Staff Groups Research Articles

Perceptions of hospital electronic health record (EHR) training, support, and patient safety by staff position and tenure

BackgroundHospitals rely on their electronic health record (EHR) systems to assist with the provision of safe, high quality, and efficient health care. However, EHR systems have been found to disrupt clinical workflows and may lead to unintended consequences associated with patient safety and health care professionals’ perceptions of and burden with EHR usability and interoperability. This study sought to explore the differences in staff perceptions of the usability and safety of their hospital EHR system by staff position and tenure.MethodsWe used data from the AHRQ Surveys on Patient Safety Culture® (SOPS®) Hospital Survey Version 1.0 Database and the SOPS Health Information Technology Patient Safety Supplemental Items (“Health IT item set”) collected from 44 hospitals and 8,880 staff in 2017. We used regression modeling to examine perceptions of EHR system training, EHR support & communication, EHR-related workflow, satisfaction with the EHR system, and the frequency of EHR-related patient safety and quality issues by staff position and tenure, while controlling for hospital ownership type and bed-size.ResultsIn comparison to RNs, pharmacists had significantly lower (unfavorable) scores for EHR system training (regression coefficient = -0.07; p = 0.047), and physicians, hospital management, and the IT staff were significantly more likely to report high frequency of inaccurate EHR information (ORs = 2.03, 1.34, 1.72, respectively). Compared to staff with 11 or more years of hospital tenure, new staff (less than 1 year at the hospital) had significantly lower scores for EHR system training, but higher scores for EHR support & communication (p < 0.0001). Dissatisfaction of the EHR system was highest among physicians and among staff with 11 or more years tenure at the hospital.ConclusionsThere were significant differences in the Health IT item set’s results across staff positions and hospital tenure. Hospitals can implement the SOPS Health IT Patient Safety Supplemental Items as a valuable tool for identifying incongruity in the perceptions of EHR usability and satisfaction across staff groups to inform targeted investment in EHR system training and support.

How are Allied Health Professionals represented at board level in NHS Trusts in the West Midlands?

PurposeAllied Health Professionals (AHPs) are the third largest professional group in the National Health Service (NHS). This qualitative study aimed to establish the representation of AHPs at NHS Trust board level.Design/methodology/approachExamination of public Trust board minutes and Care Quality Commission (CQC) reports from a sample of NHS provider Trusts in the West Midlands. One reviewer extracted data concerning all details pertaining to professional staffing groups.FindingsA stark picture of under-representation which is statistically significant emerges. AHP representation to Trust boards via public board meetings was 7% for AHPs, compared to 41% for doctors and 52% for nurses. There were similar results with CQC reports, with the representation of AHPs at 11%, whilst doctors and nurses were significantly higher at 42 and 47%, respectively.Research limitations/implicationsThe data gathered for this paper was from a small number of NHS provider Trusts in the West Midlands of England, which can be considered a limitation of the study. However, the results of this study are stark and provide a compelling snapshot of the significant under-representation of AHPs to those NHS Trust boards included.Practical implicationsAHPs are a significant staff group within the NHS; their representation at board level is of benefit to the Trust boards both in terms of engaging with staff and in terms of managing quality and risk. Recommendations are made that Trust boards ensure they have a board member with responsibility for AHPs who actively engages with, understands and provides challenge, and that the CQC considers the inclusion of examples of AHP activity and staffing levels in their inspection, and that these are confirmed with senior AHPs in the organisation being inspected.Originality/valueThis is an original paper and is the first to address the representation of AHPs at Trust board via consideration of board papers and CQC reports, providing a platform for further consideration.

Developing research priorities for palliative care in Colombia: a priority setting partnership approach

BackgroundA recent Lancet commission called for more research on palliative care in low- and middle-income (LMIC) countries such as Colombia. A research priority setting approach has been recommended by The Global Forum for Health Research to address the huge gap in research output between LMIC and high-income countries, with influential health service bodies recommending the active involvement of non-research expert stakeholders in establishing research priorities to address service user needs.MethodPriority setting partnership (PSP) following the four stages of the James Lind Alliance methodology; establishing the partnership, identifying evidence uncertainties, refining questions and uncertainties, and prioritization. Data from MS forms were analysed using descriptive statistics.ResultsA total of 33 stakeholders attended an online PSP workshop and completed the Mentimeter exercise in Microsoft Teams. A total of 48 attended the subsequent in person prioritisation exercise in urban Bogota (n = 22) and rural Popayan (n = 25). The stakeholders were a diverse group of health professionals (physicians, medical students, nurses, dentists, physiotherapists, nutritionist, occupational and speech therapists), financial and administrative staff and patients with life-limiting illness and caregivers. Top research priorities included patient and caregiver needs, service provider education and training, and better integration of palliative care with cancer and non-cancer services. The key challenges included a lack of interest in palliative care research, along with funding, time and resource constraints. Key solutions included collaboration across disciplines and settings, highlighting benefits of palliative research to help secure adequate resources, and multicentre, mixed method research, with patient involvement from the research development stage.ConclusionThe findings of this PSP should be disseminated among palliative care associations worldwide to inform international multicentre studies, and among governmental and nongovernmental organisations that promote research in Colombia. A focus on patient and family caregiver palliative care needs in Colombia should be prioritised.

Effect of General Surgery Resident Participation in Thoracic Surgery on Oncologic Outcomes: An Observational Cohort Study.

Background: Despite increasing sub-specialization, general surgeons continue to perform oncologic thoracic surgeries. Our objective was to determine whether general surgery resident participation in thoracic surgery affects surgical quality or oncologic outcomes. We hypothesized that patient outcomes with and without resident participation would be similar. Methods: We retrospectively reviewed the electronic health records of patients with stage 0-IV lung cancer undergoing oncologic pulmonary resection at BLINDED FOR REVIEW during an 11-year period (2012-2022). Patients younger than 18years or older than 85years were excluded, as were those who had incomplete follow-up data or were unregistered in our institutional cancer registry. Patients were divided into groups based on whether residents or staff surgeons completed >50% of the critical portions of the operation. We compared 30-day morbidity outcomes, overall survival (OS), and disease-free survival (DFS). Results: Three hundred thirteen patients met inclusion criteria. Demographic and clinical characteristics were similar between groups, as were types of surgical resection and median operative times. A statistical difference was found in the distribution of surgical approach. The odds of morbidity were 65% higher in the Staff group (OR=1.65; 95% CI, 1.007-2.71). Resident participation was not significantly associated with OS or DFS (P =.32 and P =.54, respectively). Discussion: General surgery resident involvement in lung cancer operations is not associated with longer operative times but is associated with a higher likelihood of a thoracotomy. General surgery resident involvement was associated with decreased postoperative morbidity and did not significantly affect OS or DFS.

Suicidal ideation among non-physician hospital system staff: Prevalence and workplace correlates

BackgroundResearch suggests that healthcare workers are at greater risk for suicide than other occupations, but most published studies focus on physicians. This study examines the prevalence of suicidal ideation (SI) and associated occupational factors among a broad group of non-physician healthcare staff. MethodsAn anonymous online survey was sent to a random sample of 30 % of non-physician healthcare staff at a large urban healthcare system between September and November 2022. Weighted multivariable binary logistic regressions were conducted to determine the workplace and mental health factors associated with SI. ResultsThe 1084 respondents included nurses, administrative staff, research staff, medical assistants, nurse practitioners, physician assistants, and other roles. Of the sample, 8.8 % endorsed having SI over the prior two weeks. Results of the regression indicated that, after adjusting for demographic factors, greater odds of SI were associated with physical violence experienced from a patient or visitor (odds ratio [OR] = 2.15, 95 % confidence interval [CI] = 1.06–4.37), lower perceived leadership support (OR = 0.95, 95 % CI = 0.92–0.98), and positive screening for depression (OR = 4.66, 95 % CI = 2.45–8.86). Exploratory analysis suggests that depression may be a mediating factor between workplace stressors and SI. LimitationsLimitations include the response rate, the use of a single item to assess SI, and the cross-sectional design. ConclusionFindings suggest that workplace violence and leadership support are important occupational factors associated with SI among healthcare workers. Reducing and mitigating workplace violence, enhancing leadership support, and improving access to mental health care should be considered targets for interventions to decrease suicide risk in this population.

Immunoprophylaxis of HBV infection in medical personnel

The intensity and duration of the preservation of the immune response to viral hepatitis B after vaccination among the medical staff of the polyclinic was studied. The features of postvaccinal immunity in medical staff have been revealed. No postvaccinal antibodies were found in 35 % of the examined patients. The intensity of post-vaccination immunity to the HBV virus among various groups of medical staff at the polyclinic depends on the type of professional activity. Revaccination led to the appearance of antibodies to the HB virus (anti-HBs) in 100 %, and the intensity of immunity was at medium or high levels.

A collaborative approach to low-frequency noise mitigation

This case study examines efforts to study and mitigate low-frequency noise produced by boilers serving a large hospital. The work was completed by a collaborative group of citizens, hospital staff, acoustical consultants, and noise control solutions providers. While none of the noise controls are novel from an engineering perspective, the criteria, experimental methods, and consensus strategies used for this project could serve as a model for similar community challenges.

910 MIND THE BUMP - a Multi-Site Initiative Promoting Allyship for Pregnant Colleagues in Theatres

Abstract Aim Awareness of considerations to keep pregnant colleagues safe in theatres is crucial for equity and diversity. National orthopaedic guidance exists for radiation, cement exposure, gas induction, scrub, and managing symptoms. Lack of knowledge of guidance can cause anxiety for pregnant staff and friction between colleagues. This multi-centre initiative assessed and improved awareness of pregnancy considerations amongst theatre staff, promoting allyship and a supportive environment, Method A questionnaire assessing knowledge of published guidance on pregnancy considerations was completed by orthopaedic theatre staff (surgeons, anaesthetists, nurses, allied health professionals and students) at eight trusts. Educational posters were displayed in theatres and changing areas. The questionnaire was then repeated. Results 290 pre-poster (49.1%:50.2%:0.7% Male:Female:Non-Binary) and 220 post-poster (37.8%:62.2%:0.0% M:F:NB) questionnaires were completed. Pre-poster, the average percentage of correct questionnaire answers was 22.4%, with a significant 47.3% increase post-poster to 69.8% (95%CI 43.8%-50.8%, p=0.0000). Knowledge varied widely across domains, increasing across all topics (radiation 9.0% to 61.4%, scrub 17.2% to 74.5%, cement 30.3% to 72.3%, gas induction 10.7% to 57.7% and symptom management 45.2% to 82.7%). There was a significant post-poster difference of 21.9% (95% CI 16.3%-27.5%, p=0.0000) between female and male scores (females scoring higher), compared to a non-significant pre-poster difference of 4.2% (95%CI -0.4% to +8.8%, p=0.0783). Conclusions This study revealed a low pre-existing knowledge of important pregnancy considerations amongst theatre staff. A simple poster campaign transformed awareness in all staff groups and should be expanded across specialties and nationwide to promote allyship and support for our pregnant colleagues.

A New Method for Documenting Sign Language Productions in Schools

Purpose: There are well-established guidelines for the recording, transcription, and analysis of spontaneous oral language samples by researchers, educators, and speech pathologists. In contrast, there is presently no consensus regarding methods for the written documentation of sign language samples. The Handshape Analysis Recording Tool (HART) is an innovative method for documenting and analyzing word level samples of signed languages in real time. Fluent sign language users can document the expressive sign productions of children to gather data on sign use and accuracy. Method: The HART was developed to document children's productions in Australian Sign Language (Auslan) in a bilingual–bicultural educational program for the Deaf in Australia. This written method was piloted with a group of fluent signing Deaf educational staff in 2014–2016, then used in 2022–2023 with a group of fluent signing professionals to examine inter- and intrarater reliability when coding parameters of sign accuracy. Results: Interrater reliability measured by Gwet's Agreement Coefficient, was “good” to “very good” across the four phonological parameters that are components of every sign: location, movement, handshape, and orientation. Conclusions: The findings of this study indicate that the HART can be a reliable tool for coding the accuracy of location, orientation, movement, and handshape parameters of Auslan phonology when used by professionals fluent in Auslan. The HART can be utilized with any sign language to gather word level sign language samples in a written form and document the phonological accuracy of signed productions.

How can digital media enhance students' mastery of threshold concepts?

Mastery of threshold concepts is driven by students’ expanding knowledge and experience. Threshold concepts cannot be taught via the simple transfer of knowledge, but instead ‘emerge’ for students via experience, conceptualisation and self-development (Meyer and Land, 2005). This can happen at different stages via different means and students may enter a liminal state whereby they oscillate between states of understanding and being (Cousin, 2006; Meyer and Land 2005). Teaching and re-teaching threshold concepts at set points adds to the teaching load and may not be an effective way to support students’ mastery on what is a messy, unpredictable and personal journey. The persistence of learning resources in the online space means that students can drive their own learning and development by visiting and revisiting interactive digital resources that demonstrate conceptually difficult or contradictory knowledge. Such troublesome knowledge is a feature of many fields of engineering. The transformative power of digital media can take students outside of the classroom and immerse them in other worlds. By taking a focussed approach in this project, we will explore what transformative and troublesome knowledge means in the literature, and to a select group of students and staff at WMG. Using the findings, we will then propose digital media solutions informed by multiple perspectives.

Prison Officers’ Perceptions of Delivering Trauma-Informed Care in Women’s Prisons

ABSTRACT Since 2015, women’s prisons across England have been working toward providing trauma-informed care (TIC) given the high rates of psychological trauma in the prison population. Research into TIC in prisons has been limited to date. This qualitative study explored the perceptions of 35 prison officers from two English women’s prisons about their experiences of providing TIC, including the role of training. Four main themes were identified using thematic analysis: Creating trauma-informed settings was noted as a dynamic process, complicated by prisons being triggering environments for women. Prison officers described attempting to negotiate the power (im)balance between them and women in prison, to allow them to nurture positive relationships with them. Operational practices reportedly regularly undermined these efforts by reinforcing the power differential. Staff also observed variable and limited capacity and opportunities for TIC, further reducing the ability to create settings conducive to TIC. These findings have important implications for women’s prisons, including the need to review and revise TIC training for new and existing staff; prioritize staff well-being and support, and improve recruitment processes to develop a staff group with the aptitude and skill to deliver TIC.

Knowledge of basic life support amongst Medical/Paramedical Professionals, in a Tertiary Care Hospital, Karachi, Pakistan

Background: Cardiopulmonary resuscitation (CPR), a critical skill within basic life support (BLS), is essential for medical professionals in cases of cardiac or respiratory failure. This study aims to evaluate the BLS knowledge and practical application among healthcare professionals at a tertiary care hospital in Karachi, Pakistan, to enhance training outcomes. Objective: The primary objective was to assess the knowledge and practical skills of BLS among medical and paramedical staff at Ziauddin Hospital and identify gaps in training to improve emergency response effectiveness. Methods: This cross-sectional descriptive study involved 400 healthcare workers from various departments of Ziauddin Hospital between February and April 2024. Participants were selected to represent a diverse group of doctors, nurses, and paramedical staff. Data was collected using a standardized questionnaire based on European standards and guidelines from the American Heart Association and the Resuscitation Council. The questionnaire included both theoretical and practical aspects of BLS. Data were analyzed using SPSS version 25, with frequencies, percentages, and chi-square tests applied to assess associations between variables. Ethical approval was obtained from the Ziauddin Hospital Ethical Review Committee, ensuring adherence to the Declaration of Helsinki. Results: The study revealed that 80% of participants knew the abbreviation for BLS. However, only 26.8% correctly identified the immediate action for an unconscious victim. The correct site for chest compressions in adults and infants was known by 88% and 84.5% of participants, respectively. Awareness of AEDs and EMS was high, at 95% and 93%. Practical skills were notably weaker, with significant variability in emergency responses: 26.8% would give two breaths immediately to an unconscious victim, and 76% incorrectly chose to compress the abdomen for a victim submerged in water. The mean age of participants was 27±4.9 years, with a gender distribution of 51.5% female and 48.5% male. Conclusion: While healthcare professionals at Ziauddin Hospital possess strong theoretical knowledge of BLS, there are significant gaps in practical application, especially in emergency scenarios. To improve patient outcomes in emergencies, more practical, scenario-based training is necessary. This study underscores the need for ongoing, hands-on training sessions to bridge the gap between knowledge and practice.

LGBT+ representation higher education in England and Wales

This paper investigates the level of LGBT+ representation among staff and students in higher education in England and Wales. We compare data from the 2021 England and Wales Census to Higher Education Statistics Agency (HESA) data. We find that LGBT+ people are more highly represented in higher education among all staff groups and students than in relevant comparator groups according to age and educational level in the general population. LGBT+ representation among students and STEM academics is modestly higher than the general population comparator group, while representation among non-STEM academics is substantially higher than one would expect from the general population comparator group. We found no statistically significant under-representation in any particular higher education institution.

Land for Whom? Diversity, Land Trusts, and Farmers and Gardeners from Marginalized Backgrounds in New England, U.S.

Land trusts in the U.S. play an important role in preventing the loss of farmland to development. Farmers seeking affordable land may benefit from these conservation efforts. Yet the distribution of these benefits across farmer groups is unclear. This study asks: To what extent are land trusts meeting the needs of farmers and gardeners from marginalized backgrounds? Interviews with land trust staff and focus groups with marginalized farmers and gardeners in New England, USA reveal discrepancies in how diversity and land access are discussed. Access to adequate, affordable land was a serious concern among farmers and gardeners, yet few land trusts had programs to increase access for diverse populations. Land trusts approached diversity, equity, and inclusion work by making limited commitments, pivoting to social class, and avoidance due to perceptions of mission drift. These findings have significant implications for who benefits and who is excluded from private farmland conservation.

Canadian Public Library Pandemic Response: Bridging the Digital Divide and Preparing for Future Pandemics

This article examines the impact of the COVID-19 pandemic on computer and Internet access services in Canadian public libraries as well as the implications of this lack of access for people facing socioeconomic barriers, and how Canadian public libraries could address digital divide issues in the post-pandemic era. Recommendations on future pandemic preparedness for public libraries are also discussed in this article. This research project conducted a bilingual (English and French) online survey targeting public library technicians, librarians, and library board members across Canada. From 1,631 research invitation emails sent to public library staff across Canada and three Facebook posts on Canadian public library staff groups, over a one-year period from November 3, 2021, to November 6, 2022. 226 individuals participated in the online survey questionnaire. Findings suggest that the COVID-19 pandemic has exacerbated social inequalities in Canada, including access to computers and the Internet. The digital divide could lead to poor health outcomes and put existing disadvantaged populations at greater risk in terms of future employment opportunities. The digital divide needs to be addressed so that Canadians in low-income households and those living with disabilities do not get left behind. Importantly, public libraries in Canada have been working tirelessly to equalize access to computers, the Internet, and digital literacy training and support. Their determination, social responsibility, and professional ethics need to be acknowledged. Finally, this article's recommendations for future pandemic preparedness in Canadian public libraries may also be applicable and beneficial to public libraries globally.

Antibiotic use in the emergency department for acute sore throat

Acute sore throat is a frequent cause of inappropriate antibiotic prescribing in primary care, despite the majority of cases being viral in nature. Following changes in consulting behaviour, many patients are now turning to emergency departments for their primary care needs. The aim of this study was to determine whether clinical scores are used between staff groups when treating acute tonsillitis in an emergency department and whether antibiotics are prescribed appropriately. A retrospective service evaluation of patients diagnosed with ‘tonsillitis’ in the emergency department over a 12-month period was conducted. Patient records were reviewed for Centor or FeverPAIN scoring documentation, antibiotic prescriptions and the clinician group providing treatment. The review found that a clinical score was documented for only 38 patients and that 44% of antibiotics were prescribed inappropriately. It is concluded that clinical scores are not being used appropriately in the emergency department to guide antibiotic prescribing for tonsillitis, leading to a high number of inappropriate prescriptions.

Connected Learning Communities

Abstract This article reports on the first results of the educational model piloted in EUTOPIA, a transnational university alliance established under the European University initiative. We discuss the theoretical underpinnings and core principles of our model which seeks to enable students, academics and societal partners to form Connected Learning Communities through enhancing existing learning activities and practices in teaching and learning. We elaborate on the value added of our model for developing a diverse portfolio of activities and a dynamic structure that has the potential to offer international learning opportunities to a large and diverse group of students, academic staff and societal partners. We close the article with recommendations for the results of European University Alliance pilots to reach their full innovation potential.

Comparison of COVID-19 Infection in Operating Room Staff During Two COVID-19 Waves Using Different Preventive Strategies in a Tertiary Care Hospital in Pakistan.

To assess if limiting elective surgeries during specific pandemic phases significantly affected COVID-19 incidence among operating room (OR) staff. Retrospective cohort study. Place and Duration of the Study: Operation Theatre (OT), The Aga Khan University Hospital, Karachi, Pakistan, from May 2020 to 2021. This retrospective study compared two pandemic waves: Wave 1, during which elective surgeries were restricted (REL), and Wave 2, during which elective surgeries were continued routinely (EL). Exposure levels were measured based on OR activity. Incidence rates were calculated per 100 OR staff, per 100 ORs, and per 100 surgeries for both Groups. No statistically significant difference emerged in COVID-19 incidence among OR staff between REL (13.8 per 100 staff) and EL (14.4 per 100 staff) Groups (p = 0.825). However, the EL Group exhibited a significantly lower incidence risk per running OR (5.6 per 100 ORs vs. REL's 12 per 100 ORs, p <0.001). Additionally, the EL Group showed a lower incidence per 100 surgeries (1.5 vs. REL's 2.9, p <0.002). Restricting elective surgeries during the early pandemic phase did not significantly reduce COVID-19 incidence among OR staff. Infections were primarily linked to interactions with colleagues and the community, emphasising the need for a balanced pandemic response considering patient care and the consequences of surgery restrictions. COVID-19 infection, Operating room staff, COVID-19 waves, COVID-19 transmission, Hospital epidemiology, Pandemic response.

A Quantitative Analysis of Intraoperative Distractions and When They Occur During General Surgical Operations.

Introduction Distractions in operating theatres prevent team members from concentrating on the complex tasks required for a successful operation. This can be a potential hazard to care for, and previously, correlations have been made between increased theatre distractions and adverse events. However, it remains unclear how frequently such events occur during routine care in theatres. The present study aims to quantify distractions and analyse any differences between staff groups, operative stages, and modes of operation. Methods A single-centre prospective study was conducted to assess disruptions in general surgical theatres. Events were recorded using a previously described categorization system on a proforma by a single researcher. The source and severity of distraction were recorded, as well as the mode of operation (elective/emergency), stage of operation, and staff team (scrubbed/floor). Results A total of 4,219 minutes of surgery were observed over four weeks, and 1,095 distraction events were recorded. Of the 14 elective and nine emergency procedures recorded, there was a mean of 54.8 distractions per procedure and a frequency of one distraction every three minutes and 51 seconds (15.6 hr-1). Irrelevant communication relating to the patient's case was the most common source, accounting for 24.7% of all distractions. The most frequently disrupted stage of the procedure for scrubbed staff was during anastomosis/resection for both elective and emergency procedures, with 16.9 and 32.6 distractions occurring per hour, respectively. Scrubbed staff were significantly more susceptible to distraction in emergency procedures than the floor staff. Discussion Our study reflects previous assessments with irrelevant communications and emergency procedures yielding the highest prevalence of distraction. This investigation provides novel information about the different stages of general surgery and the frequency of distractions that occur.

Exploring staff experiences and perceptions of patient-perpetrated violence in hospital settings: A qualitative study.

To explore hospital staff experiences and perceptions of patient-perpetrated violence. Descriptive qualitative study. Twelve semi-structured interviews (June-August 2022) were held with a diverse sample of hospital nurses, doctors, allied health professionals, security and a non-clinical manager. The framework approach was used to organise and analyse data, using Attribution Theory as a theoretical lens. Three themes were identified: violence as (un)predictable, violence as (un)preventable and the cumulative toll of violence. In making sense of why patients become violent, participants described different 'types' of aggressive patients and variably attributed behaviours to situation, disposition or a combination of both. Regardless of perceived causal factors, staff overwhelmingly appeared to view violence as predictable. Participants also reflected on the wider structural problems underpinning violence, frequently alluding to their sense of relative powerlessness to initiate change. The cumulative toll of violence was a common thread, with staff describing their acquisition of 'resilience' and reflecting on its role in their responses to escalating situations. Many hospital staff are resigned to the inevitability of violence. The concept of staff 'resilience' following violence is not unproblematic, having the potential to serve as a guise for acceptance and as an additional variable for which staff are held accountable. When designing strategies, organisations should ensure that accountability for violence reduction is distributed across multiple levels. This study makes a novel contribution by exploring the perspectives of multiple staff groups working across diverse hospital settings, and adds to a sparse literature on this subject in the UK. Efforts to address violence against healthcare staff need to be power-conscious, ensuring that accountability is distributed across multiple levels. This study is reported in line with the Consolidated Criteria for Reporting Qualitative Studies (COREQ). No patient or public contribution.