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The challenges of present-day healthcare are urgent; there is a shortage of clinicians, patient care is increasingly complex, resources are limited, clinician turnover seems ever-increasing, and the expectations of providers and patients are monumental. To transform problems into innovative opportunities, diverse perspectives and a sense of possibility are needed. The following is a collaborative manuscript authored by the speakers of the 8th World Congress of Pediatric Cardiology and Cardiac Surgery session, "Teamwork, Culture Change, and Strategy." Although this panel was diverse in the clinical roles, nationalities, and genders represented, several consistent themes emerged which are explored in this work.

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Emancipatory practice development (ePD) is a practitioner-led research methodology which enables workplace transformation. Underpinned by the critical paradigm, ePD works through facilitation and workplace learning, with people in their local context on practice issues that are significant to them. Its purpose is to embed safe, person-centred learning cultures which transform individuals and workplaces. In this article, we critically reflect on a year-long ePD study in an acute care hospital ward. We explore the challenges of practice change within systems, building collective strength with frontline collaborations and leadership to sustain new learning cultures. Our work advances practice development dialogue through working closely with the underpinning theories. Our critique analyses how ePD can enact and sustain change within a complex system. We argue that ePD works to strengthen safety cultures by challenging antidemocratic practices through communicative action. By opening communicative spaces, ePD enables staff to collectively deliberate and reach consensus. Their raised awareness supports staff to resist ways of working which conspire against safe patient care. Sustainability of practice change is fostered by the co-operative democracies created within the frontline team and meso level enablement. We conclude that the democratising potential of ePDt generates staff agency at the frontline.

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OBJECTIVES: The Nursing Home Culture Change (NHCC) movement promotes a person- and relationship-centered approach and a small-scale, homelike model for NHs. The present study aimed to integrate the most recent empirical findings regarding the impact of NHCC on resident, staff, family, and organizational outcomes. DESIGN: Integrative review. SETTING AND PARTICIPANTS: Not applicable. METHODS: OVID MEDLINE, PsycINFO, Embase, and CINAHL databases were searched for quantitative or mixed studies published in English between 2018 and 2022 and examining the effect of NHCC on resident, staff, family, and/or organizational outcomes. A narrative and tabular synthesis of the results is provided. RESULTS: A total of 1687 references were identified. Following duplicate removal, title and abstract screening, and full-text screening, 75 studies were retained for synthesis and suggest a positive impact of NHCC on resident (eg, quality of life and neuropsychiatric function), staff (eg, job satisfaction and stress), family (eg, satisfaction and depressive symptoms), and organizational (eg, NH attractiveness and occupancy rate) outcomes. CONCLUSIONS AND IMPLICATIONS: NHCC shows promising results in all studied outcome categories. Future research should further investigate obstacles to NHCC implementation, conduct cost-benefit analyses supported by appropriate statistical tests, and define ways to improve NH staff education as well as NH policies and regulations to better support NHCC initiatives.

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BACKGROUND: Recent research within the context of Obstetrics shows the added value of patient participation in in-hospital patient safety. Notwithstanding these benefits, recent research within an Obstetrics department shows that four different negative effects of patient participation in patient safety have emerged. However, the approach to addressing these negative effects within the perspective of patient participation in patient safety is currently lacking. For this reason, the aim of this study is to generate an overview of actions that could be taken to mitigate the negative effects of patient participation in patient safety within an Obstetrics department. METHODS: This study was conducted in the Obstetrics Department of a tertiary academic center. An explorative qualitative interview study included sixteen interviews with professionals (N = 8) and patients (N = 8). The actions to mitigate the negative effects of patient participation in patient safety, were analyzed and classified using a deductive approach. RESULTS: Eighteen actions were identified that mitigated the negative effects of patient participation in patient safety within an Obstetrics department. These actions were categorized into five themes: 'structure', 'culture', 'education', 'emotional', and 'physical and technology'. These five categories reflect the current approach to improving patient safety which is primarily viewed from the perspective of professionals rather than of patients. CONCLUSIONS: Most of the identified actions are linked to changing the culture to generate more patient-centered care and change the current reality, which looks predominantly from the perspective of the professionals and too little from that of the patients. Furthermore, none of the suggested actions fit within a sixth anticipated category, namely, 'politics'. Future research should explore ways to implement a patient-centered care approach based on these actions. By doing so, space, money and time have to be created to elaborate on these actions and integrate them into the organizations' structure, culture and practices.

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Despite an abundance of support for culturally inclusive learning environments, there is little consensus regarding how to change educational contexts to effectively and sustainably foster cultural inclusion. To address this gap, we report findings from a research-practice partnership that leveraged the Culture Cycle Framework (CCF) to expand educators' praxis to include both independent and interdependent models of self. Most U.S. schools validate independent cultural models (i.e., those that prioritize individuality, uniqueness, and personal agency) and overlook interdependent models (i.e., those that prioritize connectedness, relationality, and collective well-being), which are more common among students from marginalized racial and socioeconomic backgrounds. Using a quasi-experimental longitudinal design, we trained school leadership to integrate ideas about cultural inclusion (i.e., validating the importance of both independent and interdependent cultural models) into school-wide flagship practices. We assessed downstream indicators of culture change by surveying teachers and students across the district and found that a) leadership-level training enhanced school-wide beliefs about cultural inclusion, b) teachers' endorsement of culturally inclusive beliefs predicted their use of culturally inclusive practices, and c) teachers' use of culturally inclusive practices predicted enhanced psychosocial and academic outcomes among students. This research represents a comprehensive culture change effort using the CCF and illustrates a means of fostering inclusion-focused educational culture change and assessing downstream consequences of culture change initiatives.

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Introduction: Gender Advisors (GENADs) have played a key role in the efforts of military organizations worldwide to integrate gender perspectives, and culture change, within the defence and security context. Military organizations, however, continue to face challenges in regard to diversity and inclusion, including limited representation of women and other diverse groups who do not fit the white male, masculine stereotype, and subtle and overt expressions of prejudice and stigma towards under-represented and marginalized groups. In such an organizational context, the integration of gender perspectives has faced challenges, and transformative culture change has remained elusive. In particular, the experience of GENADs suggests that there may be unique challenges to serving as "gender experts" within military organizations. This paper, therefore, examines the lived experience of GENADs within the context of military organizations, as illustrated by GENADs in the Canadian Armed Forces. Methods: We consider two qualitative studies on the lived experience of GENADs and focus on the shared theme of legitimacy of gender expertise at both individual and systemic levels. Results: This analysis highlights challenges that gendered power relations may pose for GENADs as individual change agents, and for systemic, transformative culture change, within existing military organizations, while reaffirming the importance of understanding the lived experience of GENADs in their pursuit of more equitable institutional and operational outcomes. Conclusion: Using social-psychological theories of tokenism, we consider more broadly what it means to be the gender person within masculinized military organizations and conclude with reflections on the potential contours of transformative culture change within the military context.

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BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has long recognized and championed increasing diversity within the surgical workplace. SAGES initiated the Fundamentals of Leadership Development (FLD) Curriculum to address these needs and to provide surgeon leaders with the necessary tools and skills to promote diversity, equity, and inclusion (DEI) in surgical practice. In 2019, the American College of Surgeons issued a request for anti-racism initiatives which lead to the partnering of the two societies. The primary goal of FLD was to create the first surgeon-focused leadership curriculum dedicated to DEI. The rationale/development of this curriculum and its evaluation/feedback methods are detailed in this White Paper. METHODS: The FLD curriculum was developed by a multidisciplinary task force that included surgeons, education experts, and diversity consultants. The curriculum development followed the Analysis, Design, Development, Implementation and Evaluation (ADDIE) instructional design model and utilized a problem-based learning approach. Competencies were identified, and specific learning objectives and assessments were developed. The implementation of the curriculum was designed to be completed in short intervals (virtual and in-person). Post-course surveys used the Kirkpatrick's model to evaluate the curriculum and provide valuable feedback. RESULTS: The curriculum consisted of interactive online modules, an online discussion forum, and small group interactive sessions focused in three key areas: (1) increasing pipeline of underrepresented individuals in surgical leadership, (2) healthcare equity, and (3) conflict negotiation. By focusing on positive action items and utilizing a problem-solving approach, the curriculum aimed to provide a framework for surgical leaders to make meaningful changes in their institutions and organizations. CONCLUSION: The FLD curriculum is a novel leadership curriculum that provided surgeon leaders with the knowledge and tools to improve diversity in three areas: pipeline improvement, healthcare equity, and conflict negotiation. Future directions include using pilot course feedback to enhance curricular effectiveness and delivery.

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Introduction: In response to several high-profile cases of senior leaders in the Canadian Armed Forces (CAF) being accused of various forms of sexual and professional misconduct, the organization has committed to culture change. Drawing on the group engagement model and empirical evidence, we propose that CAF members' experience of thwarted belongingness reduces their capacity to show empathy, which in turn affects their support for culture change. Method: Participants were 139 Naval and Officer Cadets from the Royal Military College of Canada who were predominantly male (61%), between 18 and 21 years old (80%), and not members of a visible minority group (68%). Data was collected via an online self-report survey assessing thwarted belongingness, empathy, and attitudes toward culture change. Results: Whether participants experienced thwarted belongingness was not directly related to their level of support for culture change. Individuals' thwarted belongingness was indirectly and negatively associated with support for culture change, through its impact on empathy. Discussion: Taken together, the results demonstrate that cadets' experience of belongingness contributed to their level of empathy, which together predicted their support for culture change initiatives. Efforts to change the culture of the CAF may need to consider improving members' levels of belongingness and, by extension, their levels of empathy. Implications for inclusion efforts are discussed.

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PURPOSE: To identify "headlines" that would engage recipients to consider plant protein over red meat. DESIGN: Mail and web survey. SETTING: Urban Minnesota community. SUBJECTS: 144 survey respondents from our health plan and community program distribution lists who live with at least 1 other person and eat meat. INTERVENTION: We asked respondents how likely they would be to click on each of 24 headlines with a motivator (eating plant protein for health vs for environmental reasons) and a barrier (family preferences, knowledge about plant proteins, or cooking skills). 16 headlines contained the word "beans". MEASURES: We created categorical variables for each headline construct: (1) motivator, (2) barrier, and (3) reference to beans. Using a mixed model with random effects, we compared, for each construct, respondents' self-reported likelihood to click on a headline. RESULTS: Health-related headlines performed significantly better than environmental headlines (P = .0019, 95% CI .01, .11). Family-oriented headlines performed slightly better than skills-oriented (P = .0927, 95% CI -.01, .11) and knowledge-oriented (P = .0960, 95% CI -.01, .11) headlines. Headlines containing the word "beans" performed significantly worse than those not containing "beans" (P < .0001, 95% CI -.22, -.12). CONCLUSIONS: The population represented by our survey respondents report being most likely to click on headlines that emphasize health and family. They report they are significantly less likely to click on headlines that promote beans.

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Health inequities are costing the US health care system an estimated $320 billion annually. Those costs are predicted to increase if inequitable care is not addressed. As a Health Equity Consultant for small community-based organizations and a large healthcare system I observe and advise on a variety of organizational attempts at advancing health equity. Over many years of doing this work I have developed what I call The 8 Rights of Organizational Health Equity Work. This well-organized approach outlines the most important things an organization must get right if they want to create meaningful and sustainable movement towards heath equity. Unless healthcare organizations are intentional and strategic about reducing health disparities, any progress we have made in recent years will lag and given the costs of disparities, the industry may find itself in a financial crisis that it may not recover from. The 8 Rights of Organizational Health Equity Work provides the structure that is needed to reduce health inequities in a concerted way.

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High-quality nursing home (NH) care has long been a challenge within the United States. For decades, policymakers at the state and federal levels have adopted and implemented regulations to target critical components of NH care outcomes. Simultaneously, our delivery system continues to change the role of NHs in patient care. For example, more acute patients are cared for in NHs, and the Center for Medicare and Medicaid Services (CMS) has implemented value payment programs targeting NH settings. As a part of these growing pressures from the broader healthcare delivery system, the culture-change movement has emerged among NHs over the past two decades, prompting NHs to embody more person-centered care as well as promote settings which resemble someone's home, as opposed to institutionalized healthcare settings. Researchers have linked culture change to high-quality outcomes and the ability to adapt and respond to the ever-changing pressures brought on by changes in our regulatory and delivery system. Making enduring culture change within organizations has long been a challenge and focus in NHs. Despite research suggesting that culture-change initiatives that promote greater resident-centered care are associated with several desirable patient outcomes, their adoption and implementation by NHs are resource intensive, and research has shown that NHs with high percentages of low-income residents are especially challenged to adopt these initiatives. This chapter takes a novel approach to examine factors that impact the adoption of culture-change initiatives by assessing knowledge management and the role of knowledge management activities in promoting the adoption of innovative care delivery models among under-resourced NHs throughout the United States. Using primary data from a survey of NH administrators, we conducted logistic regression models to assess the relationship between knowledge management and the adoption of a culture-change initiative as well as whether these relationships were moderated by leadership and staffing stability. Our study found that NHs were more likely to adopt a culture-change initiative when they had more robust knowledge management activities. Moreover, knowledge management activities were particularly effective at promoting adoption in NHs that struggle with leadership and nursing staff instability. Our findings support the notion that knowledge management activities can help NHs acquire and mobilize informational resources to support the adoption of care delivery innovations, thus highlighting opportunities to more effectively target efforts to stimulate the adoption and spread of these initiatives.

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BACKGROUND: Toxic work culture contributes to healthcare worker burnout and attrition, but little is known about how healthcare organizations can systematically create and promote a culture of civility and collegiality. OBJECTIVE: To analyze peer-to-peer positive feedback collected as part of a systematized mortality review survey to identify themes and recognition dynamics that can inform positive organizational culture change. DESIGN: Convergent mixed-methods study design. PARTICIPANTS: A total of 388 physicians, 212 registered nurses, 64 advanced practice providers, and 1 respiratory therapist at four non-profit hospitals (2 academic and 2 community). INTERVENTION: Providing optional positive feedback in the mortality review survey. MAIN MEASURES: Key themes and subthemes that emerged from positive feedback data, associations between key themes and positive feedback respondent characteristics, and recognition dynamics between positive feedback respondents and recipients. KEY RESULTS: Approximately 20% of healthcare workers provided positive feedback. Three key themes emerged among responses with free text comments: (1) providing extraordinary patient and family-centered care; (2) demonstrating self-possession and mastery; and (3) exhibiting empathic peer support and effective team collaboration. Compared to other specialties, most positive feedback from medicine (70.2%), neurology (65.2%), hospice and palliative medicine (64.3%), and surgery (58.8%) focused on providing extraordinary patient and family-centered care (p = 0.02), whereas emergency medicine (59.1%) comments predominantly focused on demonstrating self-possession and mastery (p = 0.06). Registered nurses (40.2%) provided multidirectional positive feedback more often than other clinician types in the hospital hierarchy (p < 0.001). CONCLUSIONS: Analysis of positive feedback from a mortality review survey provided meaningful insights into a health system's culture of teamwork and values related to civility and collegiality when providing end-of-life care. Systematic collection and sharing of positive feedback is feasible and has the potential to promote positive culture change and improve healthcare worker well-being.

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INTRODUCTION: The 2022 Presidential Address for the Association for Academic Surgery was focused on better understanding the personal and professional challenges faced by surgeons during the COVID-19 pandemic. METHODS: As part of this work, we embarked on a listening tour, inviting surgeons from all over the country to tell us their stories. This led to forming a panel of five selected participants based on how their stories crosscut many of the most prevalent themes during those conversations. Here, we present thematic excerpts of the 2022 presidential panel, intending to capture that moment and challenge surgeons to contribute to an ever-evolving movement that pushes us to unpack some of our greatest areas of discomfort. RESULTS: We found that, in many ways, the COVID-19 pandemic brought into focus what many surgeons from marginalized groups have historically struggled with. Dominant themes from these conversations included the role of surgery in informing identity, the tensions between personal and professional identity, the consequences of maintaining medicine as an apolitical space, and reflections on initiatives to address inequities. Panelists also reflected on the hope that these conversations are part of a movement that leads to sustained change rather than a passing moment. CONCLUSIONS: The primary goal of this work was to center voices and experiences in a way that challenges us to become comfortable with topics that often cause discomfort, validate experiences, and foster a community that allows us to rethink what and whom we value in surgery. We hope this work serves as a guide to having these conversations in other institutions.

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Scientific integrity necessitates applying scientific methods properly, collecting and analyzing data appropriately, protecting human subjects rightly, performing studies rigorously, and communicating findings transparently. But who is responsible for upholding research integrity, mitigating misinformation, and increasing trust in science beyond individual researchers? We posit that supporting the scientific reputation requires a coordinated approach across all stakeholders: funding agencies, publishers, scholarly societies, research institutions, and journalists and media, and policy-makers.

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Objective: This study investigated provider-related attributes of shared decision-making (SDM). It studied how physicians rank SDM cases compared to other cases, taking 'job satisfaction' and 'complexity' as ranking criteria. Methods: Ten vignettes representing three cases of SDM, three cases dealing with patients' emotions and four with technical problems were designed to conduct a modified ordinal preference elicitation study. Gynaecologists and trainees ranked the vignettes for 'job satisfaction' or 'complexity'. Results were analysed by comparing the top three and down three ranked cases for each type of case using exact p-values obtained with custom-made randomisation tests. Results: Participants experienced more satisfaction significantly from performing technical cases than cases dealing with emotions or SDM. Moreover, technical cases were perceived as less complex than those dealing with emotions. However, results were inconclusive about whether gynaecologists find SDM complex. Conclusion: Findings suggest gynaecologists experience lower satisfaction with SDM tasks, possibly due to them falling outside their comfort zone. Integrating SDM into daily routines and promoting culture change favouring dealing with non-technical problems might help mitigate issues in SDM implementation. Innovation: Our novel study assesses SDM in the context of task appraisal, illuminating the psychology of health professionals and providing valuable insights for implementation science.

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Primary care physicians (PCPs) inherently offer a tremendous range of skills that would serve them well as chief executive officers in hospitals. Despite their immense value, very few serve in these top posts for a variety of reasons. Making changes in how we train, mentor, and support PCPs throughout their careers can reverse this trend.

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BACKGROUND: Unprofessional behaviour among hospital staff is common. Such behaviour negatively impacts on staff wellbeing and patient outcomes. Professional accountability programs collect information about unprofessional staff behaviour from colleagues or patients, providing this as informal feedback to raise awareness, promote reflection, and change behaviour. Despite increased adoption, studies have not assessed the implementation of these programs utilising implementation theory. This study aims to (1) identify factors influencing the implementation of a whole-of-hospital professional accountability and culture change program, Ethos, implemented in eight hospitals within a large healthcare provider group, and (2) examine whether expert recommended implementation strategies were intuitively used during implementation, and the degree to which they were operationalised to address identified barriers. METHOD: Data relating to implementation of Ethos from organisational documents, interviews with senior and middle management, and surveys of hospital staff and peer messengers were obtained and coded in NVivo using the Consolidated Framework for Implementation Research (CFIR). Implementation strategies to address identified barriers were generated using Expert Recommendations for Implementing Change (ERIC) strategies and used in a second round of targeted coding, then assessed for degree of alignment to contextual barriers. RESULTS: Four enablers, seven barriers, and three mixed factors were found, including perceived limitations in the confidential nature of the online messaging tool ('Design quality and packaging'), which had downstream challenges for the capacity to provide feedback about utilisation of Ethos ('Goals and Feedback', 'Access to Knowledge and Information'). Fourteen recommended implementation strategies were used, however, only four of these were operationalised to completely address contextual barriers. CONCLUSION: Aspects of the inner setting (e.g., 'Leadership Engagement', 'Tension for Change') had the greatest influence on implementation and should be considered prior to the implementation of future professional accountability programs. Theory can improve understanding of factors affecting implementation, and support strategies to address them.

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BACKGROUND: Neonatal Abstinence Syndrome (NAS), a problem common in newborns exposed to substances in-utero, is an emerging health concern. In traditional models of care, infants with NAS are routinely separated from their mothers and admitted to the Neonatal Intensive Care Unit (NICU) with long, expensive length of stay (LOS). Research shows a rooming-in approach (keeping mothers and infants together in hospital) with referral support is a safe and effective model of care in managing NAS. The model's key components are facilitating 24-h care by mothers on post-partum or pediatric units with support for breastfeeding, transition home, and access to Opioid Dependency Programs (ODP). This study will implement the rooming-in approach at eight hospitals across one Canadian Province; support practice and culture shift; identify and test the essential elements for effective implementation; and assess the implementation's impact/outcomes. METHODS: A stepped wedge cluster randomized trial will be used to evaluate the implementation of an evidence-based rooming-in approach in the postpartum period for infants born to mothers who report opioid use during pregnancy. Baseline data will be collected and compared to post-implementation data. Six-month assessment of maternal and child health and an economic evaluation of cost savings will be conducted. Additionally, barriers and facilitators of the rooming-in model of care within the unique context of each site and across sites will be explored pre-, during, and post-implementation using theory-informed surveys, interviews, and focus groups with care teams and parents. A formative evaluation will examine the complex contextual factors and conditions that influence readiness and sustainability and inform the design of tailored interventions to facilitate capacity building for effective implementation. DISCUSSION: The primary expected outcome is reduced NICU LOS. Secondary expected outcomes include decreased rates of pharmacological management of NAS and child apprehension, increased maternal ODP participation, and improved 6-month outcomes for mothers and infants. Moreover, the NASCENT program will generate the detailed, multi-site evidence needed to accelerate the uptake, scale, and spread of this evidence-based intervention throughout Alberta, leading to more appropriate and effective care and use of healthcare resources. TRIAL REGISTRATION: ClinicalTrials.gov, NCT0522662. Registered February 4th, 2022.

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PURPOSE: Acculturation, or the dual process of cultural change that takes place due to the interaction between two or more cultural identities, may contribute to the susceptibility of developing an eating disorder (ED). We conducted a systematic review exploring the relationship between acculturation-related constructs and ED pathology. METHODS: We searched the PsychINFO and Pubmed/Medline databases up to December 2022. Inclusion criteria were: (1) having a measure of acculturation or related constructs; (2) having a measure of ED symptoms; and (3) experiencing cultural change to a different culture with Western ideals. 22 articles were included in the review. Outcome data were synthesized by narrative synthesis. RESULTS: There was variability in the definition and measure of acculturation in the literature. Overall, acculturation, culture change, acculturative stress, and intergenerational conflict were associated with ED behavioral and/or cognitive symptoms. However, the nature of the specific associations differed depending on the specific acculturation constructs and ED cognitions and behaviors measured. Furthermore, cultural factors (e.g., in-group vs. out-group preferences, generational status, ethnic group, gender) impacted the relationship between acculturation and ED pathology. DISCUSSION: Overall, this review highlights the need for more precise definitions of the different domains of acculturation and a more nuanced understanding of the specific relationship between various acculturation domains and specific ED cognitions and behaviors. Most of the studies were conducted in undergraduate women and in Hispanic/Latino samples, limiting generalizability of results. LEVEL OF EVIDENCE: Level V, Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

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BACKGROUND: Cardiovascular disease is a major contributor to high mortality in Ethiopia. Hospital organizational culture affects patient outcomes including mortality rates for patients with cardiovascular disease. Therefore, the purpose of this study was to assess organizational culture and determine barriers to change in the Cardiac Unit of University of Gondar Comprehensive Specialized Hospital. METHODS: We used a mixed methods approach with a sequential explanatory design. We collected data through a survey adapted from a validated instrument measuring organizational culture (n = 78) and in-depth interviews (n = 10) with key informants from different specialty areas. We analyzed the quantitative data using descriptive statistics and the qualitative data through a constant comparative method of thematic analysis. We integrated the data during the interpretation phase to generate a comprehensive understanding of the culture within the Cardiac Unit. RESULTS: The quantitative results indicated poor psychological safety and learning and problem solving aspects of culture. On the other hand, there were high levels of organizational commitment and adequate time for improvement. The qualitative results also indicated resistance to change among employees working in the Cardiac Unit as well as other barriers to organizational culture change. CONCLUSION: Most aspects of the Cardiac Unit culture were poor or weak, signaling opportunities to improve culture through identifying culture changing needs, implying the need to be aware of the subcultures within the hospitals that influence performance. Thus, it is important to consider hospital culture in planning health policy, strategies, and guidelines. RECOMMENDATIONS: It is of paramount importance to strengthen organizational culture through fostering a safe space that enables workers to express divergent views and actively considering such views to improve the quality of care, supporting multidisciplinary teams to think creatively to address problems, and investing in data collection to monitor changes in practice and patient outcomes.

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