between interpretation flexibility (vs. rigidity) and emotional health remains understudied. The present study is a secondary analysis to test the hypothesis that higher interpretation flexibility is associated with better emotional health, as indicated by lower anxiety and depression levels, and higher quality of life. Here, interpretation flexibility focuses specifically on the ability to recognize multiple possible interpretations within and across ambiguous situations. Using baseline data from N = 939 high trait-anxious community participants who enrolled in an online anxiety intervention, multiple ways of computing interpretation flexibility were applied to help the field learn how different operationalizations can lead to varied conclusions about the connection between interpretation flexibility and emotional health. Using two measures of interpretation style, four approaches (some pre-registered , some exploratory) to computing interpretation flexibility were tested using an internal replication analytic approach. Results varied across type of approach, but in general, contrary to hypotheses, results indicated that higher interpretation flexibility was either unrelated to, or associated with higher, anxiety, and depression, and lower quality of life

    How does living in a rural location affect experiences of acquired vision impairment?

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    This research explores the lived experiences of adults with acquired sight loss who live in rural areas in Southwest England. There is a scarcity of published academic research with this group. Vision impaired people who live in rural locations are therefore unrecognised sources of vision impairment rehabilitation knowledge. The research is conducted in an interpretivist paradigm. The research is guided by phenomenological understanding, rooted in Merleau-Ponty’s concepts of perception, the centrality of tool-use, and human embodiment. Attention is centred on the process of adapting to sight loss in a domestic setting, placing this research in an experiential, community-based educational context. The researcher openly acknowledges her professional migration from urban to rural areas has informed this study. The interview method is an adaptation of the visual imagery-based Z-MET interview technique, re-designed for this group of participants. This study is connected to other multi-sensory research, particularly sensory ethnography. Semi-structured interviews were conducted with eight vision impaired people living in rural Southwest England, generating descriptive data. Interviews were analysed using an Interpretative Phenomenological Analysis framework. The identified themes, Light and Sound; Blindness: a state of difference; Changes in A Working Life; Me, My People and My Animals; My Rural Home; I am what I eat; each express an aspect of participants’ daily lives that is significant. The themes demonstrate how fundamental rurality is for every participant irrespective of whether this was chosen or the outcome of happenstance. This research shows how rural life remains emphatically different from urban living. This research identifies and conveys participants’ living expertise. In conclusion, implications for both vision impairment rehabilitation service policies and professional practice are stated.

    Mental Imagery to Reduce Alcohol-related harm in patients with alcohol use disorder and alcohol-related liver damaGE: the MIRAGE randomised pilot trial results

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    Objective The healthcare burden of alcohol-related liver disease (ARLD) is increasing. ARLD and alcohol use disorder (AUD) is best managed by reduction or cessation of alcohol use, but effective treatments are lacking. We tested whether people with ARLD and AUD admitted to hospital could be recruited to and retained in a trial of Functional Imagery Training (FIT), a psychological therapy that uses mental imagery to reduce alcohol craving. We conducted a multicentre randomised pilot trial of treatment as usual (TAU) versus FIT+TAU in people admitted to hospital with ARLD and AUD. Design Participants were randomised to TAU (a single session of brief intervention) or FIT+TAU (TAU with one hospital-based FIT session then eight telephone sessions over 6 months). Pilot outcomes included recruitment rate and retention at day 180. Secondary outcomes included fidelity of FIT delivery, alcohol use, and severity of alcohol dependence. Results Fifty-four participants (mean age 49; 63% male) were recruited and randomised, 28 to TAU and 26 to FIT+TAU. The retention rate at day 180 was 43%. FIT was delivered adequately by most alcohol nurses. 50% of intervention participants completed FIT sessions 1 and 2. There were no differences in alcohol use or severity of alcohol dependence between treatment groups at day 180. Conclusion Participants with ARLD and AUD could be recruited to a trial of FIT versus FIT+TAU. However, retention at day 180 was suboptimal. Before conducting a definitive trial of FIT in this patient group, modifications in the intervention and recruitment/retention strategy must be tested. Trial registration number ISRCTN41353774

    Educating for capability and preparing for practice: Integrating theory and skills

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    Capability is the ability to perform clinical skills in ever‐changing real world contexts, adapting to challenges and integrating technical and non‐technical skills and competencies, for example, cannulating an uncooperative patient at night. Going beyond teaching competency and ensuring capability is imperative, as recommended by the national outcomes for medical graduates. A course on intravenous cannulation was developed with e‐learning modules and high‐fidelity complex simulation scenarios, aiming to promote capability in practice. The course delivered an intravenous cannulation e‐learning package between two practical simulations to 10 final‐year medical students. The hybrid simulation design consisted of an actor with a bespoke cannulation part‐task trainer strapped to their arm. Each simulation delivered a challenging scenario, requiring the integration of procedural and behavioural skills to succeed. Simulations were video recorded, and participants reviewed their performances before completing semi‐structured interviews. Transcribed interviews were thematically analysed. Interview analysis demonstrated two overarching themes: ‘Impact on Capability’ and ‘Preparedness for Practice’. There was consistent recognition of improved capability from the interviews. Simulation exercises were described as the most valuable tool for developing capability. The e‐learning helped with structure, facilitating students' adaptation to scenarios. Participants felt that training in medical school was largely competency‐based and did not tackle complex interactions. Following e‐learning and simulations, students felt more prepared for clinical practice. The course structure has value for medical professionals in developing capability and preparing for clinical practice, helping to reach standards expected of graduates. Plans to assess capability across multiple undergraduate programmes through Entrustable Professional Activities are in progress

    Population genetics of green (Chelonia mydas) and hawksbill turtles (Eretmochelys imbricata) in Grenada, West Indies

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    Sea turtle populations within Grenada are believed to be in decline, consistent with worldwide trends. Conservation strategies for green and hawksbill turtles in Grenada are currently limited by a lack of detailed knowledge of the genetic make-up, life history and migration patterns of the local aggregates of these species. Genetic characterisation provides a means for inferring population diversity and origins for these aggregates and to assess potential impacts from regional and worldwide management strategies. Additionally, chelonid alphaherpesvirus-5 (ChHV5) and ChHV5-associated fibropapillomatosis (FP) have recently been reported within Grenada’s green turtle population, but the epidemiology of the disease in Grenada remains poorly understood. We genetically characterised Grenada’s foraging green (n = 57), nesting hawksbill (n = 18), and foraging hawksbill turtle populations (n = 22), and used mixed stock analysis (MSA) to assess the level of genetic connectivity of Grenada’s populations with other populations in the Atlantic region. Furthermore, foraging green turtles were assessed for prior exposure to ChHV5 using a serological assay to examine associations between origins and infection status. Mitochondrial DNA (mtDNA) sequencing data revealed seven haplotypes within Grenada’s foraging green turtle population, including one novel haplotype (CM-A82.1), and a total of seven haplotypes across Grenada’s nesting and foraging hawksbill turtle populations, including one (Ei-A68) and two rare haplotypes (Ei-A45, Ei-A72), respectively. We identify Grenada’s Isle de Caille rookery as a nesting population of origin for haplotype Ei-A68, which was an orphan haplotype prior to this study. MSA results indicate that Grenada’s green and hawksbill turtle populations are associated with that of 15 other countries throughout the Atlantic region. ChHV5-specific antibodies were identified in serum samples in 9.38% of green turtles, with no apparent association of ChHV5 serology status and green turtle haplotype. Mixed stock analyses strongly indicate that Grenada’s sea turtle populations are regionally shared resources and should be managed as such. Furthermore, the rare and/or unique haplotypes present within Grenada’s sea turtle populations offer valuable genetic diversity to the wider region and further conservation strategies are warranted to protect these at-risk haplotypes


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