There was heightened recognition of the importance of healthcare staffs' wellbeing during the Covid-19 pandemic. One area that has been of particular concern is the increasing incidents of moral distress and moral injury amongst healthcare staff. Discussion of moral distress and injury amongst healthcare staff increased substantially during the Covid-19 pandemic. A British Medical Association survey of its members in 2021 found that for 78.4% of respondents' moral distress resonated with their experiences at work and 51.1% said the same about moral injury. Moral injury has been seen as 'one of the greatest challenges reported by UK NHS frontline hospital staff.' Operationally, the NHS is now 'living with Covid-19', which involves continuing infection control measures, dealing with new surges in Covid-19 admissions, and managing the backlog of elective care. This shift from pandemic to endemic Covid-19 has occurred against an economic backdrop of austerity and ongoing funding restrictions. All these factors have resulted in increased and sustained pressure on NHS staff. In this context, experiences of moral distress and moral injury are continuing and are likely to become more prevalent, with the potential to (further) negatively impact standards of patient care, and healthcare staff wellbeing and retention. This follow-on-funding proposal is based on our UKRI AHRC Reset Ethics Project. This project identified that NHS hospital staff working in the pandemic were frequently exposed to circumstances that resulted in moral distress, due to their ongoing inability to carry out professional duties to what they saw as a morally acceptable standard. The provision of acceptable or optimal care was hampered by social distancing, personal protective equipment, and changes in service provision. The findings, reinforced by a direct request by clinical psychologists working with hospital staff, identified a need to help wellbeing professionals in hospitals (clinical psychologists, counsellors, welfare teams), collectively referred to here as 'hospital-based wellbeing professionals' to support staff who might be experiencing moral distress and moral injury. Our aim in this proposal is to disseminate our previous research findings to a new community, hospital-based wellbeing professionals, so that they are better able to support healthcare staff who are experiencing moral distress and moral injury. We will engage with this new community of users (of our research) to raise awareness and understanding of moral distress and moral injury amongst hospital-based wellbeing professionals. To do this, we will build a community of practice of hospital-based wellbeing professionals concerned with 'supporting healthcare staff experiencing moral distress and moral injury'. To meet the follow-on-funding project goals, we will undertake the following activities: Hold four workshops (two face to face and two online) on moral distress and injury amongst healthcare staff for hospital-based wellbeing professionals. Produce web-based resources to help hospital-based wellbeing professionals to support healthcare staff dealing with moral distress and injury. Hold a one-day showcase event bringing academic, professional, and policy perspectives together to stimulate debate and research. These outputs and activities will be designed to increase awareness and provide practical guidance and resources for hospital-based wellbeing professionals in their work with healthcare staff experiencing forms of moral distress and injury. Incidents of moral distress and injury appear to be increasing rather than abating across healthcare systems both in the UK and globally and therefore there will be a large audience for our project outputs.

Our proposal aims to use secondary analysis to provide evidence for user-centred quality improvement in health and social care. It builds on two existing initiatives: 1. An archive of 3000 qualitative video and audio interviews on over 80 topics with users about their health and illness experiences held by the Health Experiences Research Group (HERG), University of Oxford (and disseminated publicly on www.healthtalkonline.org run by the DIPEx Charity) 2. Experience-Based Co-Design (EBCD), a participatory action research approach which actively involves service users in service design and has been implemented in over 60 care services in six different countries since being piloted in 2006. Past evaluations have shown it to be effective in achieving quality improvement and cultural change. Both initiatives include video-recorded in-depth interviews with people talking about their experiences. HERG interviews are nationally collected and wide-ranging, whereas EBCD interviews are collected locally with a more specific focus on 'touchpoints' - key interactions between users and services where quality improvements can be made - in each care setting. In EBCD analysis of these touchpoints is used to create a 'trigger' film which staff and users watch together to start a discussion about improving care locally, before setting up co-design working groups to plan and implement changes together. These two initiatives have already collaborated on a recent study for the National Institute for Health Research (NIHR) which demonstrated EBCD in two care pathways based on secondary analysis of HERG interviews rather than new local interviews worked just as well, saving time and cost. This provides a strong evidence base to propose further secondary analysis to support care organisations seeking to apply experience-based quality improvement in an affordable and timely way across more conditions. We will reanalyse ten of our existing interview collections. In each case the primary research question for the secondary analysis will be: What touchpoints do users identify in their experiences of care where quality could be improved? The HERG collections are generally focused around a particular condition or health topic. However, there is much material in the collections that could inform service settings and integration of care across sectors. Alongside the analysis for touchpoints in each condition, we will also ask: What are the touchpoints for a) outpatient care and b) interactions between health and social care across a range of different conditions which could be used to redesign services? The secondary analyses will involve a researcher going back to the full transcript collection to identify touchpoints. On healthtalkonline, we also have a set of lay summaries identifying key topics of importance to interview participants in each condition (though not specifically analysed for touchpoints). A key further empirical question to ask is therefore: What touchpoints would emerge from a re-analysis of the website summaries, compared to re-analysis of the full transcripts? Can further time savings be made in identifying touchpoints by this method or is too much lost in the process? We will also involve service users in the secondary analysis process, supporting them in analysing both selected transcripts and selected website summaries, and discussing with them similarities and differences in the touchpoints they identify compared to the social science researcher. We will disseminate findings from the secondary analysis in the form of a series of trigger films made in collaboration with the DIPEx Charity, using our existing video recordings to illistrate the touchpoints we identify, and make these available through both www.healthtalkonline.org and the Point of Care Foundation online EBCD toolkit. With the close and active support of NHS England our findings will have a clear route to impact on policy and practice