The increase in care needs that comes with an ageing population, in combination with a shortage of healthcare workers, has made ethnic diversity among healthcare workers (HCW) an evident reality across many countries. This article aims to explore how a multicultural workplace is experienced, through the accounts of HCWs and leaders in nursing homes.This article reports on the findings from qualitative interviews with 16 HCWs and managers from nursing homes in Oslo. The interviews were conducted from August to September 2021. We analysed the data using a reflective thematic analysis informed by a hermeneutic-phenomenological approach.Six themes emerged from the interview data: (1) understanding diversity through shared norms and multicultural experiences, (2) greater flexibility in a multicultural workforce, (3) challenging traditional norms in a multicultural workforce, (4) language proficiency and exclusionary practices at work, (5) perceptions of the role of the ward nurse, and (6) prejudices among and harassment from patients.To ensure the effective organisation and wellbeing of HCWs in a multicultural workforce, managers must develop an inclusive organisational culture. They must be able to engage with difficult topics and conflicts that may arise in the working environment. With the ageing of the population across the world , the queTo meet the rising demands of elderly care, and in line with increasing globalisation, ethnic diversity among healthcare workforces has become an evident reality across many countries, including Norway. In 2021, approximately 18% of the population of Norway had an immigrant background . HealthcEthnic diversity has thus become a significant component of the nursing healthcare workforce in Norway. A few studies have investigated how employees with immigrant backgrounds have experienced challenges in municipal services , 13, 14.It has long been established that a diverse workforce can be a strength in healthcare; however, it must be managed in a good way to achieve the goal of good quality and equitable healthcare services for all . AccordiOrganisational culture is an important context for understanding diversity experiences among workers situated in institutional practices . AccordiOrganisational culture can be conceptualised in three components which manifest themselves at different levels of observability , which aFurthermore, assumptions help groups function and survive during external adaptation and internal integration. In the context of our study, external adaptation implies meeting the expressed goals and values of the organisation, i.e., the effective delivery of healthcare services to patients/residents. Internal integration refers to how the workforce organises and maintains itself as a group, for example, through group boundaries, criteria for inclusion and exclusion, power distribution and unexplainable events .Therefore, to understand how organisations and the workforce relate to ethnic diversity and multiculturalism, an exploration of organisational culture is pertinent. Exploration of diversity experiences reflected through the artefacts, espoused values and basic assumptions can thus provide knowledge about (a) how diversity ideas are both perceived and practised within nursing homes and (b) the implications of these on the internal and external functioning of the organisation.In Norway, nursing homes are designed for residents who require a high degree of medical care and assistance with daily activities. There are also short-term rehabilitation departments within some nursing homes for patients to stay after hospital discharge. Provision of care in nursing homes is regulated by “Regulation of quality of care”. This implies that the basic needs of the residents’ such as psychological needs, preservation of dignity and self-respect, the degree of choice within the daily routine, physical needs (including nutrition), and social needs, should be satisfied , 23.Nursing homes are funded from local and national taxes and user charges. The co-payment level by the residents is related to income and as such they typically pay between 75% and 85% of their income to the municipalities. Most nursing homes are owned by the municipalities. There is also a small percentage of nursing homes owned and managed by voluntary organisations, but where care is financed by the municipalities. In addition, there are also few commercial homes where residents pay full fee. The eligibility criteria for nursing homes are set by the municipalities. It is based on an assessment of needs, which include recommendations from the general practitioner of the patient. Decisions are taken by the provider or by an independent unity with the municipality’s health care system .This study is based on a hermeneutic-phenomenological approach , 26. We To recruit study participants, we approached The Nursing Home Agency and presented the study’s area of interest with topics and questions introduced in an information letter. The agency administration forwarded this letter to relevant nursing homes, which helped recruit study participants. We recruited 16 participants from four nursing homes in areas with a higher proportion of minority HCWs and service users. In the nursing home wards, 50–70% of the HCWs had a minority background, while 10–15% of patients had a minority background. The participants included four ward nurses, who were all ethnic Norwegians. Of the 16 participants, two were male and fourteen were female. Seven of the nurses had an ethnic minority background, and the remaining were ethnic Norwegians. The HCW group consisted of nurses and auxiliary nurses .The analyses resulted in six themes: (1) understanding diversity through shared norms and multicultural experience, (2) greater flexibility in a multicultural workforce, (3) challenging traditional norms in a multicultural workforce, (4) language proficiency and exclusionary practices at work, (5) perceptions of the role of the ward nurse, and (6) prejudices among and harassment from patients.Most of the study participants found working in a nursing home ward with colleagues of different nationalities both exciting and instructive. Yet, it was the HCWs with minority backgrounds who commented to a greater extent on situations that were of importance to them as employees in a multicultural ward. Several people felt that a multicultural ward contributes to greater understanding across different cultural backgrounds. One of the nurses, for example, said that she has worked for a long time in environments where the HCWs have different backgrounds and that this made her more aware of various issues in the intercultural relations in the wards:Those who have a multicultural background have a greater understanding, or if you have worked with multicultural people for a long time. We also had a leader who was Norwegian and who had worked with foreign people for a long time, and she had a lot of understanding; she understood the employees. You must work well together, understand them, have respect, and then you get it back. If you don’t respect and understand them, then you don’t get the help you require or, that work environment … It affects the working environment very much if you understand them. (Participant 1)This nurse felt that awareness of important issues related to a multicultural working environment in the ward required experience with such work situations, but also characteristics such as respect and understanding. This is something that several of the ward nurses also highlighted when commenting on their experiences of running a multicultural ward. One of them explained that she arranges regular lunch meetings where ethnic minority HCWs can share about their background so that those in the ward can get to know each other better and gain a greater understanding of each other:I’ve found that you get a little deeper and better respect if you know a little bit about the background, and that’s why I’ve wanted to do it. I have received very positive feedback from those I have asked if they could tell me a little bit. It’s about 15 min, some people make more of it and some don’t make much of it, but just 15 min. Some will sit, some want to stand, some make PowerPoint slides. (Participant 15)Many of the study participants mentioned specific lunch days, for example, on Wednesdays or Fridays, when they came together and tasted food from different countries. They also marked the United Nations’ (UN) International Day in the workplace, when the HCWs could contribute food from their home country and perhaps also wear their national costume. Both the lunch days and the commemoration of the UN Day were considered important by staff and managers in contributing to greater transparency, greater understanding among staff and patients, and an increased sense of community.The multicultural working environment created new opportunities for the accommodation of the HCWs’ preferences for working hours in nursing homes. Several had a cultural or religious affiliation, such that their holidays and the vacation needs were different from the majority population’s Christmas or Easter holidays. This created more room for flexibility in the organisation of the wards in particularly pressured seasons when HCWs were given days off depending on the time of year they celebrated their holidays:It’s about the operation of the ward. Those who have a different religious affiliation than Christianity, and if a deal has been made so that they can work several weekends and have a different holiday … Here, I would say that it is very narrow-minded; the Working Environment Act regulates this in a bad way. It assumes that everyone is Christian and is going to have Sunday free. It is a bit challenging when you have people with minority backgrounds and a different religion and a different holiday than what we have. (Participant 13)We had an Eid celebration last time, and we have several Muslims working with us. All the Indians who worked switched with them. It was very nice that they respect that. (Participant 1)The ward nurses adhered to the working environment rules on holidays and work-free days but needed greater flexibility to ensure the continuous operation of the ward. This flexibility was possible because enough HCWs with minority backgrounds worked on several weekends and other holidays. Several of the HCWs also traded shifts among themselves so that their colleagues could celebrate their holiday. A multicultural workforce thus allowed a greater flexibility in the nursing homes and contributed to a smoother reshuffle of shifts between the HCWs.Many of the HCWs with minority backgrounds found celebrating traditional holidays and the routines that followed in the nursing homes to be a major challenge. During holidays such as Christmas, Easter or the Norwegian national day, the norms and routines at the ward were changed for a period, and some HCWs lacked knowledge and experience with such routines. This often led to unfortunate situations in which the food service for the patients or other holiday traditions were not followed. One of the more experienced Norwegian-born auxiliary nurses described it as follows:As I said, we only have Norwegian residents, and they are in an age group where they have their habits and traditions. I understand that it is not so easy for everyone to familiarise themselves with all the Norwegian traditions, but we have experienced that custard has been poured on ribs on Christmas Eve! I have many times even offered, in conversation with the priest here at the house, to give instructions. For example, “What is May 17th? Why are we celebrating May 17th? What do we eat on May 17th and what do we do on May 17th?” The same for Easter and Christmas. The problem is that we have hectic working days, and it is difficult to get people to sit down and read. So, information, training, that’s what it’s about. (Participant 9)The HCWs with minority backgrounds often said that they had not grown up with Norwegian traditions and therefore did not have knowledge of the food traditions, manner of clothing or music associated with many of the holidays in Norway. Lack of knowledge or experience with such traditions was difficult for some:Yes, for example, for me Christmas is very difficult. The problem is that I do not know what the Norwegians sing, what food they eat, what they do, what clothes they wear. These things are very important, but often in our ward we have a Norwegian who takes responsibility; we go together. (Participant 3)In the wards, the staff on the shifts often consisted of both Norwegian-born and foreign-born HCWs, which allowed them to cooperate and help each other when challenges arose. Those who had knowledge of and experience with Norwegian traditions were often asked for advice or assistance. The ward nurses were also very concerned that all the HCWs should be able to do the job during the celebration of these holidays, and some said that they had initiated some measures to prepare them for important routines during the holidays:I want everyone here to know why we’re celebrating Easter, for example. There are also very few Norwegians who are born in Norway and are Christians who know why we celebrate Easter and know all the anniversary days of Easter. Therefore, I have often printed all these sheets for Easter … I also tell them: What day is this? Why is this a public holiday? I also want all employees to know this. I want them to bring it up with the residents because there are a lot of the residents who have a Christian view of life. (Participant 15)The ward nurses often prepared their own written guidance on the most important traditions, thus ensuring that the HCWs could perform well and that the patients had a good experience during the holidays. At the same time, both ward nurses and other HCWs said that there was a need to provide more structured training and an introduction to the most important holiday traditions.Since the communication language with the patients in the multicultural ward was Norwegian, the working language was also Norwegian. Almost all the ward nurses and the other HCWs felt that the language competence of the HCWs with minority backgrounds was satisfactory for carrying out care work. They explained that nursing homes had introduced stricter language requirements for staff, which contributed to few HCWs having linguistic challenges:Those who work here, foreigners, are good at Norwegian, so there are no problems with residents there in relation to language … Because now, if you do not know proper Norwegian, there is something called a Norwegian test that you must take to be employed. But when I was at [the name of another nursing home] at the very beginning, I remember that we had some foreigners that were bad in Norwegian, and we noticed on the residents’ expressions. (Participant 8) Even though the participants felt that most of the health personnel had good knowledge of Norwegian, there could still be situations where more nuance was needed in the language, which could create challenges for some people. This at times meant that HCWs with minority backgrounds who felt less confident in the language were reluctant to initiate conversations with, for example, relatives who visited the patients:I think that we don’t really want to do it, but with communication, it ends up with the Norwegian speakers taking that bit the most. Those with minority backgrounds are a little reluctant, and it becomes easy to say: “Can you take it?” It gets challenging sometimes. We have someone who has worked here almost as long as I, but who still struggles a little with linguistics. But I also know that there may have been situations with relatives, for example, where they have given feedback that they did not fully understand correctly. (Participant 10) Although language was not seen as a major problem among the participants, a few occasions were brought up in which it caused difficulties. Yet it was unclear whether these incidents were real problems or whether they had something to do with the minority HCWs’ confidence in their language skills and the relatives’ and patients’ impatience with and reservations about the HCWs’ imperfect Norwegian.Another issue highlighted by the multilingual staff was the need for HCWs to speak their native language with colleagues. For example, when two or more people who spoke a common language were gathered during lunch or in the dressing room, they changed from Norwegian to that language.Yes, we often use Norwegian, but sometimes when we work with someone from the same country, then we get the opportunity to use our language. We don’t meet very often, so when you meet, it’s freedom to talk about politics, other things. (Participant 3)Both ward nurses and other HCWs perceived it as “natural” that HCWs with minority backgrounds sometimes spoke in their native language during working hours. The most important thing was that they used Norwegian in the vicinity of the patients and other colleagues. However, some participants also reported that it was perceived as exclusionary when colleagues spoke a foreign language. Some felt “uncomfortable” not being able to understand what was being said, and this could lead to suspicion towards colleagues. However, everyone was aware of the importance of speaking the common language, Norwegian, and tried to avoid speaking another language in the common areas with several HCWs present. One of the ward nurses explained it this way:The common language at work is Norwegian, so we as an institution and The Nursing Home Agency are clear that it is the working language. This means that during working hours, they don’t speak native languages amongst themselves. They relate well to it. Sometimes they speak native languages when no one else is present, but as soon as someone else comes around, they turn to Norwegian. At least that’s my experience. (Participant 12)Perceptions of and behaviour towards a ward nurse were issues in a multicultural ward that many of the HCWs and ward nurses highlighted. Some pointed out that a few of the HCWs were not used to shaking hands or having close contact with their ward nurses. HCWs also reported that some colleagues were reluctant to contact them in the department and often failed to express problems they faced or needs they had. One of the ward nurses reflected on the situation as follows:There are perhaps so many people from different cultures, and who themselves have told us that our view of a leader in our culture is almost … You don’t just go and talk to your manager in a way; you’re almost on guard instead. But that’s not my wish, at all, so they’re probably struggling a little bit with it. They do not seek me out– they do, but preferably not if they experience challenges, if there is a challenge they have, a work situation, or if there is a need one has about vacation, changing shifts, which one must talk to me about … Because we can talk about it. But their threshold for talking, just to have a chat, no more than that, is higher. (Participant 12) There was a common perception among the participants that some HCWs with minority backgrounds exhibited what they perceived to be more respect for leaders. This made them less inclined to seek out their ward nurse if needed. Some said that this was often a phase at the beginning of employment and that the HCWs gradually became more accustomed to the routines and work culture regarding the employee–leader relationship in the ward. For the ward nurses, the situation in which minority HCWs had a higher threshold for contact and expressing their views created a dilemma. Although they felt that respect was positive, it became more difficult to lead the personnel group when the HCWs did not contribute feedback about their work situation. Some of the ward nurses tried to reduce the HCWs’ threshold for contact through various measures. Some often left the office door open, or they attended the morning meetings of the HCWs more often and tried to spend more time in the ward to make themselves “harmless” as leaders.At the same time, both ward nurses and other HCWs with a majority background expressed a great need for more knowledge about how they could utilise the multicultural resources but also include minority HCWs in the ward properly. One of the ward nurses explained what competence she would need in this way:While working with the whole personnel group, I’ve found out that things that many people think about, but that I have not ever thought of as a leader, can be perceived as a challenge. If something could be done to unite diversity, if one can use that word … (Participant 12). Although many of the participants wanted more knowledge to understand the backgrounds of minority colleagues, they were also concerned that such a focus could lead to more stigmatisation of the group. Nevertheless, they wanted greater awareness of multicultural issues in nursing homes. The managers also expressed a need for competence in leading a multicultural personnel group, but they also said that HCWs should gain better knowledge about their rights and how to act in the work environment.All the HCWs reported that some patients had prejudices and spoke in an ugly way to the HCWs with minority backgrounds. Often, these were minor forms of harassment, but there could also be racist statements. One of the ward nurses recalled an episode in which an older patient refused help from an HCW with a dark complexion:We’ve had an example where a girl on the ward was thrown out of a lady’s room because the lady didn’t want that person in there. When we asked why it was like: “I don’t like the colour of her skin.” We didn’t go into any confrontation with the patient at the time, and I took the nurse aside and talked to her afterwards because I thought this might be a bad situation and this person can’t help the colour of her skin. It’s a racist remark, and I’m not going to defend it at all, but maybe explain why it happens. (Participant 13)One of the HCWs with a minority background talked about what patients usually said when presented with minority HCWs:Someone could be a little like this: Why are you here? We have some challenging patients, they react, they see that we are foreigners, and they can be very ugly in their mouths. “Go back to your country, what are you doing here?” It’s rare, but it happens. Even though we speak Norwegian, they think, “What kind of language do you speak?” Some have dialects, such as those from the Philippines or Thai. They have slightly different dialects. So, the patients react, and they sometimes get ugly in the mouths in front of employees. Not all of them, but there are some. (Participant 2) Although such situations did not arise daily, there were many episodes in which the participants or other colleagues with minority backgrounds experienced being verbally harassed. For example, they would receive remarks such as “I don’t want help by a black man”, “You are not a Norwegian nurse”, “I just want Norwegian.” The verbal scolding of minority HCWs was often categorised as racist, but most of it was assumed to be due to patients’ prejudices, age, lack of experience with foreign-born people or cognitive impairment. The participants explained that they had to distinguish between the person and the work situation and that they had to be professional. One of the HCWs with a minority background put it this way:If we get frustrated and a little annoyed, we must deal with it. We’re in a dementia ward and they’re sick, so we approach them and explain: “I work here, you live in a nursing home” and then, “I’m a nurse and you need my help.” (Participant 2).Often, the staff managed to calm down the patients and finish their job. In some cases, they had to let another person take over, while the person with the minority background received emotional support from the ward nurse or colleagues. The participants felt that due to racist statements, they had to refuse patients the ability to choose from whom they would receive help. The patient and relatives who behaved in a racist way and who did not have cognitive impairment were spoken to and eventually refused the ability to change helpers. The problem of verbal harassment with racist undertones was known among all the ward nurses and HCWs. At the same time, some felt that the follow-up with the HCWs after such incidents was arbitrary. When asked if something systematic was done to remedy the situation, one of the nurses with a majority background answered as follows:Not enough. It’s easy for it to be just an incident, so it takes a long time for us to do something about it. I think in those situations, because there might be things that hurt, that you get distressed … So, taking things right away, then, “What did it do to you?” Right, “How did you feel?” (Participant 10).This HCW felt that they spoke little about racially motivated harassment openly, even though everyone saw it as a serious problem for the wellbeing of minority HCWs in the ward. The topic was described as delicate, which contributed to a lack of focus on the problem.The aim of this article was to explore how a multicultural workplace is experienced, through the accounts of HCWs and leaders in nursing homes. We highlight how increased ethnic diversity in nursing homes is experienced within the organisations’ cultural norms and practices. One of our main findings is that the HCWs from majority backgrounds, without prior experience of working in such settings, did not reflect much about diversity in their everyday work life as compared to HCWs from minority backgrounds. Prior experiences of working with ethnically diverse HCWs and getting to know ethnic minority HCWs’ backgrounds was perceived to facilitate better collaboration in the work environment. Thus, diversity was often discussed by HCWs in relation to celebrations such as UN Day or specific lunch days. Having marked days for common activities serves as a symbolic model for collective practices to unite HCWs and integrate them into a shared social and cultural sphere of meaning . In doinMoreover, our findings indicate that while issues of staffing capacity in connection with holidays and weekends are a common challenge in nursing homes, several minority HCWs were able to take up work shifts during the majority population’s holidays. Thus, the presence of HCWs from diverse cultural backgrounds was perceived as a benefit of diversity and was reflected in the staffing practices employed in the organisation. However, this seemingly valuable aspect of diversity, i.e., minority HCWs’ different religious or cultural affiliations, also created some challenges in the nursing homes. Such challenges were discussed primarily in reference to minority HCWs’ limited knowledge of Norwegian cultural traditions. Considering that living in a care setting such as a nursing home can be quite a significant change in the life of older residents , 37, it Although language problems among the minority HCWs were widely dismissed, our findings show that some patients and relatives still complained. This could serve as an example of an exclusionary practice in the multicultural workforce, especially if it is not addressed properly – if it is just taken for granted that HCWs of majority background can step in and take over. Appeasing the patient and relatives at the expense of the minority HCWs, as it may seem, underestimates the underlying processes of subtle discrimination in the workplace driven by a power process that has a disempowering impact on those exposed to this type of behaviour . AwareneLanguage is an integral aspect of organisational culture. Our study found that all HCWs acknowledged the importance of maintaining Norwegian as the common language, both when talking to and within the vicinity of residents. However, linguistic diversity was also found to become the basis for cohesiveness among minority HCWs, as they were able to talk amongst themselves in their native language and have a common cultural context. Nevertheless, in some situations, this practice was perceived as exclusionary for HCWs from a majority background who did not understand the language. Linguistic diversity in organisational culture can thus create possibilities of both solidarity and exclusion . NursingOur findings also showed that the HCWs with minority backgrounds faced challenges that the management was not always aware of. Often, these challenges were related to the HCWs’ misinterpretation of a manager’s role in a Norwegian context. This was demonstrated by HCWs’ hesitance to contact managers. It is not uncommon for expectations to exist about the relationship between the manager and the employee of another country’s organisational culture , 43. HCWDiscrimination and harassment based on ethnic affiliation are serious working environment problems. They reduce workers’ psychosocial wellbeing and is something leaders are expected to prevent . We founHowever, what makes the issue of racism challenging to tackle in the context of nursing homes is the fact that many of the residents often suffer from cognitive impairments. The politics of diversity is complex and contextual . Racism,In our study, it seems that patients referred to the same prejudices and harassment that abound in the debates about immigrants in the media . Thus, tConsidering that a larger proportion of older people in society will trigger a need for more HCWs in nursing homes, persons with immigrant backgrounds will undoubtedly be a major asset in this regard . It is tSeveral factors contribute towards the trustworthiness of this study. Although the study participants were recruited through contact with each nursing home and its managers, by reminding them that the interviews were confidential, we were able to obtain interesting and unexpected data, especially on the topic of prejudice and discrimination. In addition, the interviewer’s migrant background and experience in municipal care research seemed to help make the study participants comfortable enough to engage in meaningful dialogue. Further, all three authors were involved in the analysis and interpretation of findings, thus facilitating multiple ways of seeing the data and addressing any possible researcher bias. This also helped to ensure a good balance of closeness and analytical distance to the material . AdditioRegarding transferability, our study provides a wide range of participants’ perspectives as well as contextual information to enable thick description and meaningful interpretations , 69. HowOur findings indicate that there is a need for increased knowledge and awareness of how multicultural work communities in nursing homes function. To equip HCWs with a minority background with up-to-date competence, the employer should ensure that they are introduced to the central cultural traditions that patients value, as well as provide language support where necessary. Managers should raise their awareness of leading multicultural wards and know their employees’ situations and varied needs in working life. Importantly, they must prevent harassment in the ward by taking patients’ racism seriously, as it can have major consequences for the wellbeing of HCWs and their functioning in the workplace.With an increasing proportion of older people needing care in nursing homes, and increased recruitment of health personnel is necessary. Diversity in the health professions is therefore paramount to the capacity of the nation’s healthcare system to meet the needs of the ageing population. If people with immigrant backgrounds are to be able to provide competent help and thrive, the sector must understand that mere diversity in numbers is not sufficient. HCWs must also feel included in that the working environment is adapted to their need for increased competence and wellbeing. Diversity in the nursing workforce must therefore be acknowledged beyond mere representation. To ensure an effective organisation, managers must develop an inclusive organisational culture, and they must be able to engage with difficult topics and conflicts that may arise in a multicultural workforce. This will create a safe working environment, increase HCWs’ ability to be innovative and boost the organisations’ delivery of enhanced care for all patients.


We study the impacts and causes of dwarf shrub encroachment in the highlands of Lesotho. There, shrubs have been described as indicators of generalized land degradation and soil erosion. Surprisingly, our findings show that grass abundance is not reduced by shrub abundance, but that forb abundance does decrease with shrub abundance. We suggest that not enough research has been done to examine the role of forbs in livestock diets, nor in assessing its role in plant-plant competition in grass-shrub systems. Equating shrub presence with declines in available forage may be hasty, as according to our results, grasses were not decreased by shrub expansion in this context; however, forbs are critical components of livestock diets. We propose that the role of forbs in this system should be further studied, focusing on the role that high-nutrient or N-fixing forbs could play in returning nutrients to the soil and affecting livestock grazing patterns, both of which could reduce shrub abundances and favor the establishment of a richer forb community.Shrub encroachment is understood to be an important problem facing rangeland ecosystems globally. The phenomenon is still poorly understood both in regard to its impacts ( Although increases in shrubs biomass may sometimes mean decreases in grasses biomass, it is also possible for these two variables to be independent, or even to increase together. Woody plants and grasses can have facilitative interactions: in the silvopastoral pseudosavanna woodland of semi-arid central Chile, for example, hydraulic lift from tree roots and canopy shade increases grasses and herbs biomass, and woody cover is considered beneficial for livestock production  of 2019 we sampled ond Mine . Lesothoond Mine . The couond Mine , faciliti.e., we did not divide overlap in space into basal and canopy layers) since the shrubs are dwarf shrubs and of approximately the same size range as the grasses and forbs. In two corners of each quadrat we also measured soil hardness at the surface using a penetrometer, soil volumetric water content, soil electrical conductivity, and soil temperature, all also at the soil surface. For each site we also recorded altitude, slope aspect, grazing regime, fire recency, and shrub removal recency . All quadrat data were then combined to the site level in the treatment of the data (see details below).At each site, we took subsamples in the form of quadrats. At each site, we collected data from 3–10 quadrats (mode: 6) placed arbitrarily by throwing the quadrat a short distance in a pseudo-randomly chosen direction. The number of samples was proportional to the area of each site and to the observed heterogeneity . For eacIn addition, on a mountain slope where shrubs had recently been removed at Motšerimeli, we collected data on shrub and herb species richness. We chose this site because we had information about the dates of shrub removal, unlike at other sites. Shrub removal is a government-organised activity over which we have no control or influence, and we thus used the site where shrubs had been removed as a natural experiment. We thus cannot control for the fact that shrubs were removed from the lower end of the slope prior to the upper part (the people removing the shrubs start at the bottom of the slope and work up to the top of the mountain). Altitude, distance to the road, and time since shrub removal are confounded. However, given that the altitude difference across our sampled areas is only around 200 m, any difference in the flora observed is unlikely to be due to different altitudinal distributions. The constant flow of people walking along the road and all over the mountain slope to carry out the shrub removal itself also makes it relatively unlikely that distance to the road is a variable affecting the observed flora differently across our sampled areas .We placed the same quadrat as used in Study 1 at seven arbitrary points by throwing the quadrat a short distance in a pseudo-randomly chosen direction, moving downslope in an area where shrubs had been removed 1–2 months previously. We then placed the quadrat at eight arbitrary points moving downslope to the area just above the road , where shrubs had been removed approximately 4–5 months earlier. The number of samples is proportionate to the area of each section such that samples were on average 13 m apart. In this study we did not observe significant differences in vegetation heterogeneity across the mountain slope, so we did not adjust the sampling density to vegetation heterogeneity. In this study, in each quadrat we ignored the interior points, and simply counted the number of species or morphospecies (for shrubs and herbs) or taxa (for mosses and succulents) within the quadrat frame.Justification of the sampling methods used in Studies 1 and 2e.g., in this context, dwarf shrubs) may have particularly large plant-plant impacts, so one can consider that multiple measures of the same plant in interaction with other plants represents a weighting of its impact according to its area. This implicit weighting is appropriate because differences in biomass between interacting plants can affect the strength of competition and facilitation effects  more than once. At the same time, particularly large plants  can affect plant-plant interactions through spatial adjacency effects and impacts on biomass  whose effect we wanted to sample. We visually approximated the patchiness or homogeneity of dwarf shrubs, grasses and forbs, in terms of individual distributions and biomass differences at a 10 s of m2 scale, and in terms of species richness at a m2 scale, as recommended as the most efficient and effective method by In Study 1 we chose to sample proportionally to both site size and observed vegetation heterogeneity in order to account for important ecological interactions captured by vegetation heterogeneity. Spatial heterogeneity of underlying biophysical conditions as well as plant species autocorrelations  because it is a measure of water available in the surface layer of the soil, which may be an ecologically relevant variable for understanding vegetation cover patterns. Surface VWC declines under evapotranspiration from plant cover, and l levels . Higher l levels . In thisl levels .Statistical analysis. For the analysis of Study 1, focusing on shrubs-grasses competition, all data was first combined to the quadrat level, to reduce any pseudoreplication from multiple measures of interactions between pairs of large plants or non-genetic independence of clusters or tussocks of grasses. The counts of shrubs-grasses and shrubs-forbs overlap at quadrat points were summed per quadrat, and the height and presence data were respectively converted into mean heights and percentages (percent of points per plant category). Means of these data were then calculated from the sample replicates (the 3–10 quadrats per site), at the site level, which is the level at which different disturbance and management histories are relevant, and only the site-level data was included in the statistical analysis presented below. The site-level means of VWC, soil temperature, EC, and the penetrometer reading were also calculated from the quadrat-level measurements. Elevation and aspect were site-level variables. Finally, we codified information relating to disturbance and management history as categorical variables at the site scale. Grazing was codified according to the empirical observation of kinds of grazing, which included none, spring only, heavy, irregular, regular; recently burned was codified as 1 (yes) or 0 (no), and shrub removal was codified as 1 (yes) or 0 (no). The time since shrub removal was too heterogeneous, and in some cases, not known with sufficient precision, to be taken into account in this model.We constructed a proxy variable to measure grasses biomass to test hypothesis 1. Direct measures of biomass are destructive and the use of nondestructive approximations is more efficient and recommended . We usedlm command in R version 3.3.3  and less-recently deshrubbed areas (the last eight samples) was defined as (spp lost + spp gained)/total spp following n = 10) were conducted based on their roles at conservation agencies active in the area of field research. Interviews with herders and livestock owners (n = 15) were also semi-structured, selected either because they were present in the field while vegetation sampling took place or because they volunteered to speak to us after an open-air meeting of a local grazing association. Additionally, we observed numerous conversations among experts, as well as between experts and livestock owners. Interviewees were informed orally of the purpose of our research, and the voluntary nature of the interview. The interview material is anonymized. We do not report on or analyse this material separately in this article, but we report on its use for reasons of ethics and repeatability. These interviews partially informed our study design , provided us with data on site uses, and informed interpretation and contextualization of results. Where relevant, we summarise contextualizing information we obtained from them in the Discussion.Interviews. Semi-structured interviews with experts in Lesotho . On the other hand, we did find a trend suggesting that as number of spots with shrubs increase, number of spots with forbs decrease (Pearson’s correlation = −0.36). If shrubs do not compete with grasses then as the number of spots with shrubs increases, the number of shrubs-grasses coincidence spots should increase. We found a very high correlation between the mean number of shrubs-grasses coincidence spots and the mean number of shrub spots (Pearson’s correlation = 0.83). It was also not clear that shrubs suppress grasses growth where they co-occur. We found that shrubs up to 10 cm tall were approximately the same height as the grasses with which they co-occur, while at higher shrub heights shrubs mainly overshadow grasses. This corresponds to a shift in shrub morphology for the most common shrub species at our site, from a narrow vertical shape to a dense bowl shape, which occurs around 10 cm . There was also a marginally non-significant positive effect of soil volumetric water content. We also looked at grasses biomass alone, since this is important for herders, and because we found above that grasses and shrubs are not in competition. The best linear model explaining grasses biomass included a significant effect of grazing regime . Grasses biomass was higher in areas with no or irregular grazing. There was a non-significant positive effect of soil volumetric water content on grasses biomass.In the best linear model (see Methods for model selection criteria) explaining shrubs-grasses coexistence, the number of coexistence spots increased with shrub height . The interaction between elevation and soil hardness is highest for high soil hardness and low elevation, and lowest for low soil hardness and high elevation (Surface soil volumetric water content increased with shrub cover (site mean of number of points occupied by shrubs in quadrats), and decreased with the interaction between elevation and soil hardness . The species turnover between these two sections was calculated as 0.54, with a loss of eight species and a gain of 13, indicating that just over half of the species making up the local plant community were different with an additional 2–3 months of time since shrub removal. The taxon accumulation curve  can allocate more energy to fast growth in resource-rich situations than can woody shrubs , which cIn sum, although shrub encroachment is considered to be an important problem facing rangeland ecosystems globally, this case study shows that it is still incompletely understood, both in regard to its impacts on diversity, productivity, and soil properties, as well as its causes. The balance of relevant factors affecting shrubs may be different across different shrub species, different ecosystems, or sites with different disturbance or management histories. To better understand how to interpret and manage particular sites, a clearer picture of how each component of shrubs-grasses-forbs systems interacts is warranted. This study has sought to bring some clarity to the discussion by emphasizing the role of forbs in plant competition and livestock production. Equating shrub presence with declines in available forage may be hasty, and greater attention should be paid to the role of forbs in livestock diets and ecological interactions. Shrubs can have positive effects on rangeland productivity, given their role in facilitating precipitation infiltration into the soil, and their removal might have negative consequences that should be better understood.10.7717/peerj.13597/supp-1Supplemental Information 1Data on vegetation, soil, and grazing status are provided for each site that we sampled.Click here for additional data file.10.7717/peerj.13597/supp-2Supplemental Information 2Data are presented on the co-presence of grasses and shrubs in relation to plant height and grazing status.Click here for additional data file.10.7717/peerj.13597/supp-3Supplemental Information 3Data are provided on species identity and richness for each sampled quadrat.Click here for additional data file.


Until COVID-19, implementation and uptake of video consultations in health care was slow. However, the pandemic created a “burning platform” for scaling up such services. As health care organizations look to expand and maintain the use of video in the “new normal,” it is important to understand infrastructural influences and changes that emerged during the pandemic and that may influence sustainability going forward.This study aims to draw lessons from 4 National Health Service (NHS) organizations on how information infrastructures shaped, and were shaped by, the rapid scale-up of video consultations during COVID-19.A mixed methods case study of 4 NHS trusts in England was conducted before and during the pandemic. Data comprised 90 interviews with 49 participants , ethnographic field notes, and video consultation activity data. We sought examples of infrastructural features and challenges related to the rapid scale-up of video. Analysis was guided by Gkeredakis et al’s 3 perspectives on crisis and digital change: as opportunity , disruption , and exposure (of vulnerabilities in both people and infrastructure).Before COVID-19, there was a strong policy push for video consultations as a way of delivering health care efficiently. However, the spread of video was slow, and adopting clinicians described their use as ad hoc rather than business as usual. When the pandemic hit, video was rapidly scaled up. The most rapid increase in use was during the first month of the pandemic (March-April 2020), from an average of 8 video consultations per week to 171 per week at each site. Uptake continued to increase during the pandemic, averaging approximately 800 video consultations per week by March 2021. From an opportunity perspective, participants talked about changes to institutional elements of infrastructure, which had historically restricted the introduction and use of video. This was supported by an “organizing vision” for video, bringing legitimacy and support. Perspectives on disruption centered on changes to social, technical, and material work environments and the emergence of new patterns of action. Retaining positive elements of such change required a judicious balance between managerial (top-down) and emergent (bottom-up) approaches. Perspectives on exposure foregrounded social and technical impediments to video consulting. This highlighted the need to attend to the materiality and dependability of the installed base, as well as the social and cultural context of use.For sustained adoption at scale, health care organizations need to enable incremental systemic change and flexibility through agile governance and knowledge transfer pathways, support process multiplicity within virtual clinic workflows, attend to the materiality and dependability of the IT infrastructure within and beyond organizational boundaries, and maintain an overall narrative within which the continued use of video can be framed. There has been growing interest in the use of video as a method of consultation between clinician and patient over the past 10 years, and numerous studies have shown such consultations to be acceptable, safe, and effective in selected patients . HoweverCOVID-19 created a “burning platform” for the mainstreamed use of such services, as health care organizations worldwide halted face-to-face appointments for nonurgent care. The global emergency prompted strategic , operational , and regulatory  changes with regard to the delivery of telehealth across different national contexts -10. We iDuring the first wave of the pandemic in 2020, most countries saw a rapid reduction in face-to-face consultations and an increase in remote ones in both primary and secondary care -15. GuidAs health care organizations are looking to expand and maintain the use of video in the postpandemic “new normal,” it is important to acknowledge and harness wider system changes that have emerged. In this paper, we focus on the infrastructural aspects of the rapid scale-up of video and draw lessons for ongoing developments and sustainability. To this end, we explore the impact of the pandemic in 4 NHS organizations, where we had previously identified ways in which infrastructural features influenced the limited use of video in the years preceding the pandemic .installed base .Star  defines In the years before COVID-19, we conducted ethnographic research in 4 NHS organizations in England, all of which were seeking to introduce or scale up video consultations ,27,29. TIn our application and retheorization of Star’s  notion oopportunity for accelerated innovation and removal of barriers to experimentation; disruption to organizational and occupational practices, generating new dependencies and risks; and exposure of vulnerabilities in both people and infrastructures that have previously gone unnoticed. Gkeredakis et al  happened, they put in temporary governance structures—the Pandemic Covid Outpatient Group—headed up by one of the most senior doctors in the trust. I’ve moved full-time on this and report to them. So, if I have any problems, I have someone to escalate to, who can do something about it…Also, the clinical system team [responsible for building electronic clinic schedules] usually take[s] weeks to implement changes. But I’ve been given permission to, basically, get in touch with them to say, “This is a priority.”Bridget, program manager, Petroc Health, April 2020organizing vision (clear and consistent vision among stakeholders as to what will be achieved) , we had hearing aids where you could remotely program them, and I looked into setting up a remote programming clinic…I went to information governance, and they gave me this list, and I was like, “Oh it’s not worth it—not for a few patients.” So, I didn’t bother. And that’s terrible—I should have bothered. But it was too much work. But now, when we asked them, it went straight through to the medical director, and she just said, “Go ahead with it…” So, things progressed—which is what the NHS would struggle with sometimes.Karen, consultant, Southern Trust, November 2020As described before, regulatory constraints were also reduced through national measures by NHS England, including the central procurement of Attend Anywhere (enabling unrestricted use with no cost to trusts), endorsement of video platforms by national information governance bodies (enabling experimentation), and temporary tariffs for remote consultations .temporary arrangements to deal with the pandemic, they set organizations on a particular infrastructural path, upon which they were now destined to build:However, although these were intended as One challenge is, few of us want to change what we’ve got now [Attend Anywhere]. We will have to go through this procurement—because the region will be doing it on our behalf—and there is a slim chance another provider will be chosen, and that would be a real challenge for us.Teresa, program manager, Eastern Trust, February 2021relative advantage  has turned that on its head quite quickly.Eleanor, diabetes nurse, Southern Trust, June 2020Clinicians using video talked about the advantages over phone for basic visual assessments  and nonverbal interaction. This was reflected in the video activity data across sites, in which a large proportion of consultations were conducted within psychiatry/psychology and mental health services , pediatric services , musculoskeletal and orthopedic services , and physiotherapy .reflection in action  about how you do your assessments. And all those special tests we used to do in the consultation room, we’re suddenly finding that we were not getting any value out of them. And we are now coming to realize, it is what the patients tell us, it is how they got out their chair to get their medication or how they turn around to tell their partner to turn the telly down—all these little functional cues that we are seeing. I’m finding video a lot more helpful than these clever tests we used to do.Larry, physiotherapist, Northern Trust, August 2020strategic opening for supporters of the initiative. Other opportunities and extended uses of video included remote multidisciplinary and group consultations, which would have previously been difficult to establish as physical encounters.Christianson et al  describeHowever, although the pandemic provided a context to try out and reflect on the use of video, as predicted by Gkeredakis et al , an oppoThe big question for me is whether this change is permanent or just temporary…Are we going to see clinicians just not wanting to go back to the way they were working before, or are we going to see a slip in the use?Beth, program manager, Northern Trust, April 2021The absence of prepandemic groundwork within Eastern Trust also brought uncertainties about the extent to which the new service model can be socially and technically stabilized within the organization:We built a bridge—and it was a pretty good bridge to jump over the river—but we didn’t build the foundations. We suddenly had the technology, instantly threw ourselves into it, and got over that river. But the bridge is a little insecure…As a major change project, you would never do that—implement a new technology, try to get hundreds on board, and then build the system to support it.Teresa, program manager, Eastern Trust, December 2020Viewing the pandemic as disruption highlights how staff had to adapt to widespread displacement of social and material environments, including the need to work from home. Technology shortages also demanded improvised use of computing equipment . Staff needed to reorganize work routines to accommodate and support remote consultations in the face of prolonged uncertainty and disruption. Adaptive capabilities allowed some service provision to continue but also distorted work practices and created new demands and unintended consequences.physical copresence of patients and staff. Indeed, the inertia of established routines was a major constraint on the use of video before the pandemic, in which apparent embedding resulted from elaborate workarounds. Hence, the sudden and extensive transition to virtual created significant disruption, in which a fix for one problem generated problems elsewhere in the system.Clinic workflows are complex and structured around various interacting routines  and associated spatial and material structuring devices , which hParticularly during the early stages of the pandemic, clinicians relied on the telephone to consult with patients:We turned all into blanket telephone—and in a sense that has been the legacy—and we haven’t moved forward with video clinics, because the telephone clinics have been kind of working…There is a logistical problem. If you see people at clinic, it is really easy because they turn up, there is a slip [of paper] with their name on the trolley, and you just come out, pick up the slip…And when you’ve seen them, they will leave—you can’t double-see them. With the phone, we don’t have that. You may get someone who does not answer, so you call the next person, and come back to them—but then of course, that next person wasn’t expecting a call at that time, so then doesn’t pick up…So at the moment, I’ll start the [in clinic] appointments, and the registrar starts on the phone list. And then, when there are some less complicated patients in clinic, the registrar sees them, and I start at the bottom of the phone list and work up.Frank, neuro-oncology surgeon, Petroc Health, October 2020This extract highlights how the “installed base” both enabled and constrained the rapid reorganization of clinic routines, which, in turn, became locally embedded. Feldman  describeSimilarly, the rapid expansion of video demanded a high degree of adaptation and emergence in accordance with local needs and contingencies. One of the main areas of focus was the management of patient “entry” into their video appointment. The main video platform (Attend Anywhere) uses a consistent URL for each clinic virtual waiting area. In the initial phase, most patients were sent the relevant waiting area URL on an appointment letter, which they would be required to write into their internet browser. Although quick to implement, this arrangement was prone to problems with typing errors and incomplete knowledge of the new process:They send them a sheet. I guess it must say what they have to do, but it’s very limited. In fact, I don’t think they always even send that. Sometimes, they just send a letter saying log onto this [URL] address. And 9 times out of 10, the first time they use it, they’ll go onto Google Search…which just comes up with [Attend Anywhere] websites. And then, we say ‘No, you put it into the address bar at the top…”Betty, audiology therapist, Eastern Trust, February 2021In this extract, the clinician, patient, and administrative staff lack the mutual awareness  and emboHowever, over the course of the pandemic, various changes were made to help orientate patients, depending on local human and technical resources in place. Within Petroc, for example, existing (outsourced) text reminding services adapted the text message sent to patients so they could click directly onto the URL, although this relied on the patient having a smart phone.Another route of entry, eventually established within Petroc, Northern, and Southern Trusts, was the trust website, in which patients could click a button for the relevant virtual waiting area, although this relied on the patient being able to navigate the website and locate the correct button. The following extract describes a common problem in which patients would turn up in the wrong virtual waiting area due to difficulties distinguishing between overlapping specialties. This created a high degree of “invisible routine articulation work”  for thePatients select a waiting room to go into. But often, they would be waiting in orthopedics because they had seen that department previously…But we don’t have access to that waiting room. So, we would need to contact them and tell them to come out and go into the MSK [musculoskeletal] waiting area.Nick, physiotherapist, Petroc Health, March 2021Organizational capability to endure, and even harness, locally driven adaptations depended on the people and connections in place to monitor and embed new practices. For example, the Northern Trust implementation team continued to engage with clinicians shortly after the rapid deployment of Attend Anywhere, during which they discovered some practitioners using an alternative platform (accuRx). This platform’s texting and video call functions aligned better with their particular workflows and systems, and so it became supported at the system level.It was kind of by chance and through discussions that we found some people had started using [accuRx]...We realized it was building a bit of momentum amongst some clinicians. So, we officially approved it, did a bit of comms, and developed some training on how to use that platform.Nathan, operational support , Northern Trust, March 2021Similarly, over the course of the pandemic, the developers of Attend Anywhere incorporated new design features based on user feedback, including the “consult now” function, allowing clinicians to send the URL link directly to patients via text or email.process multiplicity (a single process incorporates many possible “paths”), in which ICT greatly expands the “space of possible paths”; different ICTs may be used at various points within the same process. Even a simple change  creates a host of new actions and pathways.The various sociotechnical arrangements to support patient entry reflect the generative tension between ostensive  and performative (specific actions taken) aspects of routines , driven Another example of process extension was clinicians’ use of the instant messaging feature to communicate with patients in the virtual waiting area , in which patients may decide to wait or exit and re-enter at a later point. In some cases, the clinician and patient would jointly decide to abandon the video option and consult by phone instead .Although some service teams brought admin support into this process , it usually relied on the clinicians to manage. Participants talked about the need for a conceptual shift in the departmental management of these new digital spaces, if they are to be sustained:If the patient has a face-to-face appointment, it isn’t just them instantly in with a clinician and instantly out with a clinician…Outpatient departments manage the physical outpatient space, but now we’ve got all of this virtual outpatient space…which actually…other than the patient and the clinician linking up together, nobody is managing that space to make sure that link-up happens correctly…We need to be taking responsibility, full responsibility—like we do for the physical space—of that virtual space.Simon, ICT manager, Northern Trust, March 2021Perspectives on exposure revealed infrastructural challenges and tensions to video consulting that have gone largely unnoticed. As Star  points oNetworks and servers came under significant strain during the first few months of the pandemic, resulting in periods of poor service reliability. Although these problems were dealt with promptly in collaboration with technology providers, local IT issues were poorly understood and more difficult to resolve:It is difficult to test the consultation capacity, because it is very dependent on the volume of calls, how the platform is doing on that day…It is really difficult to test the actual performance because it can vary so much.Tanvi, operational support, Petroc Health, January 2021Additionally, access and dependability issues extended beyond the boundaries of the organization’s IT infrastructure, including “digital poverty” . It was reported that video tended to be lower among groups with a greater health care need and already facing health inequalities, such as older people, low health literacy, weak social networks, limited mobility, limited transport, and psychological and mental health problems:Some people don’t have [smartphones], they don’t have laptops, iPads. You have to be kind of fairly well off to be able to access video consultation. We’ve definitely seen a difference in what type of patients can and can’t access.Nick, physiotherapist, Petroc Health, March 2021Clinicians talked about limited privacy in family households, as well as differences in network connectivity. Particularly for patients living in rural areas, audio-video quality was unreliable, impacting the quality of the consultation and sometimes resulting in the use of the telephone as a backup:Because if you’re talking to someone and you’re trying to explain something or you ask them a question and then you have to wait 10 seconds for them to answer, then you think, “Are they not answering, or is it they’ve not heard me or, you know, is it the delay?”Betty, audiology therapist, Eastern Trust, February 2021It was often difficult to anticipate the needs and wishes of patients in advance, requiring flexible use, alongside nondigital alternatives. Digital exclusion was not merely down to whether a person could use technology, but cut across multiple technical and social elements, as described next:I had to say to her, “I can see your background [on video].” And I don’t think she was comfortable with that…We have a large Asian population, where there is an element of larger families and smaller living spaces. If I access their space, I will not only be seeing them, I would be seeing their family. And they may not be comfortable with that…You have to be careful.Tanisha, hepatologist, Petroc Health, October 2020Mitigating digital exclusion was an effortful accomplishment between clinicians, patients, and their support networks. However, some early strategic work had begun within Northern Trust to establish local hubs for video appointments in partnership with community centers:So now, if they need help accessing technology, they can get in touch with the community center—and we trained people in these community hubs to help people access the remote consultation. But also, in the community hub, they will get access to a full package of support, such as food packages…It has taken a while just engaging with these groups, making sure they are happy.Tessa, PPI engagement lead, Northern Trust, April 2021This extract reveals the role of collegial partnerships in order to coordinate and interface between the digital and material aspects of health care and community-based infrastructures. Perspectives on exposure, therefore, reveal not only weakness within the system but also strengths to be leveraged and built upon. In a similar vein, Sanner et al  draw on opportunity highlighted the institutional elements of infrastructure, in which conventional assumptions, norms, and governance structures were challenged. The pandemic brought about a collective understanding or organizing vision [Gkeredakis et al's  3 perspeg vision  for videdisruption drew attention to the structures and practices involved in the urgent response to the pandemic. With the displacement of deeply embedded routines, new performative patterns of action emerged, in which the virtual environment greatly expanded the “space of possible paths” within consultation workflows. A large space of possible paths makes routines more resilient to disruption (by minimizing the single points of failure), but it also makes the processes more difficult to replicate and manage [The focus on d manage . The capexposure reflected inherent properties of information infrastructures, as backgrounded and taken for granted. The accelerated scale-up of video revealed social and technical impediments to video consulting and the potential to accentuate unresolved health inequalities. This raises practical and ethical challenges to scaling up such a service model and conflicts with the policy talk of such technology as state of the art, efficient, and accessible [Accounts related to cessible . ImproviResearch on information infrastructures highlights how technology-supported change needs to be cultivated in a way that acknowledges challenging organizational needs and the inertia of the installed base -62. The Despite the policy focus on digital , the reabimodal governance offers a potential approach, in which “heavyweight” IT systems  and “lightweight” IT applications  are managed separately under differing organizational structures, cultures, and regulatory mechanisms. Such a model has been shown to work well in hospital settings, in which a partitioning of IT departments—one part dealing with the traditional core IT system and the other with new applications—allowed for a “two-speed” approach to the co-evolution of these loosely couple subsystems [First is the need to balance stability  on the one hand and openness to change  on the other. Although regulatory changes during the pandemic may have brought a new-found agility to experiment and innovate, health care organizations must still ensure a high level of safety, security, and dependability . Bygstadbsystems .Second, the extended use of remote consultations highlights a need to conceptualize information infrastructures beyond the boundaries of the health care organization. The ubiquitous use of extra-organizational ICT within professional work settings has prompted calls for more theoretical and empirical research into the intersection between institutional infrastructures and individual digital assemblages . Video cvirtual consultations vastly expand the set of possible paths within an appointment process, and therefore, it is important to visualize and understand the multiple performances that could be generated in a process (as opposed to a single version of how the process should occur). Narrative networks may provide a useful methodological device to see the terrain of possible paths and purposefully increase variation in performance (for flexibility) or try to reduce it (for standardization and control). This could help identify areas to increase resilience and choice , while also ensuring associated roles and processes are consistent and coordinated.Third, close attention needs to be paid to routines and patterns of actions underpinning virtual appointments. Our findings on the disruptive forces of the pandemic resonate with other studies focusing on the redesign of care pathways using process-mapping methods ,71. TradFinally, it is important to bridge competing institutional logics with an overall narrative or organizing vision  for videThe strength of this study is that we undertook research at 4 sites before the pandemic, through which we had already identified the importance of information infrastructures on the implementation and use of video. This provided a unique opportunity to study crisis-engendered changes from the early stages. In addition, the case studies were conducted within a wider program of research on remote consultations across the United Kingdom, providing a wider national context to the organizational settings.Pandemic restrictions meant that we could not undertake ethnographic work during this phase, and our data collection during this time was affected by the unprecedented pressures on NHS staff, raising potential sample biases toward those individuals with time available to speak with us. However, our positive and longstanding relationship with these sites helped mitigate such issues; the researcher had previously visited all sites on numerous occasions before the pandemic, adapted interview schedules, and was able to draw on multiple sources of data.A further limitation of this study includes the question of how far we can generalize from our 4 case studies on the rapid scale-up of video consultations. Our theoretical analysis helped explain the empirical data on information infrastructures in our case sites but may not explain all aspects of such infrastructure in all contexts. We chose to focus on video consultations as a topic of academic interest because it exemplifies a promising innovation that has taken decades to scale up. We encourage others to apply the same theoretical lens to explore crisis engendered changes in other digital health contexts.Gkeredakis et al’s  3 perspe


Sequential lineups are one of the most commonly used procedures in police departments across the USA. Although this procedure has been the target of much experimental research, there has been comparatively little work formally modeling it, especially the sequential nature of the judgments that it elicits. There are also important gaps in our understanding of how informative different types of judgments can be (binary responses vs. confidence ratings), and the severity of the inferential risks incurred when relying on different aggregate data structures. Couched in a signal detection theory (SDT) framework, the present work directly addresses these issues through a reanalysis of previously published data alongside model simulations. Model comparison results show that SDT modeling can provide elegant characterizations of extant data, despite some discrepancies across studies, which we attempt to address. Additional analyses compare the merits of sequential lineups (with and without a stopping rule) relative to showups and delineate the conditions in which distinct modeling approaches can be informative. Finally, we identify critical issues with the removal of the stopping rule from sequential lineups as an approach to capture within-subject differences and sidestep the risk of aggregation biases. Since its formation in 1992, the Innocence Project  has exonsequential lineups, a procedure that has been the subject of a large number of empirical investigations  to the large-scale sequential lineup data reported by Wilson et al. ,Outcome TP2: Incorrect identification of a lure ,Outcome TP3: Incorrect rejection of the lineup (Miss),Target-Absent Lineups:Outcome TA1: Incorrect identification of a known lure ,Outcome TA2: Incorrect identification of a lure standing for the designated innocent suspect ,Outcome TA3: Correct rejection of the lineup (Correct Rejection).By comparing these outcomes across different procedures and/or conditions, researchers are able to draw conclusions as to how various factors  may affect identification performance.Experiments simulating lineup identifications follow a fairly standard format. Participants are shown a mock crime  and are then presented a photograph array of  six faces. The arrays either contain the face of the perpetrator (guilty suspect) of the mock crime or the perpetrator is replaced by an innocent lure. These arrays are referred to as stopping rule, along with the impossibility of revising previous “no” judgments, can be expected to affect people’s reluctance to make a positive identification at any given point. But this reluctance might change across the sequence, perhaps due to the prospect that no identification might be made by the time the sequence ends , the lineup is said to be rejected. In the USA, for our purposes, a sequential lineup is typically terminated once a “yes” decision is made on a single face. This simultaneous lineups  or the showup procedure (where only one face is presented in the entire procedure). Lindsay and Wells  have motivated researchers to compare them with other procedures, such as nd Wells  were amond Wells  and Stebnd Wells  reportednd Wells . A paralnd Wells . Regardllatent strength values of the stimuli and a response criterion. In the context of recognition memory—and eyewitness identification—when a stimulus is presented to a decision-maker, she compares the latent memory strength  of that stimulus with a previously established response criterion Receiver Operating Characteristic (ROC) function. The bottom panel of Fig. Recent modeling efforts in the field of eyewitness identification have been couched on signal detection theory  hypothesis  differences in discriminability, (2) shifts in the response criterion, (3) or both. This ability, which cannot be achieved by means of naïve summary statistics  and focus in on unique, or diagnostic, features that can provide the most aid in making a correct decision . This opportunity to learn how to better discriminate is partially compromised in the case of sequential lineups, given that witnesses only get to see one face at a time. At most, the witness can learn about the diagnosticity of features as the lineup sequence unfolds. However, there is the risk that the target is missed when presented earlier on, as well as the risk that the witness will incorrectly identify someone before having the opportunity to encounter the target. There is also the issue that memory discriminability tends to diminish along a sequence of judgments  can depend on how exactly the models being used happen to address other substantive issues . In the case of sequential lineups, it is possible that the evidence for the DFD hypothesis that was originally reported by Wilson et al.  and hits in target-absent and target-present lineups, respectively. But as shown by Rotello and Chen , the seqmentclass2pt{minimmentclass2pt{minimA key insight stemming from Rotello and Chen’s  work is I faces are presented. Assuming that lure faces are exchangeable, there are Itarget-present lineup sequences in which the target takes position i, plus one target-absent lineup sequence. If we only consider binary responses, the data from this procedure are comprised of lineup type and sequence. If we decide to unpack “yes” responses in terms of Klevels of confidence, then each category system is comprised of Unfortunately, the important lessons found in Rotello and Chen  are not n et al. , reportementclass2pt{minimmentclass2pt{minimlineup type and sequenceposition. This means that for each position i, we have a category system for each type of sequential lineup. In the case of target-present lineups, we have three categories: 1) “yes” judgments to targets, 2) “yes” judgments to lures, and 3) “no” judgments. In the case of target-absent lineups, we have “yes” and “no” responses to lures. Under this conditioning, binary “yes”/“no” judgments yield K levels of confidence, we end up with a total of lineup type  and sequence instead. This reduction in degrees of freedom indicates that some information is being lost. For instance, note that “yes” judgments to lures, conditional on position i in a target-present lineup, aggregate responses across all target-present lineups in which the target was present in positions Wilson et al.  relied on et al. , partititwenty-one times more degrees of freedom (42 vs. 2).Confidence ratings play an important role in SDT modeling  throughout the sequential lineup?Q6: Can aggregation biases be sidestepped by removing the stopping rule from the sequential lineup procedure?In the case of Wilson et al. , we are n et al. , aside fn et al.  while imnot include a stopping rule, which meant that participants always evaluated every single face in the lineup. In order to address this deviation from standard practices, we excluded any participants’ responses beyond their first “yes” judgment; i.e., we emulated a stopping rule. Because both experiments used the same stimuli and implemented the exact same lineup procedure, we were able to collapse participants’ responses into a single dataset, which is reported in Table In the two experiments reported by Wilson et al. , particiI faces that can include the target (guilty suspect) or not. For each position i in the sequence, with ith face in a given sequence s is based on the comparison of their latent strength value with a response criterion ith face was preceded by i − 1 “no” responses.The SDT modeling of sequential lineup judgments can be cast as an extension of a yes–no task  being presented in position i (or preceding position h) in a given sequence s.For a given sequence s is given by:Response Criteriafixed): The same response criterion (variation across sequence position): Response criterion (variation due to target position): Response criterion i in a target-absent lineup. Now, let i in a sequence s in which the target was encountered in a previous position h, with : Response criterion and as a function of a previous encounter with the target (see (Discriminabilityfixed discriminability): Latent strength parameters of targets ((restricted change in means): Across sequence positions, the means of the latent strength distributions for targets : Across sequence positions, the variances of the latent strength distributions of targets : Similar to (unrestricted change in variances): Similar to  are reported in Table n et al. . We evalmonotonically increasing across sequence positions, such that i implies the rejection of all preceding faces.monotonically increasing criteria was considerable , whereas BIC supports their constrained counterparts. However, it is well known that BIC can impose unreasonably large penalties per additional parameter  allowing confidence criteria to be freely estimated introduces an amount of flexibility that is unwarranted, and (2) this flexibility is limiting the ability to detect changes in discriminability. We will address (1) here and turn to (2) in the subsection below. Let us consider the SDTmore principled than the alternative of allowing them to vary haphazardly, regardless of badness-of-fit or model selection results. We identify a number of problems with this stance: First, it ignores or downplays the fact that we are dealing with aggregate data coming from heterogeneous respondents. There is a large body of work showing how certain features found in aggregate data might not be representative of any of the individual respondents  and successfully characterized by the same model framework. One should not overlook the possibility of perceiving sequential lineups through a different lens that finds criterion changes highly plausible; e.g., casting sequential lineups as an “optional-stopping problem”  is quite high, even when response criteria are allowed to vary across sequence positions, which means that there is no statistical power or likelihood ratio rationale for questioning the specification of unconstrained response criteria.Beyond binary proclamations of “statistical significance,” the distributions illustrated in Fig. see Fig. , we findConfidence ratings turn out to be necessary.Our analyses of binary and confidence judgments from Wilson et al.  showed hAt first glance, one might see this result as a mere demonstration of something that is well established in the context of recognition memory: that binary responses alone  cannot support a complete SDT characterization, an inability that ultimately leads to failures in distinguishing differences in discriminability from differences in response criteria ,Groups A and B differ in terms of discriminability (Discriminability),Groups A and B differ in terms of response criteria (Criteria),Groups A and B differ in terms of both discriminability and response criteria (Both).Binary response data were generated from these different models, once again using the SDTIn a second simulation, we evaluated the ability to correctly identify the causes behind the differences between two groups: Are they caused by differences in discriminability, response bias, or both? In order to answer this question, we fit different versions of the SDTmentclass2pt{minimIn a third and final simulation, we evaluated the ability to detect differences in see Fig. , only thAltogether, these simulation results show that binary judgments coming from sequential lineups can be used to obtain valid SDT characterizations and conduct simple between-group comparisons. However, the use of binary judgments severely impairs our ability to detect differences in discriminability across sequence positions, as postulated by the DFD hypothesis. To be clear, none of these simulation results puts into question the overall value of confidence judgments in the study of eyewitness identifications—they only delineate the circumstances in which confidence ratings are not strictly necessary .showup procedure, in which participants are only shown a single face, which is either the target or a lure. The availability of such data allows us to directly compare the relative merits of the two procedures. We conducted a first comparison by directly fitting the showup data jointly with the data from the first sequence position.In their second experiment, Wilson et al. also collected responses from a The SDT model used allowed mentclasspt{minimaexpected utility of each procedure:the expected utility of sequential lineups is greater when the probability of the suspect being guilty is moderate or small (less than .40). A second look at Table However, a different and arguably more nuanced picture is obtained when taking into consideration the different possible outcomes associated with each procedure, their respective utilities, and the prior probability of suspect being guilty  are consistent with the null hypothesis and inconsistent with the presence of an effect, even if small see Fig. . In shorarbitrary utility values assigned to each possible outcome. That being said, we believe that the present utility values are more sensible than simply setting the utilities of all un/desirable outcomes to absent lineup. Researchers are of course encouraged to consider alternative utilities, provided that some kind of justification is provided.Finally, we compared sequential lineups with showups. The discriminability estimated in both procedures was essentially the same, which speaks against the use of sequential lineups altogether given the effects of target sequence positioning . We also note that the learning effect is limited in scope: The improvements offered by models and SDTAn inspection of the parameters estimates of models SDTnot lead to statistically significant increases in badness of fit described in terms of a change in mixture weights . It turns out that these assumed invariances are what ultimately drives the discrepancies between both analyses. These issues are discussed in detail below, as they demonstrate how careful researchers must be when dealing with aggregate lineup data.We disagree with the understanding behind this between-/within-subjects distinction. As we will show below, it is a mistake to think that this “within-subjects” analysis offers some kind of alternative perspective: When properly construed, it becomes clear that one analysis is a censoring imposed by the stopping rule: Whereas one analysis only includes the first “yes” response, the other includes the entire sequence of responses. Consider the following censored response sequence, in which the item in sequence position 4 is (the first to be) recognized and the uncensored sequences of length six that can stem from it:Let us begin with the between/within-subjects distinction. This distinction traditionally refers to the comparison between different groups of individuals viz-à-viz the comparison of the same group of individuals across experimental conditions. But this contrast cannot be applied here, given that the “between-subjects” analysis also considers the responses made by the same participant across different conditions . What distinguishes both analyses is the Going from censored to uncensored sequences increases the total number of unique sequences that can be observed in a given lineup. For lineups of length six, we have to consider how each of the seven censored patterns can be expanded, which ends up amounting to at most one target in a given lineup. We are not dealing with a randomized test list comprised of multiple studied and non-studied words, of the kind typically found in recognition memory studies. For instance, it is sensible to assume that a second “yes” response is only produced when the latent strength of a given face is greater than the previously recognized one, which implies a conservative shift of the response criterion. The possibility of discriminability being affected by a previous “yes” response is also plausible a priori, as evidenced by the numerous studies investigating the effects of repeating sequences and/or providing feedback .are treated as equivalent when determining The relationship between the two kinds of analyses is not obvious in Dunn et al.’s  analysesi is the same across all of the possible preceding sequences  the researcher is effectively unable to determine its violation by inspecting SDT model misfits .Dunn et al.’s . Further empirical work is necessary in order to determine the merits of this alternative explanation. In terms of response criteria, we did not find any reason to dismiss the effects of target rejection as the outcome of a “selection bias” that overrepresents conservative individuals (Q5). Finally, we critically evaluated the “within-subjects” analysis proposed by Dunn et al., which attempts to sidestep aggregation biases by removing the stopping rule from the sequential lineup procedure. Our critique lays out the reasons why this analysis should be dismissed in toto (Q6): It enforces i.i.d. assumptions that are not only unreasonable a priori but also rejected by the data when directly tested. Relaxing these i.i.d. assumptions does not provide any kind of relief though; it only leads to a redundant analysis of uncensored response sequences. To be clear, we are see Fig. . We are SDT is arguably one of the greatest success stories in modern psychological research, with its application to recognition memory being a particularly notable example . For instance, one can easily think of applied scenarios in which confidence ratings are simply not available or are perhaps unreliable. Fortunately, SDT models can be successfully applied to binary responses in order to answer a number of relevant questions, as demonstrated here. This possibility is an important reminder that models can serve multiple roles: They can provide a rich medium for theoretical development and refinement, but also serve as measurement tools. These roles are beholden to different standards (see Kellen,