Objects As Polyagents: Tracing The Histories Of The Gweagal Spears

This paper explores the capacity for objects entangled in complex - and often painful - histories to become constituted of multiple agencies (Gell 1998) through their interaction with various actants in complex and ever-expanding networks of association (Latour 1993; 2005). It does so by analysing how such objects become symbols for multiple histories, presences, and political agendas throughout their social lives (Appadurai 1986; Kopytoff 1986). The paper also examines how these objects influence and construct the pathways of their social lives through their polyagency. ‘Polyagency’ reflects a theory of object agency that I have developed through engaging literature on materiality and agency (Gell 1998), consumption and object movement (Appadurai 1986; Kopytoff 1986), and networks of relationality (Latour 2005). It considers the multiple gathered identities that objects come to embody through the sum of their interactions with various human actors during the objects’ social lives - agencies which then become efficacious in later interactions with people. The productivity of this theory is demonstrated by applying it to the analysis of a complicated repatriation case involving the Gweagal Spears, currently owned by Trinity College and held at the Museum of Archaeology and Anthropology in Cambridge. This application illustrates the impact that innovations in theory and repatriation cases can have on the perceived role of museums regarding object return, decolonisation and reconciliation efforts through relationship-building with source communities.Isaac Newton Trust and Corpus Christi College (under the 'Newton College Masters Scheme'

Supporting your support staff during crises: recommendations for practice leaders to develop a relational workplace

Background: The workload and wellbeing of support staff in general practice has been critically understudied. This includes reception, secretarial and administrative workers who are critical in the daily practice function. Currently, only reception staff are mentioned in the evidence base on general practice working conditions, and all support staff are excluded from studies about the impact of the pandemic on healthcare workers’ work and wellbeing. Aim: To outline the unique work support staff do, the additional burden it places on them, and how the symphony of crises in 2020–2023 compounded those burdens. Additionally, to provide practical advice for practice leaders on how to support staff wellbeing through developing a relational and psychologically safe working environment. Methods: These findings are drawn from qualitative research (case studies built through observations, interviews and focus groups) conducted in 2022–2023. Results: Through theoretically informed analysis, we found that support staff do specialist intersectional guiding work to support patients, other staff, and the practice as a whole. We define this as lay translation, specialist-lay translation, and occupational translation. Under crises, the volume of this work grows, complexifies, and becomes more fragmented. Relational and supportive teams were more able to adapt to these challenges. Discussion: Support staff should be recognised and enabled to perform these specialised roles. Therefore, we provide a set of recommendations for practice leaders to consider integrating into their own workplaces

Economic evaluation of an Australian nurse home visiting programme : a randomised trial at 3 years

Objectives To investigate the additional programme cost and cost-effectiveness of ‘right@home’ Nurse Home Visiting (NHV) programme in relation to improving maternal and child outcomes at child age 3 years compared with usual care. Design A cost–utility analysis from a government-as-payer perspective alongside a randomised trial of NHV over 3-year period. Costs and quality-adjusted lifeyears (QALYs) were discounted at 5%. Analysis used an intention-to-treat approach with multiple imputation. Setting The right@home was implemented from 2013 in Victoria and Tasmania states of Australia, as a primary care service for pregnant women, delivered until child age 2 years. Participants 722 pregnant Australian women experiencing adversity received NHV (n=363) or usual care (clinic visits) (n=359). Primary and secondary outcome measures First, a cost–consequences analysis to compare the additional costs of NHV over usual care, accounting for any reduced costs of service use, and impacts on all maternal and child outcomes assessed at 3 years. Second, cost–utility analysis from a government-as-payer perspective compared additional costs to maternal QALYs to express cost-effectiveness in terms of additional cost per additional QALY gained. Results When compared with usual care at child age 3 years, the right@home intervention cost $A7685 extra per woman (95$A7006 to $A8364) and generated 0.01 more QALYs (95$A50 000 per QALY. Conclusions Benefits of NHV to parenting at 2 years and maternal health and well-being at 3 years translate into marginal maternal QALY gains. Like previous cost-effectiveness results for NHV programmes, right@home is not cost-effective at 3 years. Given the relatively high up-front costs of NHV, long-term follow-up is needed to assess the accrual of health and economic benefits over time

Training needs for staff providing remote services in general practice: a mixed-methods study

Background Contemporary general practice includes many kinds of remote encounter. The rise in telephone, video and online modalities for triage and clinical care requires clinicians and support staff to be trained, both individually and as teams, but evidence-based competencies have not previously been produced for general practice. Aim To identify training needs, core competencies, and learning methods for staff providing remote encounters. Design and setting Mixed-methods study in UK general practice. Method Data were collated from longitudinal ethnographic case studies of 12 general practices; a multi-stakeholder workshop; interviews with policymakers, training providers, and trainees; published research; and grey literature (such as training materials and surveys). Data were coded thematically and analysed using theories of individual and team learning. Results Learning to provide remote services occurred in the context of high workload, understaffing, and complex workflows. Low confidence and perceived unmet training needs were common. Training priorities for novice clinicians included basic technological skills, triage, ethics (for privacy and consent), and communication and clinical skills. Established clinicians’ training priorities include advanced communication skills (for example, maintaining rapport and attentiveness), working within the limits of technologies, making complex judgements, coordinating multi-professional care in a distributed environment, and training others. Much existing training is didactic and technology focused. While basic knowledge was often gained using such methods, the ability and confidence to make complex judgements were usually acquired through experience, informal discussions, and on-the-job methods such as shadowing. Whole-team training was valued but rarely available. A draft set of competencies is offered based on the findings. Conclusion The knowledge needed to deliver high-quality remote encounters to diverse patient groups is complex, collective, and organisationally embedded. The vital role of non-didactic training, for example, joint clinical sessions, case-based discussions, and in-person, whole-team, on-the-job training, needs to be recognised

Remote care in UK general practice: baseline data on 11 case studies [version 2; peer review: 2 approved]

Background: Accessing and receiving care remotely (by telephone, video or online) became the default option during the coronavirus disease 2019 (COVID-19) pandemic, but in-person care has unique benefits in some circumstances. We are studying UK general practices as they try to balance remote and in-person care, with recurrent waves of COVID-19 and various post-pandemic backlogs. Methods: Mixed-methods (mostly qualitative) case study across 11 general practices. Researchers-in-residence have built relationships with practices and become familiar with their contexts and activities; they are following their progress for two years via staff and patient interviews, documents and ethnography, and supporting improvement efforts through co-design. In this paper, we report baseline data. Results: Reflecting our maximum-variety sampling strategy, the 11 practices vary in size, setting, ethos, staffing, population demographics and digital maturity, but share common contextual features—notably system-level stressors such as high workload and staff shortages, and UK’s technical and regulatory infrastructure. We have identified both commonalities and differences between practices in terms of how they: 1] manage the ‘digital front door’ (access and triage) and balance demand and capacity; 2] strive for high standards of quality and safety; 3] ensure digital inclusion and mitigate wider inequalities; 4] support and train their staff (clinical and non-clinical), students and trainees; 5] select, install, pilot and use technologies and the digital infrastructure which support them; and 6] involve patients in their improvement efforts. Conclusions: General practices’ responses to pandemic-induced disruptive innovation appear unique and situated.  We anticipate that by focusing on depth and detail, this longitudinal study will throw light on why a solution that works well in one practice does not work at all in another. As the study unfolds, we will explore how practices achieve timely diagnosis of urgent or serious illness and manage continuity of care, long-term conditions and complex needs

Protocol: Remote care as the ‘new normal’? Multi-site case study in UK general practice [version 1; peer review: 2 approved]

Background: Following a pandemic-driven shift to remote service provision, UK general practices offer telephone, video or online consultation options alongside face-to-face. This study explores practices’ varied experiences over time as they seek to establish remote forms of accessing and delivering care. Methods: This protocol is for a mixed-methods multi-site case study with co-design and national stakeholder engagement. 11 general practices were selected for diversity in geographical location, size, demographics, ethos, and digital maturity. Each practice has a researcher-in-residence whose role is to become familiar with its context and activity, follow it longitudinally for two years using interviews, public-domain documents and ethnography, and support improvement efforts. Research team members meet regularly to compare and contrast across cases. Practice staff are invited to join online learning events. Patient representatives work locally within their practice patient involvement groups as well as joining an online patient learning set or linking via a non-digital buddy system. NHS Research Ethics Approval has been granted. Governance includes a diverse independent advisory group with lay chair. We also have policy in-reach (national stakeholders sit on our advisory group) and outreach (research team members sit on national policy working groups). Results (anticipated): We expect to produce rich narratives of contingent change over time, addressing cross-cutting themes including access, triage and capacity; digital and wider inequities; quality and safety of care (e.g. continuity, long-term condition management, timely diagnosis, complex needs); workforce and staff wellbeing (including non-clinical staff, students and trainees); technologies and digital infrastructure; patient perspectives; and sustainability (e.g. carbon footprint). Conclusion: By using case study methods focusing on depth and detail, we hope to explain why digital solutions that work well in one practice do not work at all in another. We plan to inform policy and service development through inter-sectoral network-building, stakeholder workshops and topic-focused policy briefings

Relational Coordination and Relational Systems:how teams navigate transformation and crisis in UK General Practice, a multi-method qualitative case study analysis

This paper presents findings from a multi-method case study of UK general practice. Empirically, this case study examined influences on teams’ ability to navigate crisis and change in the context of UK general practice. Theoretically, we explored the significance of relationships and their enabling structures or mechanisms during such navigation.Our results highlight the importance of complementary organisational structures of relational advocacy and relational coordination in GP practice teams, given the complexity and interdependency of modern general practice work and the environmental context of persistent crisis and change. Our findings indicate that these structures support the development of adaptable teams that protect individual and organisational resilience. In turn, ensuring the team's resilience helps stabilise the system's relational advocacy and maintain an organisational culture of relational coordination.Significant crisis events can disturb this cycle, sometimes so severely that the system can no longer be attentive to relational advocacy, and slips into indifference. Critically, there is the capacity for future work to facilitate movement into relational advocacy by establishing the conditions for positive change and supporting teams to build the critical structures and processes that support relational coordination, psychological safety, and attentive infrastructures

Why is safety in intrapartum electronic fetal monitoring so hard? A qualitative study combining human factors/ergonomics and social science analysis.

Peer reviewed: TrueAcknowledgements: We thank the staff and patients of the participating maternity units for their cooperation and support in the conduct of the study. We thank Matt Woodward of THIS Institute for his support of this work.BACKGROUND: Problems in intrapartum electronic fetal monitoring with cardiotocography (CTG) remain a major area of preventable harm. Poor understanding of the range of influences on safety may have hindered improvement. Taking an interdisciplinary perspective, we sought to characterise the everyday practice of CTG monitoring and the work systems within which it takes place, with the goal of identifying potential sources of risk. METHODS: Human factors/ergonomics (HF/E) experts and social scientists conducted 325 hours of observations and 23 interviews in three maternity units in the UK, focusing on how CTG tasks were undertaken, the influences on this work and the cultural and organisational features of work settings. HF/E analysis was based on the Systems Engineering Initiative for Patient Safety 2.0 model. Social science analysis was based on the constant comparative method. RESULTS: CTG monitoring can be understood as a complex sociotechnical activity, with tasks, people, tools and technology, and organisational and external factors all combining to affect safety. Fetal heart rate patterns need to be recorded and interpreted correctly. Systems are also required for seeking the opinions of others, determining whether the situation warrants concern, escalating concerns and mobilising response. These processes may be inadequately designed or function suboptimally, and may be further complicated by staffing issues, equipment and ergonomics issues, and competing and frequently changing clinical guidelines. Practice may also be affected by variable standards and workflows, variations in clinical competence, teamwork and situation awareness, and the ability to communicate concerns freely. CONCLUSIONS: CTG monitoring is an inherently collective and sociotechnical practice. Improving it will require accounting for complex system interdependencies, rather than focusing solely on discrete factors such as individual technical proficiency in interpreting traces.This study was funded by Health Foundation’s grant to the University of Cambridge for The Healthcare Improvement Studies (THIS) Institute. The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK

Why is safety in intrapartum electronic fetal monitoring so hard? A qualitative study combining human factors/ergonomics and social science analysis

International audienceBackground: Problems in intrapartum electronic fetal monitoring with cardiotocography (CTG) remain a major area of preventable harm. Poor understanding of the influences on safety may have hindered improvement. Taking an interdisciplinary perspective, we sought to characterise the everyday practice of CTG monitoring and the work systems within it takes place, with the goal of identifying potential sources of risk.Methods: Human factors/ergonomics (HF/E) experts and social scientists conducted 325hours of observations and 23 interviews in three maternity units in the UK, focusing on how CTG tasks were undertaken, the influences on this work, and the cultural and organisational features of work settings. HF/E analysis was based on the SEIPS 2.0 model. Social science analysis was based on the constant comparative method.Results: CTG monitoring can be understood as a complex sociotechnical activity, with tasks, people, tools and technology, organisational and external factors all combining to affect safety. Fetal heart patterns need to be recorded and interpreted correctly. Systems are also required for seeking the opinions of others, determining whether the situation warrants concern, escalating concerns, and mobilising response. These processes may be inadequately designed or function sub-optimally, and may be further complicated by staffing issues, equipment and ergonomics issues and competing and frequently changing clinical guidelines. Practice may also be affected by variable standards and workflows, variations in clinical competence, teamwork and situation awareness, and the ability to communicate concerns freely.Conclusions: CTG monitoring is an inherently collective and sociotechnical practice.59Improving it will require accounting for complex system interdependencies, rather than focusing solely on discrete factors such as individual technical proficiency in interpreting traces