Joseph Charles Manning

Background: Families frequently recognise early signs of deterioration in their children. In English‐centric environments, families from culturally and linguistically diverse (CALD) backgrounds face challenges in escalating concerns in hospital because of language barriers, limited health literacy, uncertainty about escalation pathways, and variable staff responsiveness. Although digital approaches may support communication, it remains unclear whether they address the wider organisational conditions required for equitable escalation of care. Objective: This study explored hospital experiences of CALD families and investigated their views on a potential digital tool to escalate acute clinical concerns during their child's hospitalisation. Material and Methods: This qualitative study was guided by a multicultural consumer advisory group. Families from CALD backgrounds participated in semi‐structured focus groups and one‐to‐one interviews, conducted in English or with interpreters. Audio‐recordings were transcribed, de‐identified and analysed using reflexive thematic analysis. Results: Thirty‐four parents/carers representing 34 distinct families and 15 CALD backgrounds participated in 11 focus groups and two individual interviews. Three themes were identified: (i) communicating is not easy; (ii) shaping health system satisfaction; (iii) communicating using digital tools. Families described both supportive and challenging interactions with health staff and the system. Positive experiences were associated with plain language, clear explanations, and inclusive communication. Negative experiences included not feeling heard when raising concerns, inconsistent access to interpreters, unclear information about how to escalate concerns, and distress associated with waiting and uncertainty in emergency care. Although some families saw the value in digital tools, particularly for translation, rapid communication, and access to information, they consistently prioritised broader service changes. These included routine offers of interpreter support, clearer explanations of hospital processes, more detailed information about their child's condition and treatment, and a more welcoming environment for asking questions and raising concerns. Conclusions: Families viewed digital tools as potentially useful, but not sufficient on their own. Inequities in escalation of care were shaped not only by language discordance, but also by wider organisational conditions, including inconsistent interpreter access, unclear escalation pathways, variable staff responsiveness, and limited opportunities for families to feel heard. System change is therefore essential if digital approaches are to support equitable escalation of care in hospital settings for these families. Lived Experience or Public Contribution: A consumer and community involvement was integral to the study. A Multi‐Cultural Consumer Advisory Group (MCAG), comprising six members from CALD backgrounds (China, Egypt, India, Russia, Sierra Leone, and Vietnam), contributed to study design, recruitment planning, interpretation of findings, and refinement of the developing intervention. MCAG members also supported recruitment by sharing study information with their communities.

Aim: To identify and describe the barriers and enablers to nurses routinely screening for dysphagia in hospital and map these to domains in the Theoretical Domains Framework. Design: Systematic review with meta‐ethnography. Data Base Sources: CINAHL, Embase, PubMed, Scopus, Clinical Trials and World Health Organisation trials registry (database inception to November 2024). Methods: The review protocol was registered on PROSPERO ( CRD42024608080 ). Studies set in stroke and older adult wards were included. Data were coded as barriers or enablers, mapped to the original authors' themes and then synthesised into higher‐level themes. Barrier and enabler codes were also mapped to domains in the Theoretical Domains Framework. Results: From 6750 studies identified, six were included. None of the included papers were conducted in an older adult ward setting. Four high‐level themes were developed: (i) The surrounding environment, (ii) Variation in practice, (iii) Influence of knowledge and skills, and (iv) The value of dysphagia screening. Identified barriers and enablers were predominantly mapped to ‘Environmental context and resources,’ ‘Knowledge,’ ‘Beliefs about capabilities’ and ‘Beliefs about consequences’ Theoretical Domains Framework domains. Conclusions: For successful dysphagia screening, nurses require adequate training, a standardised screening tool and sufficient environmental support. Further work is required to contextualise these findings specifically to older adult ward settings. Impact: To introduce routine nurse screening for dysphagia into different contexts, this paper provides guidance on how to set up and create a theory informed service. Mapping of barriers and enablers to the Theoretical Domains Framework can facilitate the development of a behaviour change intervention through the framework's linkage to a taxonomy of behaviour changes strategies. Reporting Method: ENhancing Transparency in REporting the synthesis of Qualitative research. Patient or Public Contribution: Patient and public involvement focused on interpretation of findings, ensuring the review identified patient‐relevant priorities. Trial Registration: PROSPERO registration number: CRD42024608080

Background: Advancements in neonatal and paediatric intensive care have improved survival of children born very preterm or with complex health conditions. However, many of these children will subsequently require admission to paediatric intensive care. How families navigate experiences and knowledge across these different admissions remains poorly understood. Aim: To explore the experiences of parents with a child admitted to both a neonatal unit (NNU) and a paediatric intensive care unit (PICU) with a focus on the development of parental knowledge. Study Design: We conducted an exploratory qualitative study. Semi‐structured interviews were conducted with 18 parents of 15 children who experienced admission to both NNU and PICU. Participants were recruited via national charities and interviewed remotely. Data were analysed using inductive content analysis, focussing on parents' temporal experiences. Findings: Parents described knowing their child as a dynamic state evolving throughout the NNU to the PICU. In the NNU, parents initially learned to know their child through hands‐on care, often facilitated by staff, though physical and emotional barriers sometimes hindered bonding. Discharge from NNU was a key transition moment, with some parents feeling confident while others felt uncertain about managing their child's healthcare needs at home without the support of staff and medical equipment. At PICU admission, parents brought experiential knowledge, the value of which was not always recognised by healthcare professionals. This lack of acknowledgement sometimes led to missed opportunities for provision of safe care. During PICU stays, parents wanted their expertise respected and integrated into care, particularly for children requiring ongoing specialist care, which was often provided by families, outside of PICU. Conclusions: Parental knowledge of their child, and their previous experiences, is vital to support safe care delivery but sometimes overlooked. Recognising parents as expert and equal partners in care can potentially improve safety, communication and family‐centred practice. Relevance for Clinical Practice: Neonatal and paediatric healthcare teams should actively acknowledge and incorporate parental expertise during and when transitioning between NNU and PICU. Parents' experiences provide additional insights, which provide opportunities for better care. Improved communication across neonatal and paediatric services may enhance outcomes and parental confidence.

Core Outcome Sets (COS) are used by researchers to enable synthesis and comparison of results from trials in similar patient groups and contexts. Around 50% of older adults on care of the older person wards may have Oropharyngeal Dysphagia (OD). Routine OD screening may reduce the risk of mortality and duration of hospital stay. Research is required to identify the effectiveness and cost-effectiveness of an OD screening service. Using a modified Delphi methodology, this study aimed to develop a COS for trials evaluating hospital-based OD screening services. A long list of outcomes, created from a systematic review and similar existing COS, was sent out to nurses, speech and language therapists (SLT), pharmacists, senior hospital staff, researchers, people with OD and carers who rated each outcome’s importance using a Likert scale to help refine this list. A 90-minute online consensus workshop then finalised the COS. 54 outcomes were sent to 34 stakeholders at round one. 25 outcomes were sent to 28 stakeholders at round two.13 stakeholders finalised the COS in the consensus workshop. The final COS consists of; mortality, aspiration pneumonia, choking, medication intake, patients’ experience with the intervention, swallowing-related quality of life, hospitalisation & proportion of patients referred to SLT. This study developed the first COS for evaluating OD screening services in care of the older person hospital wards. Adoption of this COS will facilitate consistency in outcome measurement, evidence synthesis and translation of OD research into clinical practice.

Objective: This study aimed to identify and prioritise practical risk mitigation strategies that can be implemented by paediatric teams to improve the safety of children and young people (CYP) in mental health crises admitted to acute paediatric care. Design: A sequential two-stage mixed-methods exploratory study. Setting: UK acute paediatric hospitals/wards. Participants: 16 Healthcare Professionals/CYP experts through experience. Interventions: None. Main outcome measures: In stage 1, risk mitigation strategies were identified through a systematic review and qualitative interviews followed by thematic analysis. In stage 2, strategies were prioritised using a hybrid Nominal Group Technique and modified Delphi process and stratified according to clinical risk level (low, medium, high, very high) using a validated paediatric mental health risk assessment framework. Results: 26 risk mitigation strategies were identified, of which 16 achieved expert consensus (≥70%) for clinical usefulness. Clinically actionable strategies included: structured safety checks on admission and daily thereafter; proactive environmental modification to reduce triggers (noise, crowding, ligature risks); active 1:1 observation focused on therapeutic engagement rather than surveillance; prioritisation of timely assessment and escalation to specialist mental health services and routine use of multidisciplinary safety huddles. Strategies were mapped to risk level, enabling paediatric teams to tailor interventions proportionately to assessed risk. Conclusions: This study provides an evidence-informed, consensus-based set of risk mitigation strategies that can be implemented immediately within acute paediatric care. By embedding structured safety checks, therapeutic engagement and risk-informed environmental controls into routine practice, non-mental health clinicians can enhance safety and consistency of care for CYP admitted in mental health crisis.

Background: Patient and Public Involvement and Engagement (PPIE) is increasingly recognised as essential to the relevance, feasibility, and impact of paediatric intensive/critical care research. However, reporting of PPIE processes and outcomes, particularly in child health studies, remains limited, often lacking detail on sustained involvement and its influence across the research lifecycle. Case study: This case study presents the PPIE approach embedded within the OCEANIC Study, a multi-centre longitudinal mixed-methods investigation into the outcomes and support needs of children and families following paediatric intensive care unit (PICU) discharge. The study uniquely sustained engagement with a Children, Young People and Parent Advisory Group (CYPPAG) over eight years, aligning with the National Institute for Health and Care Research (NIHR) standards for public involvement. We detail the strategies used to foster inclusive, respectful, and impactful collaboration, including co-development of study materials, iterative feedback on recruitment and retention strategies, and involvement in qualitative data interpretation and dissemination. The advisory group’s contributions shaped study design, enhanced recruitment, and informed dissemination, including co-authorship and conference presentations. PPIE impact was explored qualitatively through CYPPAG feedback, tracking of study changes informed by the CYPPAG, and ongoing reflection within the research team. Conclusion: The OCEANIC Study demonstrates the feasibility and value of longitudinal, embedded PPIE in paediatric critical care research. It offers a novel model for sustained advisory group involvement, evidencing how meaningful collaboration can improve research relevance, rigour, and reach. This case study provides actionable insights for researchers seeking to integrate PPIE across the research continuum and highlights the therapeutic and empowering impact of involvement for contributors.

Background: Survivors of pediatric intensive care often experience prolonged morbidity, but recovery trajectories and features associated with impairment in general PICU populations remain uncertain. We aimed to explore the trajectory of health-related quality of life (HRQoL) and fatigue in critically ill children over the first year following PICU discharge, and to identify baseline and PICU factors associated with worse outcomes. Methods: OCEANIC is a multicenter prospective cohort study across 10 English PICUs. Children aged 1 month–17 years with PICU stay ≥ 48 h were enrolled (2019–2022) and followed for 12-months (to 2023). HRQoL (PedsQL™ 4.0 Acute Versions) and fatigue (PedsQL™ Multidimensional Fatigue) were assessed at baseline (pre‑admission), PICU discharge, and 1, 3, 6 and 12 -months. We used Random Forest models with SHapley Additive exPlanations (SHAP) to identify features associated with below‑baseline HRQoL at each timepoint. Results: Of 326 children enrolled, 220 had ≥ 3 HRQoL assessments. Mean PedsQL fell from 73.3 (SD 20.99) at baseline to 54.3 (SD 23.52) at discharge, then rose to 62.9 (1-month, SD 21.73) and 67.1 (3-months, SD 20.38), stabilizing thereafter (70.4 (SD 21.34) at 6-months; 69.8 (SD 22.46) at 12-months; p < 0.001 across time). At discharge, 71.8% were below their baseline HRQoL. Among 12‑month respondents, 58.1% remained below their baseline. Physical and school functioning showed persistent impairment, with cognitive functioning returning to baseline by 1-month. Fatigue largely normalized by 6-months. Higher baseline HRQoL and older age were consistently influential features with worse HRQoL, with physiological/illness markers important features across timepoints. Conclusion: At 12-months, 58% of responding children remained below their pre-PICU baseline HRQoL, with persistent impairment most evident in physical and school functioning. Modelling identifies population-level subgroups of children characterized by higher baseline or lower discharge HRQoL, older age, and prolonged PICU exposure who may warrant closer multidisciplinary follow‑up after PICU discharge. Trial registration: ISRCTN28072812 14/02/2020

Children with complex care needs represent a growing and highly vulnerable population within inpatient hospital settings. They experience disproportionately long lengths of stay, higher rates of safety incidents, and poorer care experiences than other children. Their increasing prevalence in hospitals reflects broader advances in medical care that have improved survival, yet current inpatient systems remain largely designed around episodic, single-condition models of care. As a result, children with complex care needs and their families frequently encounter inpatient services which are fragmented and stretched and environments which are not adequately suited to their needs. The challenges are well recognised, and current drivers exist to move toward meaningful system change. Recent policy drivers, workforce development agendas, and new funding streams provide an opportunity to reimagine how inpatient services are organised and delivered for this population. This opinion piece, situated within the UK healthcare context, offers a structured analysis of the systemic challenges facing inpatient services for children with complex care needs and identifies priority domains of safe care, workforce development, and knowledge generation, where targeted redesign is both feasible and urgently required.