Background Involving patients in their healthcare using shared decision-making (SDM) is promoted through policy and research, yet its implementation in routine practice remains slow. Research into SDM has stemmed from primary and secondary care contexts, and research into the implementation of SDM in tertiary care settings has not been systematically reviewed. Furthermore, perspectives on SDM beyond those of patients and their treating clinicians may add insights into the implementation of SDM. This systematic review aimed to review literature exploring barriers and facilitators to implementing SDM in hospital settings from multiple stakeholder perspectives. Methods The search strategy focused on peer-reviewed qualitative studies with the primary aim of identifying barriers and facilitators to implementing SDM in hospital (tertiary care) settings. Studies from the perspective of patients, clinicians, health service administrators, and decision makers, government policy makers, and other stakeholders (for example researchers) were eligible for inclusion. Reported qualitative results were mapped to the Theoretical Domains Framework (TDF) to identify behavioural barriers and facilitators to SDM. Results Titles and abstracts of 8724 articles were screened and 520 were reviewed in full text. Fourteen articles met inclusion criteria. Most studies (n = 12) were conducted in the last four years; only four reported perspectives in addition to the patient-clinician dyad. In mapping results to the TDF, the dominant themes were Environmental Context and Resources, Social/Professional Role and Identity, Knowledge and Skills, and Beliefs about Capabilities. A wide range of barriers and facilitators across individual, organisational, and system levels were reported. Barriers specific to the hospital setting included noisy and busy ward environments and a lack of private spaces in which to conduct SDM conversations. Conclusions SDM implementation research in hospital settings appears to be a young field. Future research should build on studies examining perspectives beyond the clinician-patient dyad and further consider the role of organisational- and system-level factors. Organisations wishing to implement SDM in hospital settings should also consider factors specific to tertiary care settings in addition to addressing their organisational and individual SDM needs. Trial Registration The protocol for the review is registered on the Open Science Framework and can be found at https://osf.io/da645/, DOI 10.17605/OSF.IO/DA645.

In the current century, organisations are facing unprecedented changes in their working environments. In order to remain viable, organisations must learn to adapt to the changes they face. We investigate the influence of senior leaders on organisational learning from the employees' perspective. Data were based upon qualitative research utilising a case study of a New Zealand-operated information technology company. By employing an explorative, exploitative and transformative organisational learning framework, and a transactional and transformational model of leadership, the findings contribute empirically to the limited body of research surrounding how senior leaders influence organisational learning. In particular, the findings illustrate the way in which senior leaders employed a transformational leadership approach during explorative and transformative learning, while adopting a transactional leadership style during exploitative learning. Also compelling were participants' comments highlighting how senior leaders had employees emotionally connect and test business ideas and assumptions throughout the learning process.

Background Shared decision-making (SDM) has been shown to improve healthcare outcomes and is a recognized right of patients. Policy requires health services to implement SDM. However, there is limited research into what interventions work and for what reasons. The aim of the study was to develop a series of interventions to increase the use of SDM in maternity care with stakeholders. Methods Interventions to increase the use of SDM in the setting of pregnancy care were developed using Behaviour Change Wheel and Theoretical Domains Framework and building on findings of an in-depth qualitative study which were inductively analysed. Intervention development workshops involved co-design, with patients, clinicians, health service administrators and decision-makers, and government policy makers. Workshops focused on identifying viable SDM opportunities and tailoring interventions to the local context (the Royal Women’s Hospital) and salient qualitative themes. Results Pain management options during labour were identified by participants as a high priority for application of SDM, and three interventions were developed including patient and clinician access to the Victorian Government’s maternity record via the patient portal and electronic medical records (EMR); a multi-layered persuasive communications campaign designed; and clinical champions and SDM simulation training. Factors identified by participants for successful implementation included having alignment with strategic direction of the service, support of leaders, using pre-standing resources and workflows, using clinical champions, and ensuring equity. Conclusion Three interventions co-designed to increase the use of SDM for pain management during labour address key barriers and facilitators to SDM in maternity care. This study exemplifies how health services can use behavioural science and co-design principles to increase the use of SDM. Insights into the co-design of interventions to implement SDM in routine practice provide a framework for other health services, policy makers and researchers.

How effective are interventions in optimizing workplace mental health and well-being? A scoping review of reviews and evidence map by Waddell A,

Background The impact and management of sub-clinical hypoxia during hemodialysis is a significant medical challenge. As key determinants of O2 availability and delivery, proposed mechanisms contributing to hypoxia include ischemia, alkalemia and pulmonary leukocyte sequestration. However, no study has comprehensively investigated and compared these interrelated mechanisms throughout a typical hemodialysis treatment week. This study aimed to comprehensively assess the physiological mechanisms that contribute to hypoxia during hemodialysis. Methods In 76 patients, we measured arterial blood gases and pH at four time-points during hemodialysis (start, 15 min, 60 min, end) over the course of a standard treatment week. For the mid-week hemodialysis session, we additionally measured central hemodynamics (non-invasive cardiac output monitoring) and white blood cell count. Results Linear regression modelling identified changes in pH, but not central hemodynamics or white blood cell count, to be predictive of changes in PaO2 throughout hemodialysis (e.g. at 60 min, β standardised coefficient pH = 0.45, model R2 = 0.25, P < 0.001). Alkalemia, hypokalemia, decreased calcium, and increased hemoglobin-O2 affinity (leftward shift in the oxyhemoglobin dissociation curve) were evident at the end of hemodialysis. pH and hemoglobin-O2 affinity at the start of hemodialysis increased incrementally over the course of a standard treatment week. Conclusion These data highlight the important role of pH in regulating O2 availability and delivery during hemodialysis. Findings support routine pH monitoring and personalized dialysate bicarbonate prescription to mitigate the significant risk of alkalemia and sub-clinical hypoxia.