Synthesis of the Gambia-un Country Team Development Forum 2003

This compendium highlights the activities of the Gambia-United Nations Country Team Development Forum in sharing experiences and examinations of the complexities of the development process. It advocates for volunteerism and CSR as key drivers of sustainable development

Evaluation of the organisation and delivery of patient-centred acute nursing care

In 2002, a team of researchers from the School of Nursing, University of Salford were commissioned by Bolton Hospitals NHS Trust to evaluate the delivery and organisation of patient-centred nursing care across the acute nursing wards within the Royal Bolton Hospital. The key driver for the commissioning of this study arose from two serious untoward incidents that occurred in the year 2000. Following investigation of both these events the Director of Nursing in post at that time believed that poor organisation and delivery of care may have been a contributory factor. Senior nurses in the Trust had also expressed their concern that care may not be organised in a way that made best use of the skills available

Hospital administration

The Administrator of a hospital, particularly of a teaching hospital, is faced with the task of organising increasingly complex and specialised, high technology institutions, under constant pressure to improve patient care and community services, training of health personnel, and to seek new knowledge, therapies and techniques. In addition, acute general hospitals are being forced to re-examine their goals and functions in the light of greater competition from other health and social services for scarce resources - and of changing environmental circumstances. These activities must be undertaken in the context of new theories of management with greater emphasis on the psycho-social aspects of organisation, decision-making processes and advances in information-processing techniques. To be equipped for this task the hospital administrator must also acquire new knowledge and skills. It was therefore frustrating to discover that no training courses for hospital administrators, medical or otherwise were available in this country and that there was a dearth of literature with specific reference to the Republic. Thus, it was as a measure of desperation that this thesis was embarked on, in order to satisfy a personal need to learn about the theory of administration and to meet the need for basic research into, and documentation of, hospital administration in South Africa. In view of the necessity to study virtually every aspect of the subject and the fact that so little research had been done on the management of South African hospitals, it was felt that hospital administration should be examined as a totality rather than selecting any single aspect of the subject. General Systems theory which views any open system as a whole, in constant interaction with its environment, provided an appropriate conceptual framework for the general study of hospital administration. The Groote Schuur Hospital Group provided a suitable model within which to l examine the application of general systems theory; for analysis of the environment, resources, organisation and products of a hospital; and upon which to base some general conclusions regarding the administration of hospitals, recommendations for change and for further research. This thesis which is presented in eight chapters with a short summary of the contents at the end of each chapter has examined one teaching hospital group as a whole system. No attempt has been made to study any aspect of hospital administration in great detail, but rather to identify areas where immediate changes can be implemented to improve the effective and efficient utilisation of resources, and those where further research is essential to find better ways of achieving these goals and meeting societal needs. In the words of Tenon - The hospital is the conscience of a civilisation whose worth, in the end will be measured not by articles of faith and lofty doctrines but by the way it nurtures life; succours distress, rights injustices and transforms misery, frailty and want into hope, dignity and sufficiency

A qualitative study of the knowledge-brokering role of middle-level managers in service innovation: managing the translation gap in patient safety for older persons’ care

Background: Brokering of evidence into service delivery is crucial for patient safety. We study knowledge brokering by ‘hybrid’ middle-level managers (H-MLMs), who hold responsibility for clinical service delivery as well as a managerial role, in the context of falls, medication management and transition, in care of older people. Objectives: Generate insight into processes and structures for brokering of patient safety knowledge (PSK) by H-MLMs. Design: We utilise mixed methods: semistructured interviews, social network analysis, observation, documentary analysis, tracer studies and focus groups. Setting: NHS East and NHS West Midlands. Participants: One hundred and twenty-seven H-MLMs, senior managers and professionals, in three hospitals, and external producers of PSK. Main outcome measures: Which H-MLMs broker what PSK, and why? (1) How do H-MLMs broker PSK? (2) What are contextual features for H-MLM knowledge brokering? (3) How can H-MLMs be enabled to broker PSK more effectively in older persons’ care? Results: Health-care organisations fail to leverage PSK for service improvement. Attempts by H-MLMs to broker PSK downwards or upwards are framed by policy directives and professional/managerial hierarchy. External performance targets and incentives compel H-MLMs in clinical governance to focus upon compliance. This diverts attention from pulling knowledge downwards, or upwards, for service improvement. Lower-status H-MLMs, closer to service delivery, struggle to push endogenous knowledge upwards, because they lack professional and managerial legitimacy. There is a difference between how PSK is brokered within ranks of nurses and doctors, due to differences in hierarchal characteristics. Rather than a ‘broker chain’ upwards and downwards, a ‘broken chain’ ensues, which constrains learning and service improvement. Conclusions: Clinical governance is decoupled from service delivery. Brokering knowledge for service improvement is a ‘peopled’ activity in which H-MLMs are central. Intervention needs to mediate interprofessional and intraprofessional hierarchy, which, combined with compliance pressures, engender a ‘broken’ chain for applying PSK for service improvement, rather than a ‘brokering’ chain. Lower-status H-MLMs need to have their legitimacy and disposition enhanced to broker knowledge for service improvement. More informal ‘social mechanisms’ are required to complement clinical governance for development of a brokering chain. More research is needed to (1) examine why some H-MLMs are more disposed and able than others to broker PSK for service improvement, and (2) understand how knowledge brokering might be enhanced so that exogenous and endogenous knowledge is better fused for service improvement

Regime characteristics and health policy reform in the post-colonial state : a comparative case study of the influence of regime characteristics on health human resources policy and policy reform processes in Guyana, Jamaica and Trinidad and Tobago, 1970-1990

In this dissertation, I examine and compare the influence of the following regime characteristics -strength, stability, ideology, democracy and survival/maintenance - on post-colonial health human resources policy processes within one sub-region: the Commonwealth Caribbean; with special reference to Guyana, Jamaica and Trinidad and Tobago (hereinafter called Trinidad) between 1970 to 1990. As I want to comparatively assess the role of these characteristics in post-colonial policy processes, I shall in this chapter place my study within the context of colonial regime characteristics, society and reform processes, assessing its possible influences on post-colonial political developments. This forms the basis of my analysis of policy within these three `post-colonial' states during the 1970s and 1980s. Section One describes the paradox of health and health human resources status in the Commonwealth Caribbean during the 1970s and 1980s. In Section Two, I describe the area under study. In Section Three, I examine possible linkages with the nature of power and reform under colonial regimes. In Section Four, I analyse the influence of regime characteristics on policy processes by assessing health policy outcomes of postwar reform. I begin with an examination of the contradictory status of Commonwealth Caribbean health and health human resources development in the 1970s and 1980s

Oxford City PCG and PCT : a case study of collaboration

In 1997 the New Labour government instigated a period of radical reform for the National Health Service, a key element of which was the establishment across England of Primary Care Groups (PCGs), which subsequently became Primary Care Trusts (PCTs). These were local statutory governance bodies with responsibility to deliver and develop primary care and to improve the health of their local population: complex functions requiring collaboration with a range of organisations and agencies. The central aim of this study was to investigate whether and how PCG/Ts developed and facilitated collaboration within primary care, and between it and other NHS and non-NHS bodies, and to identify factors which enabled and inhibited collaboration. Using a theoretical framework which draws on a critical realist tradition, an approach was adopted to the analysis of organisational change which was attentive not only to rational, incremental processes of change but which took into account the political, cultural and economic context in which PCG/Ts operated. A key element of this context was the strong resemblance between New Labour's prominent `third way' discourse of collaboration and the defining characteristics of a network mode of governance: trust, loyalty, reciprocity and voluntariness. Inductive and deductive approaches were combined to test and develop theory about the interactions between context and organisational form, using multiple qualitative methods within a longitudinal nested case study. The study demonstrated that the locality-wide base of PCG/Ts, their explicit health improvement remit, budgetary arrangements and the presence of clinicians on their governing bodies were aspects of their organisational forms which equipped them to facilitate collaboration. However, over time, certain contradictions became apparent in New Labour's approach to organising the NHS which undermined many of the PCG/T's collaborative processes. This thesis argues that the alignment of the third way discourse with a network mode of governance exemplified 'symbolic politics. ' What was presented as a rational response to complex social problems and fragmentation of public services, was in fact largely a pragmatic political manoeuvre designed to distance itself from the perceived failure of previous administrations' hierarchy and market modes of governance

Acting in Time: Transport Nurses optimising critically ill patients for transfer to a regional ECMO centre. A Grounded Theory Study

Regionalisation and centralisation of Intensive Care Units, coupled with demographic changes, have resulted in an increased demand for inter-hospital transport. The Conventional ventilatory support vs Extracorporeal membrane oxygenation for Severe Adult Respiratory Failure Trial (CESAR), validated the use of ECMO in the UK for critically ill adults. The H1N1 Influenza A epidemic in 2009, led to four more adult ECMO centres being designated, and more recently the World Health Organisation (WHO, 2020), recommended ECMO for eligible patients in the COVID-19 pandemic. A critical incident occurred while I was undertaking the transport of a critically ill adult, which led to the unplanned use of mobile ECMO, still in its infancy. Seeking answers to the questions raised from this incident a research proposal was formed in order to investigate what could be learnt from the actions of transport nurses in promoting stability and preventing deterioration of patient acuity during the transport process. A grounded theory approach was used to try and understand the processes and strategies that experienced transport nurses used in optimising their patients’ stability and generate a substantive theory in explaining their timely actions. Under a pragmatic paradigm, this grounded theory study utilised the methods of Retrospective Medical Records Review and Interviews. Quantitative random sampling of 50 patients retrieved to a regional ECMO centre, allowed the collection of vital physiological variables staged over three time points. Data analysis showed that two out of the eight variables demonstrated a statistical significance in deterioration. Qualitative unstructured interviews from six transport nurses revealed a variety of activities, proactive and reactive, cognitive and physical, with overwhelming attention to time constraints, employed to benefit the patient. An explanatory theory was identified. Acting in Time encapsulated extant theory from the Secure Base Model (SBM) in fostering studies, and the Actor-Network Theory (ANT), from sociological literature. Acting in Time made overt the core virtues, practices, and skills of the transport nurse in aiming to reduce the risks associated will transport of the critically ill adult while striving to maintain patient stability. The study identified a growing need for centralisation, coordination, standardisation, audit, education and training for all those involved in transporting critically ill patients to a regional ECMO centre. It recommends that dedicated regional transport centres should be implemented for the transport of the adult critical care patient. A centralised database should be created for the import of data from the regional transport teams. Education for all nurses, not just transport nurses, needs to be available to deliver high quality care at any point of patient retrieval. A curriculum for transport education for nurses is outlined. This research reinforces and adds to the Intensive Care Society and Faculty of Intensive Care Medicine (ICS & FICM, 2019), and standards of education for nurses enhanced

Health policy and hospital mergers: how the impossible became possible

This study seeks to explain major shifts in health policy. It takes as case studies two governmentally-led hospital mergers in the 1990s - one in London and one in Reykjavik - when national governments, as part of broader administrative reforms, decided to merge teaching hospitals in their capitals. The decision to merge, and the implementation of the decision, followed a long history in both cities, in which the mergers had been repeatedly held up as highly desirable but had always been blocked or abandoned. The merger decisions in the 1990s represent “the impossible becoming possible”. And they stand out as defining moments because of the way they shape the successive course of events in the health care systems. By answering the empirical question why it was possible to merge these hospitals in the 1990s but not in the 1980s, the research aims to contribute to a body of literature that seeks to improve theoretical understanding about how health care systems are shaped by national governments. It carries out two sets of analysis: historical analysis of the main explanatory factors within the health care arenas in both cities; and political analysis of the degree of political authority and will for action of the governments of Britain and Iceland in the 1980s and 1990s. The research concludes that in both cases the merger decisions in the 1990s are best understood as resulting from a confluence of three main factors: 1) weakening cohesion inside the health care arenas; 2) national governments with a long-term hold on power providing an opportunity to consolidate political authority and will through which the wider context of the reform agenda was adopted, 3) the prolonged continuity of executive forces in the governments providing specific political actors with scope for action. In bringing these factors together, ideas which had once united and divided groups of actors in the health care arenas and caused fragmentations in the old order, became glue to the new structure. Theoretical interpretations of the findings suggest that public policies “happen”, as opposed to being made. The merger decisions can be seen more as indicative of past development within the health care systems than as directive themselves. Political interventions, however, changed the balance between groups of actors in the system resulting in strengthening of influence of particular groups of actors, who now possess ever greater control over where, how, when, how much and at what price medical services are provided