Frontline Perspective Research Articles

Excellence in Homelessness Services: Evidence-Based Frontline Practices

Optimizing the performance of frontline workers in homelessness services (FWHSs) is vital for delivering effective support to individuals experiencing homelessness while prioritizing worker wellness. This paper builds on a previous study applying Orlick's "Wheel of Excellence" mental success elements, originally based on research with Olympic athletes, to social services. It assessed how high-performing FWHSs used these elements, providing practical insights for tailored mental-readiness training in social service facilities. The success elements—commitment, self-belief, positive imagery, mental preparation, full focus, distraction control, and constructive evaluation—were evident in FWHSs when successfully navigating challenging situations. This study provides further analysis of the elements contributing to FWHS’s mental readiness, including quotations from “excellent” FWHSs to highlight their common best practices. It defines excellence in frontline homelessness services, illustrates the use of the seven success elements, and identifies performance blocks and coping strategies from a frontline perspective. Performance blocks include general stressors and mistakes by trainees. The accompanying motivational quotes from high performers are akin to storytelling, elevating understanding and facilitating learning. Recommendations advocate tailoring existing tools, creating online learning opportunities, and implementing an Indigenous-inspired Sharing Circle for evidence-based practice discussions in homelessness services.

The changing context of Postings and Transfer with subsequent postings: A frontline perspective from India.

The deployment of the health workforce, carried out through initial and subsequent Posting and Transfer (PT) is a key element of health workforce management. However, the focus of the currently available PT literature is mostly on subsequent PT, and the distinction between initial and subsequent PT has received little research attention. Drawing on this gap, in this paper, we examine how doctors experience their subsequent PT compared to their initial postings in two states in India. The distinctions have been drawn using the prism of six norms that we developed as evidence for implied policy in the absence of documented policy. This mixed methods study used in depth interviews of doctors and key informants, with job histories providing quantitative data from their accounts of their PT experience. Based on the interviews of these front-line doctors and other key policy actors, this paper brings to light key differences between initial and subsequent postings as perceived by the doctors: compared to initial postings, where the State demands to meet service needs dominated, in subsequent postings, doctors exercised greater agency in determining outcomes, with native place a central preoccupation in their choices. Our analysis provides a nuanced understanding of PT environment through this shift in doctor's perceptions of their own position and power within the system, with a significant change in their behaviour of doctors in subsequent PT compared to their initial postings. The paper brings to light the changing behaviour of doctors with subsequent PT, providing a deeper understanding of PT environment, expanding the notion of PT beyond the simple dichotomy between service needs and doctors' requests.

Exploring paramedic perspectives on emergency medical service (EMS) delivery in Alberta: a qualitative study.

Emergency Medical Services (EMS) in Alberta are facing critical challenges. This qualitative study aims to describe and understand the frontline perspective regarding system level issues and propose provider-informed policy recommendations. 19 semi-structured one-on- one interviews were conducted with Primary or Advanced Care Paramedics (PCP/ACP) across Alberta. Participants were asked to share their perspectives, experiences and recommendations in relation to EMS response times and the working environment. Interviews were analyzed using thematic analysis to identify themes and subthemes. Two core themes were identified as areas of concern: poor response times and the EMS working environment, which each influence and impact the other. Within response times, paramedics highlighted specific difficulties with ED offloading, a lack of resources, low-acuity calls, and rural challenges. In terms of the EMS working environment, four subthemes were apparent including attrition, unhealthy culture, organizational barriers and the need for paramedic empowerment. Providers made many recommendations including creating and expanding emergency mobile integrated health (MIH) branches, sharing 811 and 911 responses, and enforcing ED target offload times amongst other suggestions. While response times are a key and highly visible problem, there are many critical factors like the EMS working environment that degrade patient care and cause concern amongst frontline practitioners. Multifaceted policy changes are to be explored to reduce disfunction within EMS services, enhance the well-being of the workforce and deliver improved patient care. Specific EMS-oriented policies are important for moving forward to reduce transfers to EDs, but the broader health system which is over capacity is causing downstream effects into EMS must be addressed by government and health administrators.

Deconcentrating regulation in low- and middle-income country health systems: a proposed ambidextrous solution to problems with professional regulation for doctors and nurses in Kenya and Uganda

BackgroundRegulation can improve professional practice and patient care, but is often weakly implemented and enforced in health systems in low- and middle-income countries (LMICs). Taking a de-centred and frontline perspective, we examine national regulatory actors’ and health professionals’ views and experiences of health professional regulation in Kenya and Uganda and discuss how it might be improved in LMICs more generally.MethodsWe conducted large-scale research on professional regulation for doctors and nurses (including midwives) in Uganda and Kenya during 2019–2021. We interviewed 29 national regulatory stakeholders and 47 subnational regulatory actors, doctors, and nurses. We then ran a national survey of Kenyan and Ugandan doctors and nurses, which received 3466 responses. We thematically analysed qualitative data, conducted an exploratory factor analysis of survey data, and validated findings in four focus group discussions.ResultsKenyan and Ugandan regulators were generally perceived as resource-constrained, remote, and out of touch with health professionals. This resulted in weak regulation that did little to prevent malpractice and inadequate professional education and training. However, interviewees were positive about online licencing and regulation where they had relationships with accessible regulators. Building on these positive findings, we propose an ambidextrous approach to improving regulation in LMIC health systems, which we term deconcentrating regulation. This involves developing online licencing and streamlining regulatory administration to make efficiency savings, freeing regulatory resources. These resources should then be used to develop connected subnational regulatory offices, enhance relations between regulators and health professionals, and address problems at local level.ConclusionProfessional regulation for doctors and nurses in Kenya and Uganda is generally perceived as weak. Yet these professionals are more positive about online licencing and regulation where they have relationships with regulators. Building on these positive findings, we propose deconcentrating regulation as a solution to regulatory problems in LMICs. However, we note resource, cultural and political barriers to its effective implementation.

Improving Hospital-Acquired Pressure Injury Outcomes by Overcoming Barriers to Implementing Patient Positioning Devices.

Improving Hospital-Acquired Pressure Injury Outcomes by Overcoming Barriers to Implementing Patient Positioning Devices.

How China's Cognitive Warfare Works: A Frontline Perspective of Taiwan's Anti-Disinformation Wars

Abstract Cognitive warfare—controlling others’ mental states and behaviors by manipulating environmental stimuli—is a significant and ever-evolving issue in global conflict and security, especially during the COVID-19 crisis. In this article, we aim to contribute to the field by proposing a two-dimensional framework to evaluate China's cognitive warfare and explore promising ways of counteracting it. We first define the problem by clarifying relevant concepts and then present a case study of China's attack on Taiwan. Next, based on predictive coding theory from the cognitive sciences, we offer a framework to explain how China's cognitive warfare works and to what extent it succeeds. We argue that this framework helps identify vulnerable targets and better explains some of the conflicting data in the literature. Finally, based on the framework, we predict China's strategy and discuss Taiwan's options in terms of cognitive and structural interventions.

The growing epidemic of insurance denials: A frontline perspective.

The growing epidemic of insurance denials: A frontline perspective.

Barriers and drivers for industrial energy management: The frontline perspective

Implementing energy efficiency measures is widely regarded as a high priority in the search for carbon dioxide emission reductions and can create competitive advantage for industry. Yet, approximately 50% of industry's cost effective energy efficiency measures are never implemented. The lack of implementation of energy efficiency measures results in the energy efficiency gap, which is generally attributed to barriers. Attempts to close the gap are directed at overcoming barriers and leveraging drivers. However, the current view of barriers and drivers may be incomplete due to the under representation of frontline workers' perspectives in research. Frontline workers strongly influence energy use because they make decisions about how and when industrial equipment is operated and maintained. This study compares survey responses from frontline workers and managers to investigate the barriers and drivers to industrial energy efficiency. Analysis of free text responses found perceived barriers and drivers for energy efficiency are different for frontline workers and managers. Differences between frontline workers' and managers' views are less prominent when only responses to Likert-type questions are considered. In response to this, new taxonomies for barriers and drivers were created. It is proposed these new taxonomies will be useful for empirical research as they can incorporate more complete views of frontline workers and managers. Common methods used to overcome barriers may have limited impact on the barriers found in this study. This more complete understanding of barriers and drivers could be useful for industry to characterise their challenges, contribute meaningfully to policy creation and generate new ways to close the energy efficiency gap. The novelty of this research stems from its investigation and presentation of the frontline workers' perspective. Further research into drivers, barriers and data gathering for frontline workers is needed to validate this exploratory study.

Toxic Leadership and Employee Misconduct of hotel and tourism institution: A Frontline Perspective

This study determined the impact of Toxic Leadership on Employee Misconduct among frontline employees in restaurants within the Klang Valley, aiming to address persistent challenges in the hospitality sector. Employee Misconduct poses a significant threat to service-oriented cultures and financial stability. Specifically, this research explores how Toxic Leadership behaviors contribute to frontline employee misconduct, potentially exacerbating issues such as service quality and organizational reputation. Employing a quantitative approach, 120 questionnaires were distributed among frontline employees in various Klang Valley restaurants using non-probability purposive sampling. Correlation analysis of collected data indicated a statistically significant positive relationship between Toxic Leadership and employee misconduct (r= .280, p<0.01). These findings underscore the detrimental influence of toxic leadership on employee behavior within service settings. The study's outcomes contribute to a deeper understanding of organizational dynamics within the restaurant industry and the broader hospitality sector in Malaysia. By highlighting the prevalence and impact of Toxic Leadership, this research underscores the urgency for strategic interventions to mitigate employee misconduct and foster healthier work environments. Future research directions should explore additional facets of employee misconduct triggered by toxic leadership actions, offering insights for proactive management strategies and policy development in service-oriented industries.

A qualitative assessment of factors affecting nursing home caregiving staff experiences during the COVID-19 pandemic.

BackgroundA large portion of COVID-19 cases and deaths in the United States have occurred in nursing homes; however, current literature including the frontline perspective of staff working in nursing homes is limited. The objective of this qualitative assessment was to better understand what individual and facility level factors may have contributed to the impact of COVID-19 on Certified Nursing Assistants (CNAs) and Environmental Services (EVS) staff working in nursing homes.MethodsBased on a simple random sample from the National Healthcare Safety Network (NHSN), 7,520 facilities were emailed invitations requesting one CNA and/or one EVS staff member for participation in a voluntary focus group over Zoom. Facility characteristics were obtained via NHSN and publicly available sources; participant demographics were collected via SurveyMonkey during registration and polling during focus groups. Qualitative information was coded using NVIVO and Excel.ResultsThroughout April 2021, 23 focus groups including 110 participants from 84 facilities were conducted homogenous by participant role. Staffing problems were a recurring theme reported. Participants often cited the toll the pandemic took on their emotional well-being, describing increased stress, responsibilities, and time needed to complete their jobs. The lack of consistent and systematic guidance resulting in frequently changing infection prevention protocols was also reported across focus groups.ConclusionsAddressing concerns of low wages and lack of financial incentives may have the potential to attract and retain employees to help alleviate nursing home staff shortages. Additionally, access to mental health resources could help nursing home staff cope with the emotional burden of the COVID-19 pandemic. These frontline staff members provided invaluable insight and should be included in improvement efforts to support nursing homes recovering from the impact of COVID-19 as well as future pandemic planning.

The aspects of healthcare quality that are important to health professionals and patients: A qualitative study

ObjectiveExisting quality of care frameworks insufficiently integrate the perspectives of physicians, nurses and patients. We collected narrative accounts from these three groups to explore if their perspectives might add new content to these existing definitions. MethodsNinety-seven descriptions of “good” and “poor” care episodes were collected from a convenience sample of physicians, nurses and outpatients at eight regional hospitals. Two coders classified the narrative contents into themes related to structures, processes and outcomes of care. ResultsThe physicians, nurses and patients raised the following “quality of care” aspects: Successful communication among staff, with patients and care companions; staff motivation; frequency of knowledge errors; prioritization of patient-preferred outcomes; institutional emphasis on building “quality cultures”; and organizational implementation of fluid system procedures. ConclusionRespondents primarily referred to care processes in their descriptions of “quality of care.” “Hippocratic pride” (in response to care successes) and “Rapid reactivity” (in response to (near) failures) emerged as two new outcome indicators of high-quality care. Practice implicationsThis study provides a first qualitative fundament for understanding the components of “quality of care” from a triangulated frontline perspective. Future research needs to validate our findings with quantitative data to explore their usefulness for completing existing quality frameworks.

On the front-line: controlling the illicit cultural heritage trade in Norway

ABSTRACT This article draws on interviews with customs officers to identify and discuss the intricacies of controlling the illicit trade in cultural heritage objects from a front-line perspective. The complexity of distinguishing illicit from licit trade in cultural objects presents customs officers with unique challenges. The findings reveal a perpetual relationship between several factors: poor knowledge of what is illicit trade among customs officers, few detections and recorded seizures, limited familiarity with the legal framework, logistical challenges in collaborations with cultural institutions and insufficient allocation of resources for capacity building leading to continued marginalisation of the field. Besides awareness building for officers, recommendations to break the cycle and encourage prioritisation include establishing a national, single point of contact to bridge the gap between organisations and a system that recognises impounding of suspected illicit material as well as formal seizures.

Capturing the Moments: An Autoethnographic Exploration of Self-Preservation in Clerkship

Phenomenon For most medical students, clerkship represents a transitional phase into the ‘real world’ of medicine. This transition is often accompanied by significant mental stressors, burnout, and empathy decline. Educator led resilience curricula designed to support students during this critical period often focus on teaching generalized strategies to promote wellness and lack the student input and perspective in their development. Thus, they may be of minimal value when learners are faced with acute moments of challenge and distress in their day-to-day work. The following project seeks to provide an insider view on the experience, interpretation, and response to these moments of challenge and distress from the frontline perspective of clinical clerks. Approach: Using collaborative autoethnography, two medical students documented 85 reflections on their emerging professional identity over the course of a core clerkship year. A narrative analysis was conducted iteratively in partnership with a staff internist and a medical education researcher experienced in autoethnography, allowing for robust multi-perspective input. Reflections were analyzed and coded thematically; disagreements were resolved by consensus discussion. Findings: A key theme of the reflections was self-preservation, conceptualized within two principal contexts: (i) Clerk-patient relationships, wherein we found ourselves in emotionally difficult situations; and (ii) Clerk-preceptor relationships, in which self-preservation manifested through a series of self-protective mechanisms. Insights: The practice of self-preservation is understood as the conscious act of boundary-setting and psychological defense in situations that pose a real (or perceived) threat to the clerk’s wellbeing. At best, self-preservation serves as a temporary compromise to the stressors and burnout of clerkship. We speculate, however, that, left unchecked, acts of self-preservation may lead to habitual selfishness and apathy, qualities that are in diametric opposition to those expected of future physicians, and may manifest later (when these learners progress through the hierarchy) as the unprofessional behaviors that perpetuate the cycle of the hidden curriculum.

Maintenance of Composite-Based Aircraft Components and Structures through the Perspective of Aviation Maintenance Technicians in the United States

For the last three decades, the field of aircraft construction and manufacturing has been experiencing a significant change as the material of choice for aircraft construction has been continuously transitioning from metal to composite materials. This underlying change to the way aircraft structures and components are manufactured is propelled by composite materials’ intrinsic design and operational advantages. Nevertheless, as new technologies are introduced into the aviation industry, it is crucial to consider how all aspects thereof are affected, most importantly to ensure that safety is not compromised. As a critical part of the aviation industry and a key factor influencing the safety thereof, maintenance activities and certified aviation maintenance technicians (AMTs) need to be considered when evaluating the impact of the introduction of composite materials in the aeronautical field. Consequently, the conducted study specifically focuses on aircraft maintenance activities, especially as it pertains to the interaction of certified AMTs with composite materials. The goal of the study was to highlight and understand the opinions and perceptions of AMTs on composite materials and how, from a front-line perspective, aviation maintenance activities have changed with the introduction of novel materials. The input gathered from AMTs is a tool to understand potential pitfalls, deficiencies in training and resources, and safety threats from a maintenance perspective that may stem from the increased use of composite materials. With this purpose, certified maintenance technicians in the United States were surveyed and their responses were analyzed to identify recurring themes in the topics presented. Responses indicated issues related to formal composite-centered AMT training, knowledge, and resources available for composite maintenance.

Health risks of frozen raw breaded chicken products: A local health unit perspective.

Raw chicken, including frozen raw breaded chicken products, has been implicated in 18 outbreaks of nontyphoidal salmonellae in Canada since 2017. The Canadian Food and Inspection Agency has since implemented industry requirements, from April 2019, aimed at reducing salmonellosis risks in frozen raw breaded chicken products prior to their distribution in the retail marketplace. This commentary explores key issues identified by a local public health unit during an investigation of two cases of salmonellosis that occurred within the context of a recent Canada-wide outbreak linked to frozen raw breaded chicken products. Consumer handling and preparation practices, product appearance and labelling issues were essential factors in the development of disease. From this front-line perspective, new industry requirements by the Canadian Food and Inspection Agency are analyzed for their potential to reduce salmonellosis risks in such chicken products, while also identifying additional measures that could be implemented to further reduce the risk of product associated outbreaks.

ID/HIV Physician Ambassadors: Advancing Policy to Improve Health.

ID/HIV physicians and other healthcare professionals advocate within the healthcare system to ensure adults and children receive effective treatment. These advocacy skills can be used to inform domestic and global infectious disease policies to improve healthcare systems and public health. ID/HIV physicians have a unique frontline perspective to share with federal policymakers regarding how programs and policies benefit patients and public health. Providing this input is critical to the enactment of legislation that will maximize the response to infectious diseases. This article discusses the advocacy of ID/HIV physicians and other healthcare professionals in federal health policy. Key issues include funding for ID/HIV programs; the protection of public health and access to health care; improving research opportunities; and advancing the field of ID/HIV, including supporting the next generation of ID/HIV clinicians. The article also describes best practices for advocacy and provides case studies illustrating the impact of ID/HIV physician advocacy.

Infectious Diseases/Human Immunodeficiency Virus Physician Ambassadors: Advancing Policy to Improve Health.

Infectious diseases/human immunodeficiency virus (ID/HIV) physicians and other healthcare professionals advocate within the healthcare system to ensure adults and children receive effective treatment. These advocacy skills can be used to inform domestic and global infectious diseases policies to improve healthcare systems and public health. ID/HIV physicians have a unique frontline perspective to share with federal policymakers regarding how programs and policies benefit patients and public health. Providing this input is critical to the enactment of legislation that will maximize the response to infectious diseases. This article discusses the advocacy of ID/HIV physicians and other healthcare professionals in federal health policy. Key issues include funding for ID/HIV programs; the protection of public health and access to healthcare; improving research opportunities; and advancing the field of ID/HIV, including supporting the next generation of ID/HIV clinicians. The article also describes best practices for advocacy and provides case studies illustrating the impact of ID/HIV physician advocacy.

Front-line staff's perspective on patient safety culture in Iranian medical centers: A systematic review and meta-analysis.

The prerequisite for promoting safety culture is to assess the existing safety culture level of institutes, because safety precautions without appropriate evaluation increase costs and unforeseen risks. This study aimed to systematically review the status of patient safety culture from the perspective of clinical personnel at Iranian hospitals through a meta-analysis of studies using the Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire. The present systematic review and meta-analysis was conducted in 2018. Data were gathered by searching Google Scholar, Scopus, PubMed, and Web of Science databases up to November 2018. Search keywords were "patient", "safety", "culture", "healthcare", "hospital", "medical center", "HSOPSC tool", and "Iran". The search protocol was limited to 10 years. To estimate the PSC score, computer software CMA:2 (Comprehensive Meta-Analysis) was used. The presence of heterogeneity across the studies was assessed with the I2 statistic. A forest plot was used to report the results. Publication bias was assessed through a funnel plot. The meta-analysis of studies showed that the PSC score based on the random effect model was 52.7% (95% CI: 50.2%-55.2%), (Q = 522.3, df = 54, P < 0.05, I2 = 89.6). A mean of 12 dimensions of HSOPSC showed that the "Teamwork within units" dimension had the highest PSC score (67.2%) and "Non-punitive response to error" had the lowest score (40.4%). Managers and policymakers should be directed towards non-punitive responses to errors and persuade staff to report errors and execute the approach to learn from mistakes. Also, a periodic government evaluation of the patient safety culture will help further its sustainable development.

Echocardiography in Pandemic: Front-Line Perspective, Expanding Role of Ultrasound, and Ethics of Resource Allocation

The grave clinical context of the coronavirus disease 2019 (COVID-19) pandemic must be understood. Italy is immersed in the COVID-19 pandemic. Most of the world will soon follow. The United States currently has the most documented cases of COVID-19 of any nation. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)–associated acute cardiomyopathy is common in critical care patients and is associated with a high mortality rate. Patients with COVID-19 frequently require mechanical support for adequate oxygenation. A severe shortfall of ventilators is predicted. Of equal concern is the projected shortage of trained professionals required to care for patients on mechanical ventilation. Ultrasonography is proving to be a valuable tool for identifying the pulmonary manifestations and progression of COVID-19. Lung ultrasound also facilitates successful weaning from mechanical ventilation. Ultrasonography of the lung, pleura, and diaphragm are easily mastered by experienced echocardiographers. Echocardiography has an established role for optimal fluid management and recognition of cardiac disease, including SARS-CoV-2-associated acute cardiomyopathy. Cardiologists, anesthesiologists, sonographers, and all providers should be prepared to commit their full spectrum of skills to mitigate the consequences of the pandemic. We should also be prepared to collaborate and cross-train to expand professional services as necessary. During a declared health care crisis, providers must be familiar with the ethical principles, organizational structure, practical application, and gravity of limited resource allocation.

Frontline perspective on credentialing and privileging of ambulatory care pharmacists.

To present the current state of, and frontline advice on, the implementation of successful credentialing and privileging processes for practicing pharmacists in the United States. The American Society of Health-System Pharmacists (ASHP) Section Advisory Group on Compensation and Practice Sustainability surveyed ambulatory care pharmacists via ASHP Connect about the status, structure and oversight of their ambulatory care clinical practice sites with credentialed and privileged (C&P) pharmacists. Over 80% of survey respondents identified themselves as a C&P pharmacist, and over 90% indicated it is 'Important' or 'Very Important' for pharmacists to be C&P. Qualitative survey responses indicated the most important considerations for establishing or expanding a credentialing and privileging process for ambulatory care pharmacists were 'don't re-create the wheel', 'establish a physician champion and/or obtain leadership buy-in', 'be persistent and patient', 'develop a guidance document' and 'work within existing processes'. Starting a credentialing and privileging process is critical in preparation for, or response to, provider status recognition of pharmacists in the United States. When used with existing guidance documents on credentialing and privileging, 'front line' advice from practicing pharmacists can help promote expanded roles for pharmacists within healthcare systems.