Mixed Methods Pilot Evaluation Research Articles

Family Involvement Training for Staff and Family Caregivers: Case Report on Program Design and Mixed Methods Evaluation.

The COVID-19 pandemic underscored the imperative for meaningful family involvement in long-term care, aligning with policy and safety standards while enhancing outcomes for caregivers, residents, and staff. The objectives of this article are as follows: (1) a case study report on implementing a family involvement intervention designed to facilitate the formal and safe engagement of family caregivers in resident care and (2) the pilot evaluation of the intervention. We used Knapp's six-step implementation science model to guide and describe intervention development to provide insight for others planning family involvement projects. We employed sequential mixed methods, including surveys with quantitative and qualitative questions before and after program implementation for providers, and surveys and interviews with family caregivers a year after. We used the Mann-Whitney U test (p < 0.05) to assess differences in health providers' perceptions pre- and post-education. Families and staff perceived that the Family Involvement Program was important for improving the quality of care, residents' quality of life and family/staff relationships. Providers' perceptions of the program's positive impact on residents' quality of life (p = 0.020) and quality of care (p = 0.010), along with their satisfaction with working relationships with families (p = 0.039), improved significantly after the program. Qualitative data confirmed improvements in family-staff relationships. In conclusion, we documented the design of this family involvement initiative to encourage family caregivers and staff to work together in residents' care. Youville's Family Involvement Program gives families and family caregivers an explicit role as partners in long-term care. The mixed methods pilot evaluation documented improvements in staff and family relationships.

Effects of a community-based, multi-level family planning intervention on theoretically grounded intermediate outcomes for couples in rural Uganda: Results from a mixed methods pilot evaluation.

This study tested the theoretically grounded conceptual model of a multi-level intervention, Family Health = Family Wealth (FH = FW), by examining FH = FW's effect on intermediate outcomes among couples in rural Uganda. FH = FW is grounded in the social-ecological model and the social psychological theory of transformative communication. A pilot quasi-experimental controlled trial. Two matched clusters (communities) were randomly allocated to receive the FH = FW intervention or an attention/time-matched water, sanitation and hygiene intervention (N = 140, 35 couples per arm). Quantitative outcomes were collected through interviewer-administered questionnaires at baseline, 7-months and 10-months follow-up. Focus group discussions (n = 39) and semi-structured interviews (n = 27) were conducted with subsets of FH = FW participants after data collection. Generalized estimated equations tested intervention effects on quantitative outcomes, and qualitative data were analysed through thematic analysis-these data were mixed and are presented by level of the social-ecological model. The findings demonstrated an intervention effect on family planning determinants across social-ecological levels. Improved individual-level family planning knowledge, attitudes and intentions, and reduced inequitable gender attitudes, were observed in intervention versus comparator, corroborated by the qualitative findings. Interpersonal-level changes included improved communication, shared decision-making and equitable relationship dynamics. At the community level, FH = FW increased perceived acceptance of family planning among others (norms), and the qualitative findings highlighted how FH = FW's transformative communication approach reshaped definitions of a successful family to better align with family planning. This mixed methods pilot evaluation supports FH = FW's theoretically grounded conceptual model and ability to affect multi-level drivers of a high unmet need for family planning.

Getting a "SMART START" to gestational diabetes mellitus education: a mixed-methods pilot evaluation of a knowledge translation tool in primary care.

South Asian people living in Canada face higher rates of gestational diabetes mellitus (GDM) compared to national trends. The objective of this study was to design and pilot test a knowledge translation (KT) tool to support GDM prevention counselling in primary care. This study is a mixed-methods pilot evaluation of the "SMART START" KT tool involving 2 family physicians in separate practices and 20 pregnant South Asians in Ontario, Canada. We conducted the quantitative and qualitative components in parallel, developing a joint display to illustrate the converging and diverging elements. Between January and July 2020, 20 South Asian pregnant people were enrolled in this study. A high level of acceptability was received from patients and practitioners for timing, content, format, language, and interest in the interventions delivered. Quantitative findings revealed gaps in patient knowledge and behaviour in the following areas: GDM risk factors, the impact of GDM on the unborn baby, weight gain recommendations, diet, physical activity practices, and tracking of weight gain. From the qualitative component, we found that physicians valued and were keen to engage in GDM prevention counselling. Patients also expressed personal perceptions of healthy active living during pregnancy, experiences, and preferences with gathering and searching for information, and key preventative behaviours. Building on this knowledge can contribute to the design and implementation of other research opportunities or test new hypotheses as they relate to GDM prevention among South Asian communities.

A Codeveloped Web-Based Disability Disclosure Toolkit for Youth With Disabilities: Mixed Methods Pilot Evaluation.

Youth and young adults with disabilities experience many barriers in securing employment such as discrimination, inaccessible environments, and lack of support. Youth often need to decide whether and how they should disclose their need for accommodations to employers, which can help them to do their best at work. However, few evidence-based toolkits focusing on disability disclosure exist for youth with various types of disabilities. Supporting youth to develop self-advocacy skills is salient because they are an underrepresented and marginalized group in the labor market. The objective of this study was to conduct a pilot evaluation of a web-based toolkit to enhance disability disclosure for youth and young adults helping to advocate for their needs and request workplace accommodations. We conducted 2 in-person focus groups to codevelop a web-based disability disclosure toolkit, which was followed by a pilot evaluation with a pre-post survey. Primary outcomes focused on the relevance of the toolkit content, preliminary perceived impact on knowledge and confidence, and open-ended feedback on the usefulness of the toolkit. Secondary outcomes focused on effectiveness (ie, measures of self-determination). A total of 14 youths with various types of disabilities took part in the study (aged 20-25 years; n=11, 78% female) including 3 who participated in the codevelopment focus group sessions and 11 youths who participated in the surveys. Our findings involved three main themes in the codevelopment sessions that included (1) disability disclosure and workplace accommodation experiences (ie, knowing when, whether, and how to disclose their disability and request workplace accommodations), (2) usefulness of the tool (ie, relatable content, format and design, and suggestions for further development), and (3) perceived impact of the toolkit (ie, navigating disclosure decisions and how to approach employers and develop other relevant employment skills). The survey findings showed that the majority of participants (10/11, 91%) reported that the toolkit increased or changed their knowledge or understanding of disability disclosure. Most participants (8/11, 73%) reported that the toolkit helped to increase their perceived confidence in their daily activities. The majority of participants (8/11, 73%) agreed or strongly agreed that the toolkit was easy to understand and comprehensive. Regarding the preliminary impact of the toolkit, participants did not demonstrate any significant improvements in self-determination (all P>.05). Our findings emphasize the importance of codeveloping a disability disclosure toolkit with youth to enhance its relevance for their needs. Our toolkit indicates preliminary potential as an educational resource for youth and young adults with disabilities as they search for and secure employment. Further research is needed to assess the impact of the tool with larger samples to understand the impact of workplace disability disclosure decisions for youth with disabilities.

A trauma-informed intervention for foster caregivers in Central Massachusetts: A mixed methods pilot evaluation

The Encompass program trains and supports foster, kinship, and pre-adoptive caregivers to recognize trauma in children, attend to foster children’s behavioral health needs, and ease the stress of caregiving. We used a caregiver survey at two time points to evaluate the preliminary efficacy of the Encompass program on foster parent (n = 17) and child (n = 25) outcomes, and conducted qualitative interviews with caretakers (n = 15). We observed significant positive changes in caretakers’ perceived knowledge about trauma, confidence in trauma-informed fostering, and use of external support care providers. Qualitative data suggest that participants found the Encompass program to be helpful and enjoyable, but that systemic issues in the child welfare system, which were beyond the scope of this program to impact, contribute to caregiver dissatisfaction and fostering difficulties. Findings suggest that Encompass has a positive impact on caregiver perceptions of knowledge about trauma and confidence in their capacity to provide trauma-informed foster care. Continued evaluation of the Encompass program using an experimental design will be informative about program impact.

Feasibility of a text-mediated recall system to increase cardiovascular disease risk assessment in general practice: Mixed-methods pilot evaluation.

The uptake of formal cardiovascular disease risk assessment in the primary prevention setting is low. We tested the feasibility of an SMS recall system to invite eligible patients for a Heart Health Check in Australian general practice. Of 332 general practices that expressed interest in the study, 231 were randomised to either an intervention orwait list control group. Intervention general practices sent SMS invitations linked to digital information to eligible patients via general practice software. Deidentified baseline and two-month data were extracted via clinical audit software. Asurvey was administered to 35intervention general practices. General practice visits were similar between the control and intervention groups, but Heart Health Check billing increased 14-fold in the intervention group. This study showed that an SMS recall system for Heart Health Checks can beeffective and acceptable in general practice. The findings will inform a broader implementation trial over 2022-23.

Solution-Focused Body-Mind-Spirit (SF-BMS) Group Therapy for Mental Health and Trauma Symptoms Among Asian American Youth: A Mixed Methods Pilot Evaluation

Solution-focused and body-mind-spirit practices have shown promising evidence for addressing various mental health and trauma-related problems, though there is limited research regarding their joint application. In addition, Asian American youth are often underrepresented in social work intervention literature despite increasing risk of negative effects from anti-Asian hate and violence since the start of the coronavirus pandemic. Solution-Focused Body-Mind-Spirit (SF-BMS) group therapy is a novel intervention approach with roots in traditional Eastern and postmodern Western philosophies that may be particularly applicable for the cross-cultural experience of second-generation immigrants from Southeast Asian countries. This study conducted a mixed methods pilot evaluation of SF-BMS group therapy with Asian American youth and found modest pre–post improvements in overall problems and qualitative evidence of the intervention’s acceptability.

Novel intervention to promote COVID-19 protective behaviours among Black and South Asian communities in the UK: protocol for a mixed-methods pilot evaluation

IntroductionCulturally appropriate interventions to promote COVID-19 health protective measures among Black and South Asian communities in the UK are needed. We aim to carry out a preliminary evaluation of an...

Compas-Y: A mixed methods pilot evaluation of a mobile self-compassion training for people with newly diagnosed cancer.

Compas-Y is a compassionate mind training app that was co-designed to be fully adapted to mobile technology and to people with newly diagnosed cancer. This study aimed to evaluate the use, appreciation and impact of the app. Seventy-one people with cancer who created an app account were included (38% breast cancer, 72% diagnosed <4 months ago, 76% received chemotherapy). Participants had very high baseline scores of self-compassion. In a convergent mixed methods design, back-end log-data (n = 71), pre-post surveys (n = 34) and semi-structured interviews (n = 23) collected for >8 weeks and were concurrently analysed using joint displays. About half of the participants (45%) used 4 of the 6 modules. Compas-Y was highly appreciated, with all content considered relevant and a source of support. Experienced benefits related to improved mental health. Particularly, we found significant changes in anxiety, but not in depression or well-being. In the interviews, people reported experiencing more rest and more positive emotions due to using the app. Process benefits included significant reductions in self-criticism (inadequate self and self-blame), but not self-compassion. In the interviews, people reported improved self-compassion and less self-criticism, more self-awareness, recognition and support, and improved emotion regulation and coping. The surveys did not capture the full range of outcomes that participants reported in the interviews. Compas-Y is a highly appreciated mobile intervention that supported users in aspects of their mental health. Findings are discussed in terms of reach and adherence, app functionalities, co-design and tailoring of cancer-related and compassion-based eHealth.

Exploring the Impact of a Family-Focused, Gender-Transformative Intervention on Adolescent Girls' Well-Being in a Humanitarian Context.

While family functioning interventions show promise for improving adolescent girls' well-being in humanitarian contexts, few programs employ a gender-transformative approach to maximize benefits for adolescent girls. This paper presents findings from a mixed-methods pilot evaluation of a whole-family, gender-transformative intervention conducted with Syrian refugee families in Jordan. The Siblings Support of Adolescent Girls in Emergencies program was implemented with 60 Syrian refugee households in Azraq and Za'atari camps in Jordan. A quantitative survey was administered to 18 households at baseline and endline, and researchers conducted qualitative interviews and focus group discussions with caregivers, paired interviews and participatory discussions with adolescents, and key informant interviews with program mentors. Paired t-tests revealed statistically significant improvements in mental distress, resilience, and gender equitable attitudes in the full sample and for girls only and marginally significant improvements in family functioning. Qualitative findings revealed improvements in four domains of girls' well-being-self-efficacy, self-confidence, pro-social behavior, and mental health-through three primary pathways: family members' increased gender equitable attitudes, healthier intrahousehold communication, and greater affective involvement. Findings from this mixed-methods evaluation point to the potential value in merging gender-transformative and whole-family approaches in humanitarian programming to maximize positive impacts for adolescent girls.

School-Based Suicide Prevention through Gatekeeper Training: The Role of Natural Leaders

One Tier 2 approach to school-based youth suicide prevention is gatekeeper training, where teachers and school staff learn to respond to students in distress. Although promising, implementation-sensitive prevention efforts could be advanced by providing additional training to natural leaders in the school building, so they can support and coach others. The purpose of this study is to describe the development and initial mixed-methods pilot evaluation of a natural leader training to support the real-world implementation of QPR®gatekeeper training, a Tier 2 (selective) intervention. This study underscores the importance of creating implementation approaches to meet the needs of real-world school contexts.

A Mixed-Methods Pilot Evaluation of Manhood 2.0, a Program to Reduce Unintended Pregnancy Among Young Men.

One promising though understudied approach to addressing race/ethnic disparities in teen pregnancy rates is through sexual and reproductive health (SRH) programming for young men. This pilot study assessed the feasibility, quality, and preliminary efficacy of Manhood 2.0—a group-based, after-school SRH program for young Black and Latino men, which examines gender norms. This mixed-methods study describes program attendance and quality; participant experiences and engagement in the program; and changes in participant gender norms, knowledge, attitudes, self-efficacy, and social support. Quantitative data from baseline and post-intervention surveys (n = 51) were analyzed using paired t-tests and McNemar’s tests. Qualitative data from five post-intervention focus groups (n = 27) were transcribed, coded, and analyzed for themes. At baseline, participants were ages 15 to18 years (M = 16.4 years), 30% were Latino, 66% were Black, 34% ever had sex, and 44% of sexually active participants had sex without any contraceptive method or condom. Quality ratings by program observers were high. The majority of participants (61%) attended at least 75% of sessions, and 96% rated Manhood 2.0 as “very good” or “excellent.” Pre–post comparisons showed increases in receipt of SRH information; contraception knowledge; positive attitudes about supporting partners in pregnancy prevention; self-efficacy in partner communication about sex; discussing program content with friends and family; and social competence and support. Focus group participants described benefits from the Manhood 2.0 content (i.e., full range of contraceptive methods, sexual consent, gender norms) and delivery (i.e., reflective discussion, nonjudgmental facilitators). Findings suggest that Manhood 2.0 is a promising SRH program for young men.

Water Safety Education Programs in Culturally and Linguistically Diverse Seattle Communities: Program Design and Pilot Evaluation

Drowning is a public health concern that disproportionally affects children and minorities in Washington State. Community health educators from Seattle Children’s Hospital designed a Water Safety Education and Lifejacket Giveaway Program for low-income parents of preschool-aged children from culturally and linguistically diverse backgrounds. The program was interpreted into multiple languages and parents and children in attendance received free lifejackets. The mixed-methods pilot evaluation of this program found statistically significant relationships between language and self-reported parent swim skill level (English-speaker OR 4.6; 95%CI: 1.84 – 11.54); and confidence of keeping one’s child safe (English-speaker OR 3.34; 95%CI: 1.10 – 10.4). Additionally, parents who self-reported that they could swim had four times the odds of feeling confident in keeping their children safe around the water (95% CI: 1.21 - 13.28). Qualitative data from follow-up interviews identified that the program boosted parent knowledge and confidence in safe water practices. Multi-lingual delivery and the role of partner preschools was critical to this program’s success. Specific programmatic focus on adult parent/caregiver skills and knowledge that reduce risk around the water should be a priority for future efforts to reduce drowning.

The Friendship Bench as a brief psychological intervention with peer support in rural Zimbabwean women: a mixed methods pilot evaluation

AbstractBackgroundThere is a large treatment gap for common mental disorders in rural areas of low-income countries. We tested the Friendship Bench as a brief psychological intervention delivered by village health workers (VHWs) in rural Zimbabwe.MethodsRural women identified with depression in a previous trial received weekly home-based problem-solving therapy from VHWs for 6 weeks, and joined a peer-support group. Depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS) and Shona Symptom Questionnaire (SSQ). Acceptability was explored through in-depth interviews and focus group discussions. The proportion of women with depression pre- and post-intervention was compared using McNemar's test.ResultsTen VHWs delivered problem-solving therapy to 27 women of mean age 33 years; 25 completed six sessions. Women valued an established and trustful relationship with their VHW, which ensured confidentiality and prevented gossip, and reported finding individual problem-solving therapy beneficial. Peer-support meetings provided space to share problems, solutions and skills. The proportion of women with depression or suicidal ideation on the EPDS declined from 68% to 12% [difference 56% (95% confidence interval (CI) 27.0–85.0);p= 0.001], and the proportion scoring high (&gt;7) on the SSQ declined from 52% to 4% [difference 48% (95% CI 24.4–71.6);p&lt; 0.001] after the 6-week intervention.ConclusionVHW-delivered problem-solving therapy and peer-support was acceptable and showed promising results in this pilot evaluation, leading to quantitative and qualitative improvements in mental health among rural Zimbabwean women. Scale-up of the Friendship Bench in rural areas would help close the treatment gap for common mental disorders.

Promoting Problem Solving About Health Management: A Mixed-Methods Pilot Evaluation of a Digital Health Intervention for Older Adults With Pre-Frailty and Frailty.

Background: There is a need for interventions to promote health management of older adults with pre-frailty and frailty. Technology poses promising solutions, but questions exist about effective delivery. Objectives: We present the results of a mixed-methods pilot evaluation of Virtual Online Communities for Older Adults (VOCALE), an 8-week intervention conducted in the northwestern United States, in which participants shared health-related experiences and applied problem solving skills in a Facebook group. Methods: We performed a mixed-methods process evaluation, integrating quantitative and qualitative data, to characterize the intervention and its effects. We focus on four areas: health-related measures (health literacy and self-efficacy), participation, problem solving skills enacted, and subjective feedback. Results: Eight older adults with pre-frailty and frailty (age = 82.7 ± 6.6 years) completed the study. There was an upward trend in health literacy and health self-efficacy post-intervention. Participants posted at least two times per week. Content analysis of 210 posts showed participants were able to apply the problem solving skills taught, and exit interviews showed participants’ increased awareness of the need to manage health, and enjoyment in learning about others. Conclusion: This mixed-methods evaluation provides insight into feasibility and design considerations for online interventions to promote health management among vulnerable older adults.

Mixed methods pilot evaluation of interpersonal psychotherapy for body image for adolescents.

Body dissatisfaction is common in adolescence and associated with poor outcomes. The aim of this mixed method pilot evaluation was to determine acceptability, feasibility and preliminary efficacy of Interpersonal Psychotherapy for Body Image (IPT-BI), a school-based group intervention for young people with high levels of body dissatisfaction. Eighteen participants (11–13 years, 78% female) took part in two IPT-BI groups (n = 10; n = 8). Feasibility was measured by recruitment and attrition rates; acceptability using a treatment satisfaction questionnaire and focus groups; and clinical outcomes at baseline, each session and post intervention. The majority of young people (72%, n = 18/25) who were referred or expressed interest went on to take part. Average session attendance was 100% and 89%. Participants expressed high levels of treatment satisfaction with 94% (n = 16/17) rating IPT-BI as ‘quite helpful’ or ‘very helpful’ and 94% (n = 16/17) stating they would recommend it to others. Preliminary exploration of efficacy showed significant improvements in body image and significant reductions in interpersonal difficulties and appearance-based conversations. Young people valued specific IPT-BI skills (role play, communication strategies), alongside generic therapeutic factors (therapeutic alliance, group cohesion). IPT-BI is feasible and acceptable with promising provisional clinical outcomes indicating the need for a fully powered randomised controlled trial.

Advancing Allyship Through Anti-Oppression Workshops for Public Health Students: A Mixed Methods Pilot Evaluation

This pilot mixed methods evaluation describes the impact of an anti-oppression workshop on allyship development among a group of public health graduate students. After completing a mandatory anti-oppression workshop, a survey including closed- and open-ended questions was administered to 41 public health students specializing in health promotion. Closed-ended questions gathered basic demographic data and Likert-type scale responses to assess changes in participant knowledge, awareness, and attitudes surrounding anti-oppression concepts discussed during the workshop, while open-ended questions asked respondents to reflect on how such changes might influence their development as allies. A response rate of 65.85% (27 respondents) was achieved. The majority of the study group were between the ages of 20 and 24 years (74.07%), self-identified as straight (77.8%), and self-identified as non-White (77.8%), while almost the entire group identified as female (92.59%). Five key themes emerged from a directed content analysis of qualitative data, identifying the importance of anti-oppression workshops for allyship development: conducive environments, positionality, knowledge, active listening and learning, and advocacy. These themes were used to construct a mixed methods joint display for comparative interpretation of quantitative and qualitative data. Mixed methods analysis revealed that anti-oppression workshops can promote allyship development by increasing knowledge of key terms and concepts associated with anti-oppression and facilitating critical reflections on power, privilege, and social location. Our findings demonstrate a profound need for ongoing anti-oppression training among future public health students and professionals.

The impact of maternity training on knowledge, confidence, and empowerment: A mixed method pilot evaluation.

Maternity training is a critical global issue. In the United Kingdom (UK), the need for safer care and patient safety is emphasized through NHS policy. Health Education England (HEE) recommends that training should support a culture of continuous learning and improvement, particularly in the area of reducing the rates of stillbirths, neonatal and maternity deaths, and other adverse outcomes, such as intrapartum brain injuries. Training has been shown to play a crucial role in improving quality of care and reducing maternal and perinatal mortality and morbidity. This evaluation was undertaken to determine both the immediate and sustained impact of multiprofessional training in cardiotocograph (CTG) interpretation and community-based simulation training in obstetric emergencies: childbirth emergencies in the community (CEC). The impact was measured in terms of practitioner knowledge, confidence, and empowerment immediately pretraining and posttraining and at 12weeks following training. A longitudinal mixed methods design was used. Attendees to maternity training sessions on cardiotocograph interpretation and management of childbirth emergencies in the community provided the sample. Quantitative data were collected using questionnaires to assess knowledge, confidence, and empowerment. Qualitative data were collected using open-ended questions embedded in the questionnaires. Quantitative data were analysed using within-subject t test to compare differences in the dependent variable measures. Qualitative data analysis was guided by Braun and Clarke (2013) method thematic analysis. The combined qualitative and quantitative results lucidly highlight that training positively impacts upon knowledge, confidence, and empowerment, an impact which is observed across three time points. Training in CTG and CEC is effective in improving knowledge, confidence, and empowerment across all groups. Furthermore, the provision of training packages in these subject areas facilitates improvements in the longer term.

Implementation of latent tuberculosis infection screening and treatment among newly arriving immigrants in the Netherlands: A mixed methods pilot evaluation.

IntroductionTo reach pre-elimination levels of tuberculosis (TB) incidence in the Netherlands, prevention of TB among immigrants through diagnosis and treatment of latent TB infection (LTBI) is needed. We studied the feasibility of a LTBI screening and treatment program among newly arriving immigrants for national implementation.MethodsWe used mixed methods to evaluate the implementation of LTBI screening and treatment in five Public Health Services (PHS) among immigrants from countries with a TB incidence >50/100,000 population. We used Poisson regression models with robust variance estimators to assess factors associated with LTBI diagnosis and LTBI treatment initiation and reported reasons for not initiating or completing LTBI treatment. We interviewed five PHS teams using a semi-structured method to identify enhancing and impeding factors for LTBI screening and treatment.ResultsWe screened 566 immigrants; 94 (17%) were diagnosed with LTBI, of whom 49 (52%) initiated and 34 (69%) completed LTBI treatment. LTBI diagnosis was associated with male gender, higher age group, higher TB incidence in the country of origin and lower level of education. Treatment initiation was associated with PHS (ranging from 29% to 86%), lower age group, longer intended duration of stay in the Netherlands, and lower level of education. According to TB physicians, clients and their consulted physicians in the home country lacked awareness about benefits of LTBI treatment. Furthermore, TB physicians questioned the individual and public health benefit of clients who return to their country of origin within the foreseeable future.ConclusionsDoubt of physicians in both host country and country of origin about individual and public health benefits of LTBI screening and treatment of immigrants hampered treatment initiation: the high initiation proportion in one PHS shows that if TB physicians are committed, the LTBI treatment uptake can be higher.

Collective leadership and safety cultures (Co-Lead): protocol for a mixed-methods pilot evaluation of the impact of a co-designed collective leadership intervention on team performance and safety culture in a hospital group in Ireland

IntroductionThere is accumulating evidence implicating the role of leadership in system failures that have resulted in a range of errors in healthcare, from misdiagnoses to failures to recognise and respond...