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Barnard R, Spooner S, Hubmann M, Checkland K, Campbell J, Swinglehurst D. The hidden work of general practitioners: An ethnography. Soc Sci Med 2024; 350:116922. [PMID: 38713977 DOI: 10.1016/j.socscimed.2024.116922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 04/17/2024] [Accepted: 04/25/2024] [Indexed: 05/09/2024]
Abstract
High quality primary care is a foundational element of effective health services. Internationally, primary care physicians (general practitioners (GPs), family doctors) are experiencing significant workload pressures. How non-patient-facing work contributes to these pressures and what constitutes this work is poorly understood and often unrecognised and undervalued by patients, policy makers, and even clinicians engaged in it. This paper examines non-patient-facing work ethnographically, informed by practice theory, the Listening Guide, and empirical ethics. Ethnographic observations (104 h), in-depth interviews (n = 16; 8 with GPs and 8 with other primary care staff) and reflexive workshops were conducted in two general practices in England. Our analysis shows that 'hidden work' was integral to direct patient care, involving diverse clinical practices such as: interpreting test results; crafting referrals; and accepting interruptions from clinical colleagues. We suggest the term 'hidden care work' more accurately reflects the care-ful nature of this work, which was laden with ambiguity and clinical uncertainty. Completing hidden care work outside of expected working hours was normalised, creating feelings of inefficiency, and exacerbating workload pressure. Pushing tasks forward into an imagined future (when conditions might allow its completion) commonly led to overspill into GPs' own time. GPs experienced tension between their desire to provide safe, continuous, 'caring' care and the desire to work a manageable day, in a context of increasing demand and burgeoning complexity.
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Affiliation(s)
- Rachel Barnard
- Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK
| | - Sharon Spooner
- Centre for Primary Care & Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - Michaela Hubmann
- Centre for Primary Care & Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - Kath Checkland
- Centre for Primary Care & Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - John Campbell
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Deborah Swinglehurst
- Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK.
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Park S, Owen-Boukra E, Burford B, Cohen T, Duddy C, Dunn H, Fadia V, Goodman C, Henry C, Lamb EI, Ogden M, Rapley T, Rees E, Vance G, Wong G. General practitioner workforce sustainability to maximise effective and equitable patient care: a realist review protocol. BMJ Open 2024; 14:e075189. [PMID: 38772888 PMCID: PMC11110576 DOI: 10.1136/bmjopen-2023-075189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 04/29/2024] [Indexed: 05/23/2024] Open
Abstract
INTRODUCTION There are not enough general practitioners (GPs) in the UK National Health Service. This problem is worse in areas of the country where poverty and underinvestment in health and social care mean patients experience poorer health compared with wealthier regions. Encouraging more doctors to choose and continue in a GP career is a government priority. This review will examine which aspects of the healthcare system affect GP workforce sustainability, how, why and for whom. METHODS AND ANALYSIS A realist review is a theory-driven interpretive approach to evidence synthesis, that brings together qualitative, quantitative, mixed-methods research and grey literature. We will use a realist approach to synthesise data from the available published literature to refine an evidence-based programme theory that will identify the important contextual factors and underlying mechanisms that underpin observed outcomes relating to GP workforce sustainability. Our review will follow Pawson's five iterative stages: (1) finding existing theories, (2) searching for evidence, (3) article selection, (4) data extraction and (5) synthesising evidence and drawing conclusions. We will work closely with key stakeholders and embed patient and public involvement throughout the review process to refine the focus of the review and enhance the impact and relevance of our research. ETHICS AND DISSEMINATION This review does not require formal ethical approval as it draws on secondary data from published articles and grey literature. Findings will be disseminated through multiple channels, including publication in peer-reviewed journals, at national and international conferences, and other digital scholarly communication tools such as video summaries, X and blog posts. PROSPERO REGISTRATION NUMBER CRD42023395583.
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Affiliation(s)
- Sophie Park
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emily Owen-Boukra
- Department of Primary Care and Population Health, University College London, London, UK
| | - Bryan Burford
- School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Tanya Cohen
- Department of Primary Care and Population Health, University College London, London, UK
| | - Claire Duddy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Harry Dunn
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Vacha Fadia
- Department of Primary Care and Population Health, University College London, London, UK
| | - Claire Goodman
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK
| | - Cecily Henry
- Department of Primary Care and Population Health, University College London, London, UK
| | - Elizabeth I Lamb
- School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Margaret Ogden
- Department of Primary Care and Population Health, University College London, London, UK
| | - Tim Rapley
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Eliot Rees
- Department of Primary Care and Population Health, University College London, London, UK
- School of Medicine, Keele University, Keele, UK
| | - Gillian Vance
- School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Sinnott C, Alboksmaty A, Moxey JM, Morley KI, Parkinson S, Burt J, Dixon-Woods M. Operational failures in general practice: a consensus-building study on the priorities for improvement. Br J Gen Pract 2024; 74:e339-e346. [PMID: 38621805 PMCID: PMC11044020 DOI: 10.3399/bjgp.2023.0321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/19/2023] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND System problems, known as operational failures, can greatly affect the work of GPs, with negative consequences for patient and professional experience, efficiency, and effectiveness. Many operational failures are tractable to improvement, but which ones should be prioritised is less clear. AIM To build consensus among GPs and patients on the operational failures that should be prioritised to improve NHS general practice. DESIGN AND SETTING Two modified Delphi exercises were conducted online among NHS GPs and patients in several regions across England. METHOD Between February and October 2021, two modified Delphi exercises were conducted online: one with NHS GPs, and a subsequent exercise with patients. Over two rounds, GPs rated the importance of a list of operational failures (n = 45) that had been compiled using existing evidence. The resulting shortlist was presented to patients for rating over two rounds. Data were analysed using median scores and interquartile ranges. Consensus was defined as 80% of responses falling within one value below and above the median. RESULTS Sixty-two GPs responded to the first Delphi exercise, and 53.2% (n = 33) were retained through to round two. This exercise yielded consensus on 14 failures as a priority for improvement, which were presented to patients. Thirty-seven patients responded to the first patient Delphi exercise, and 89.2% (n = 33) were retained through to round two. Patients identified 13 failures as priorities. The highest scoring failures included inaccuracies in patients' medical notes, missing test results, and difficulties referring patients to other providers because of problems with referral forms. CONCLUSION This study identified the highest-priority operational failures in general practice according to GPs and patients, and indicates where improvement efforts relating to operational failures in general practice should be focused.
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Affiliation(s)
- Carol Sinnott
- The Healthcare Improvement Studies (THIS) Institute, Cambridge
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Edwards PJ. GPs spend 14% of their session time documenting consultation notes and updating electronic health records. Br J Gen Pract 2024; 74:202. [PMID: 38664059 PMCID: PMC11060803 DOI: 10.3399/bjgp24x737097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024] Open
Affiliation(s)
- Peter J Edwards
- NIHR Clinical Research Fellow, University of Bristol, Bristol.
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Woolford SJ, Watson J, Reeve J, Harris T. The real work of general practice: understanding our hidden workload. Br J Gen Pract 2024; 74:196-197. [PMID: 38664043 PMCID: PMC11060809 DOI: 10.3399/bjgp24x737061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024] Open
Affiliation(s)
- Stephen J Woolford
- Population Health Research Institute, St George's, University of London, London
| | - Jessica Watson
- Population Health Sciences, University of Bristol, Bristol
| | - Joanne Reeve
- Academy of Primary Care, Hull York Medical School, University of Hull, Hull
| | - Tess Harris
- Population Health Research Institute, St George's, University of London, London
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Dixon-Woods M, Summers C, Morgan M, Patel K. The future of the NHS depends on its workforce. BMJ 2024; 384:e079474. [PMID: 38538029 DOI: 10.1136/bmj-2024-079474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Affiliation(s)
| | | | - Matt Morgan
- University Hospital of Wales and Cardiff University, Cardiff, UK
- Curtin University, Australia
- The BMJ
| | - Kiran Patel
- University Hospitals Birmingham and University of Warwick, UK
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Sinnott C, Vedanthan R, van Olmen J. Elusive but hopefully not illusive: coordinating care for patients with heart failure with preserved ejection fraction. BMJ Qual Saf 2024; 33:212-215. [PMID: 38195252 DOI: 10.1136/bmjqs-2023-016754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2024] [Indexed: 01/11/2024]
Affiliation(s)
- Carol Sinnott
- THIS Institute, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Rajesh Vedanthan
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Josefien van Olmen
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
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Fisher R, Alderwick H. The performance of general practice in the English National Health Service (NHS): an analysis using Starfield's framework for primary care. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae022. [PMID: 38770436 PMCID: PMC11103734 DOI: 10.1093/haschl/qxae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/16/2024] [Accepted: 02/22/2024] [Indexed: 05/22/2024]
Abstract
General practice in the English National Health Service (NHS) is in crisis. In response, politicians are proposing fundamental reform to the way general practice is organized. But ideas for reform are contested, and there are conflicting interpretations of the problems to be addressed. We use Barbara Starfield's "4Cs" framework for high-performing primary care to provide an overall assessment of the current role and performance of general practice in England. We first assessed theoretical alignment between Starfield's framework and the role of general practice in England. We then assessed actual performance using publicly available national data and targeted literature searches. We found close theoretical alignment between Starfield's framework and the model of NHS general practice in England. But, in practice, its model of universal comprehensive care risks being undermined by worsening and inequitable access, while continuity of care is declining. Underlying causes of current challenges in general practice in England appear more closely linked to under-resourcing than the fundamental design of the system. General practice in England must evolve, but wholesale re-organization is likely to damage and distract. Instead, policymakers should focus on adequately resourcing general practice while supporting general practice teams to improve the quality and coordination of local services.
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Bradley SH, Harper AM, Smith L, Taylor N, Delap H, Pyke H, Girkin J, Sinnott C, Watson J. Great expectations? GPs' estimations of time required to deliver BMJ's '10 minute consultations'. BMJ Open 2024; 14:e079578. [PMID: 38413154 PMCID: PMC10900324 DOI: 10.1136/bmjopen-2023-079578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
OBJECTIVES To estimate the time required to undertake consultations according to BMJ's 10-minute consultation articles.To quantify the tasks recommended in 10-minute consultation articles.To determine if, and to what extent, the time required and the number of tasks recommended have increased over the past 22 years. DESIGN Analysis of estimations made by four general practitioners (GPs) of the time required to undertake tasks recommended in BMJ's 10-minute consultation articles. SETTING Primary care in the UK. PARTICIPANTS Four doctors with a combined total of 79 years of experience in the UK National Health Service following qualification as GPs. MAIN OUTCOME MEASURES Median minimum estimated consultation length (the estimated time required to complete tasks recommended for all patients) and median maximum estimated consultation length (the estimated time required to complete tasks recommended for all patients and the additional tasks recommended in specific circumstances). Minimum, maximum and median consultation lengths reported for each year and for each 5-year period. RESULTS Data were extracted for 44 articles. The median minimum and median maximum estimated consultation durations were 15.7 minutes (IQR 12.6-20.9) and 28.4 minutes (IQR 22.4-33.8), respectively. A median of 17 tasks were included in each article. There was no change in durations required over the 22 years examined. CONCLUSIONS The approximate times estimated by GPs to deliver care according to 10-minute consultations exceed the time available in routine appointments. '10 minute consultations' is a misleading title that sets inappropriate expectations for what GPs can realistically deliver in their routine consultations. While maintaining aspirations for high-quality care is appropriate, practice recommendations need to take greater account of the limited time doctors have to deliver routine care.
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Affiliation(s)
- Stephen Henry Bradley
- Academic Unit of Primary Care, University of Leeds, Leeds, UK
- York Street Practice, Leeds, UK
| | - Alice M Harper
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Lesley Smith
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | | | | | | | - Carol Sinnott
- The Healthcare Improvement Studies (THIS) Institute, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Court St Medical Practice, Enniscorthy, Ireland
| | - Jessica Watson
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Stringer G, Ferguson J, Walshe K, Grigoroglou C, Allen T, Kontopantelis E, Ashcroft DM. Locum doctors in English general practices: evidence from a national survey. Br J Gen Pract 2023; 73:e667-e676. [PMID: 37604697 PMCID: PMC10471140 DOI: 10.3399/bjgp.2023.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/16/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Locum doctors give practices flexibility to deliver patient services but there are concerns about the impact of locum working on continuity of care, patient safety, team function, and cost. AIM To explore locum working in English general practices, and understand why and where locum doctors were needed and how they were engaged, supported, perceived, and managed. DESIGN AND SETTING An online survey was sent to 3745 practices. METHOD Quantitative responses were analysed using frequency tables, t-tests, and correlations. Free-text responses were analysed using thematic analysis. RESULTS In total, 605 (16.2%) responses were returned between June and December 2021. Practices made frequent use of locums, preferring regular locums familiar with processes and patients. Disadvantages of agency locums included cost, lack of patient familiarity, and impact on continuity of care. Care provided by locums was generally viewed as the same but sometimes worse compared with permanent GPs. Some practices reported that locums did not always perform the full range of duties, resulting in increased workload for other staff. Practices were largely unfamiliar with national guidance for organisations engaging locums, and, although processes such as verifying documentation were conducted, far fewer responders reported providing feedback, support for revalidation, or professional development. CONCLUSION Locum working is an essential part of English general practice, but this research raises some concerns about the robustness of arrangements for locum working and the impact on quality and safety of care. Further research is needed about the clinical practice and performance of locums, and to explore how locum working can be organised in ways that assure safe and high-quality care.
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Affiliation(s)
- Gemma Stringer
- Alliance Manchester Business School, Institute for Health Policy and Organisation, University of Manchester, Manchester, UK
| | - Jane Ferguson
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Kieran Walshe
- Alliance Manchester Business School, Institute for Health Policy and Organisation, University of Manchester, Manchester, UK
| | - Christos Grigoroglou
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Thomas Allen
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK; Danish Centre for Health Economics, University of Southern Denmark, Denmark
| | - Evangelos Kontopantelis
- National Institute for Health and Care Research School for Primary Care Research, Centre for Primary Care and Division of Informatics, Imaging and Data Science, University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
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Pradere P, Caramella C, Salem FB, Florea V, Crutu A, Hanna A, Mabille L, Kim YW, De Montpreville V, Feuillet S, Naltet C, Planchard D, Blanc E, Fadel E, Pavec JL, Mercier O. A Patient-Centered Model of Fast-Track Lung Cancer Diagnosis. Clin Lung Cancer 2023:S1525-7304(23)00047-5. [PMID: 37030992 DOI: 10.1016/j.cllc.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 02/14/2023] [Accepted: 03/02/2023] [Indexed: 04/09/2023]
Abstract
INTRODUCTION Despite the increasing importance of digital resources in modern life over the past decades, little is known about the impact of internet-based solutions on patient's health. We aimed to study the potential benefit of a digital platform helping patients to deal with abnormal chest CT scan revealing possible lung cancer. METHODS We set up a fast-track lung cancer diagnosis pathway through a secure online platform. Patient-generated information combined with online review of their imaging enables preplanning of further investigations ahead of clinical assessment. We compared outcomes of "self-referred" patients (patient group), who directly fill out the online questionnaire, to general practitioner-driven patients (GP group), who were referred by their GP. RESULTS From June 2021 to June 2022, we included 125 patients (61% males, median age 67 years, IQR 56.9-72.5): 41% in the patient group and 59% in the GP group. No difference was found between groups in terms of time from contact to first appointment (median 5 days in both groups, P = .6), percentage of pathways including prebooked tests (94% vs. 92%, P = .6), number of scheduled invasive procedures (median 1, IQR 1-2 vs. 2, IQR 1-2, P = .4) and in final cancer diagnosis (76% vs. 78%, P = .4). CONCLUSION A lung cancer diagnosis pathway directly accessible by patients through a secure online platform was feasible and as efficient as the usual general practitioner pathway. It demonstrated the benefit of leaning on new digital tools in order to answer to the new challenges of a patient-centered health care system.
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Mistry P. Digital health and care plan: a compelling and surprisingly realistic vision. BMJ 2022; 378:o1635. [PMID: 35777785 DOI: 10.1136/bmj.o1635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Sanford N, Lavelle M, Markiewicz O, Reedy G, Rafferty AM, Darzi A, Anderson JE. Capturing challenges and trade-offs in healthcare work using the pressures diagram: An ethnographic study. APPLIED ERGONOMICS 2022; 101:103688. [PMID: 35121407 DOI: 10.1016/j.apergo.2022.103688] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 12/03/2021] [Accepted: 01/13/2022] [Indexed: 06/14/2023]
Abstract
Healthcare workers must balance competing priorities to deliver high-quality patient care. Rasmussen's Dynamic Safety Model proposed three factors that organisations must balance to maintain acceptable performance, but there has been little empirical exploration of these ideas, and little is known about the risk trade-offs workers make in practice. The aim of this study was to investigate the different pressures that healthcare workers experience, what risk trade-off decisions they make in response to pressures, and to analyse the implications for quality and safety. The study involved 88.5 h of ethnographic observations at a large, teaching hospital in central London. The analysis revealed five distinct categories of hospital pressures faced by healthcare workers: efficiency, organisational, workload, personal, and quality and safety pressures. Workers most often traded-off workload, personal, and quality and safety pressures to accommodate system-level priorities. The Pressures Diagram was developed to visualise risk trade-offs and prioritising decisions and to facilitate communication about these aspects of healthcare work.
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Affiliation(s)
- Natalie Sanford
- The Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care King's College London, UK.
| | - Mary Lavelle
- School of Psychology, Queen's University Belfast, UK; NIHR Patient Safety and Translational Research Centre, Imperial College London, UK
| | - Ola Markiewicz
- NIHR Patient Safety and Translational Research Centre, Imperial College London, UK
| | - Gabriel Reedy
- Centre for Education, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Anne Marie Rafferty
- The Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care King's College London, UK
| | - Ara Darzi
- NIHR Patient Safety and Translational Research Centre, Imperial College London, UK
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