Generative mechanisms of IT-enabled organisational performance in resource-constrained Emergency Medical Services organisations in South Africa

Problem Statement: Emergency medical services (EMS) organisations have one of the highest levels of dependence on and use of information technology (IT) to support delivery of emergency medical services. The need for EMS organisations to provide efficient and effective emergency medical services has emphasised the importance of performance management. Organisational performance which is monitored and evaluated through key performance indicators (KPIs) plays an important role in EMS organisations. Organisational performance helps to monitor, evaluate and communicate outcomes in the form of KPIs. Empirical evidence shows that quantitative KPIs have been designed with little in-depth understanding of the underlying IT usage mechanisms that influence organisational performance. Unfortunately, such quantitative KPI reports have been limited in explaining organisational performance underpinned by IT. Purpose / rationale of the research: The purpose of this research study was to identify the generative mechanisms associated with IT-enabled organisational performance and to explain how these mechanisms interact. In the context of resource-constrained EMS organisations, quantitatively defined KPIs are not suitable for explaining the underlying causes of performance variations and outcomes. The lack of empirical evidence on IT-enabled organisational performance as well as the lack of theoretical explanations of the underlying mechanisms provided the primary rationale for this study. In addition, this study sought to provide answers to the following research question: What generative mechanisms explain IT-enabled organisational performance in resource-constrained EMS organisations? Theoretical approach/methodology/design: This study was informed by the critical realist philosophy of science and used the complex adaptive systems theory together with institutional theory as the theoretical lenses to investigate the research question in a manner that jointly explained the generative mechanisms. Using interviews, participant observation, organisational performance data and documents collected from a single case study, the study used abduction and retroduction techniques to explicate the mechanisms of IT-enabled organisational performance. Findings: Findings indicate that the IT-enabled organisational performance mechanisms can be categorised into two types of generative mechanisms. These are structural and coordination mechanisms. The explanation of the mechanisms developed in this study take into consideration three important elements: (1) the technological, cultural and structural mechanisms that influence IT-enabled organisational performance; (2) the unpredictable, non-linear, adaptive nature of emergency medical services environments; and (3) the complexities that arise in the interactions between EMS organisations and their environments. Originality/contribution: In respect of IT-enabled organisational performance this study contributes to both organisational and health information systems literature by developing a multi-level research framework that is informed by the realist philosophical stance. The framework plays an explanatory role which relates to its inherent ability to offer explanatory insights into the necessary mechanisms that give rise to organisational performance. This framework has the potential to guide empirical research and provide theoretical explanations of different domains or disciplines that are concerned with identifying IT usage mechanisms which influence organisational performance. These include the significance of the coordination and structural mechanisms which, under differing conditions of uncertainty, produce variations in performance outcomes. Implications: Findings from this study can be integrated into broader emergency medical policy planning and health programme management. The model developed by the study provides a fresh understanding of the underpinning mechanisms enabling performance in resource-constrained EMS organisations. It can be used to assist emergency medical institutions and practitioners in South Africa and other sub-Saharan African countries, especially Southern African Development Community (SADC) countries to improve emergency medical service delivery to the public. The findings provide a guide for improving management of emergency medical situations and resources in their respective resource-constrained contexts. Furthermore, findings from the study can also guide improved design and implementation strategies and policies of EMS systems initiatives in South Africa and sub-Saharan developing countries

Analysing the role of complexity in explaining the fortunes of technology programmes : Empirical application of the NASSS framework

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background: Failures and partial successes are common in technology-supported innovation programmes in health and social care. Complexity theory can help explain why. Phenomena may be simple (straightforward, predictable, few components), complicated (multiple interacting components or issues) or complex (dynamic, unpredictable, not easily disaggregated into constituent components). The recently published NASSS framework applies this taxonomy to explain Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability. This paper reports the first empirical application of the NASSS framework. Methods: Six technology-supported programmes were studied using ethnography and action research for up to 3 years across 20 health and care organisations and 10 national-level bodies. They comprised video outpatient consultations, GPS tracking technology for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organising software and integrated case management via data warehousing. Data were collected at three levels: micro (individual technology users), meso (organisational processes and systems) and macro (national policy and wider context). Data analysis and synthesis were guided by socio-technical theories and organised around the seven NASSS domains: (1) the condition or illness, (2) the technology, (3) the value proposition, (4) the adopter system (professional staff, patients and lay carers), (5) the organisation(s), (6) the wider (institutional and societal) system and (7) interaction and mutual adaptation among all these domains over time. Results: The study generated more than 400 h of ethnographic observation, 165 semi-structured interviews and 200 documents. The six case studies raised multiple challenges across all seven domains. Complexity was a common feature of all programmes. In particular, individuals' health and care needs were often complex and hence unpredictable and 'off algorithm'. Programmes in which multiple domains were complicated proved difficult, slow and expensive to implement. Those in which multiple domains were complex did not become mainstreamed (or, if mainstreamed, did not deliver key intended outputs). Conclusion: The NASSS framework helped explain the successes, failures and changing fortunes of this diverse sample of technology-supported programmes. Since failure is often linked to complexity across multiple NASSS domains, further research should systematically address ways to reduce complexity and/or manage programme implementation to take account of it.Peer reviewedFinal Published versio

Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method

Background: The extensive and rapidly expanding research literature on electronic patient records (EPRs) presents challenges to systematic reviewers. This literature is heterogeneous and at times conflicting, not least because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches. Aim: To map, interpret and critique the range of concepts, theories, methods and empirical findings on EPRs, with a particular emphasis on the implementation and use of EPR systems. Method: Using the meta-narrative method of systematic review, and applying search strategies that took us beyond the Medline-indexed literature, we identified over 500 full-text sources. We used ‘conflicting’ findings to address higher-order questions about how the EPR and its implementation were differently conceptualised and studied by different communities of researchers. Main findings: Our final synthesis included 24 previous systematic reviews and 94 additional primary studies, most of the latter from outside the biomedical literature. A number of tensions were evident, particularly in relation to: [1] the EPR (‘container’ or ‘itinerary’); [2] the EPR user (‘information-processer’ or ‘member of socio-technical network’); [3] organizational context (‘the setting within which the EPR is implemented’ or ‘the EPR-in-use’); [4] clinical work (‘decision-making’ or ‘situated practice’); [5] the process of change (‘the logic of determinism’ or ‘the logic of opposition’); [6] implementation success (‘objectively defined’ or ‘socially negotiated’); and [7] complexity and scale (‘the bigger the better’ or ‘small is beautiful’). Findings suggest that integration of EPRs will always require human work to re-contextualize knowledge for different uses; that whilst secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper, far from being technologically obsolete, currently offers greater ecological flexibility than most forms of electronic record; and that smaller systems may sometimes be more efficient and effective than larger ones. Conclusions: The tensions and paradoxes revealed in this study extend and challenge previous reviews and suggest that the evidence base for some EPR programs is more limited than is often assumed. We offer this paper as a preliminary contribution to a much-needed debate on this evidence and its implications, and suggest avenues for new research

Shaping innovation and coordination of healthcare delivery across boundaries and borders : A comparative case study

Peer reviewedPublisher PD

Escalation: Explorative studies of high-risk situations from the theoretical perspectives of complexity and joint cognitive systems

The main aim of the research is to explore different aspects of organisational resilience in escalating situations, with an investigation of both theoretical and practical implications. From the platform of an explorative approach, this study makes use of naturalistic research in the domain of health care and experimental simulation studies, in order to establish a broad theoretical framework vis-à-vis the processes of escalation. Rather than treating notions of crisis as processes taking place outside the organisation, the thesis outlines a view of escalation as an inherent part of organisational reproduction and structure, rooted in historical relations of power and professional identities. The thesis goes on to look at pragmatic implications in areas such as the establishment of efficient coordination structures in escalating situations, and team performance assessment

Implementation, context and complexity

Background - Context is a problem in research on health behaviour change, knowledge translation, practice implementation and health improvement. This is because many intervention and evaluation designs seek to eliminate contextual confounders, when these represent the normal conditions into which interventions must be integrated if they are to be workable in practice. Discussion - We present an ecological model of the ways that participants in implementation and health improvement processes interact with contexts. The paper addresses the problem of context as it affects processes of implementation, scaling up and diffusion of interventions. We extend our earlier work to develop Normalisation Process Theory and show how these processes involve interactions between mechanisms of resource mobilisation, collective action and negotiations with context. These mechanisms are adaptive. They contribute to self-organisation in complex adaptive systems. Conclusion - Implementation includes the translational efforts that take healthcare interventions beyond the closed systems of evaluation studies into the open systems of ‘real world’ contexts. The outcome of these processes depends on interactions and negotiations between their participants and contexts. In these negotiations, the plasticity of intervention components, the degree of participants’ discretion over resource mobilisation and actors’ contributions, and the elasticity of contexts, all play important parts. Understanding these processes in terms of feedback loops, adaptive mechanisms and the practical compromises that stem from them enables us to see the mechanisms specified by NPT as core elements of self-organisation in complex systems

Moving on after critical incidents in health care. Second victims: A qualitative study of the experiences of nurses and midwives

Aims: The aims of this study were to gain a deeper understanding of the experiences of nurses and midwives who have been involved in a critical incident in a non-critical care area and to explore how they have ‘moved-on’ from the event. Background: It is irrefutable that health care is intrinsically risk-laden and perceived to be personally and professionally demanding for those who are employed within it. The term ‘second victim’ has been assigned to health care professionals who experienced emotional distress as a result of their involvement in critical incidents. Despite the recognition that critical incidents contribute to workrelated stress, strategies employed by nurses and midwives to move-on from their often traumatic experiences of these events in non-critical care settings were not widely reported. Research design: An interpretive descriptive design based on the scientific worldview of constructivism guided inductive inquiry to interpret the meaning of moving-on central to nurses and midwives who have lived through the impact of critical incidents. Methods: Purposive sampling was used to recruit 10 nurses and midwives to participate in the study. Data collection comprised of semi-structured interviews, memos and field notes. Data was concurrently collected and analysed with the data management software NVivo 11, to derive themes and patterns, which enabled the researcher and the study-participants to co-construct knowledge. A thematic analytical method stipulated a coherent analytical framework to evolve the emerging themes and transform the data into credible interpretive description findings. Findings: The findings revealed five main themes (1) initial emotional and physical response, (2) the aftermath, (3) long-lasting repercussions, (4) workplace support and (5) moving-on. Nurses and midwives experienced intense initial reactions and tumultuous emotions in the aftermath of the event and desired to share their burden. Various unsupportive workplace practices convoluted the reclamation of their professional competence, whilst adaptive strategies to promote physical and mental well-being enabled the participants to rise above the impact of critical incidents. Discussion: This study highlighted several issues fundamental to withstand and overcome the personally damaging and professionally destructive challenges associated with critical incidents. The discussion of findings revealed new insights into the significance of support and a generally optimistic outlook derived from a well-adjusted work-life balance. Future research is required to explore the perceived effectiveness of workplace practices, as well as the role of education. Relevance: This study presented an opportunity to shed light on the perceptions of ‘nurse and midwife-second victims’ within a range of non-critical care settings. Through their lens, the strategies they engaged in to move-on from the event were identified and their call for organisational and collegial support received a voice. Conclusion: This study explored how nurses and midwives moved-on following critical incidents in various clinical areas. The identification of adaptive strategies contributed to the existing body of knowledge surrounding this phenomenon. Findings have the potential to inform health care organisations with the aim to support others who experienced critical incidents in health care, as well as guide nursing and midwifery education programs to raise awareness of the potential effects associated with the impact of critical incidents

Beyond adoption: A new framework for theorising and evaluating Non-adoption, Abandonment and challenges to Scale-up, Spread and Sustainability (NASSS) of health and care technologies

© 2017 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.Background: Many promising technological innovations in health and social care are characterized by nonadoption or abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the organization or system level. Objective: Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program. Methods: The study had 2 parallel components: (1) secondary research (hermeneutic systematic review) to identify key domains, and (2) empirical case studies of technology implementation to explore, test, and refine these domains. We studied 6 technology-supported programs—video outpatient consultations, global positioning system tracking for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organizing software, and integrated case management via data sharing—using longitudinal ethnography and action research for up to 3 years across more than 20 organizations. Data were collected at micro level (individual technology users), meso level (organizational processes and systems), and macro level (national policy and wider context). Analysis and synthesis was aided by sociotechnically informed theories of individual, organizational, and system change. The draft framework was shared with colleagues who were introducing or evaluating other technology-supported health or care programs and refined in response to feedback. Results: The literature review identified 28 previous technology implementation frameworks, of which 14 had taken a dynamic systems approach (including 2 integrative reviews of previous work). Our empirical dataset consisted of over 400 hours of ethnographic observation, 165 semistructured interviews, and 200 documents. The final nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework included questions in 7 domains: the condition or illness, the technology, the value proposition, the adopter system (comprising professional staff, patient, and lay caregivers), the organization(s), the wider (institutional and societal) context, and the interaction and mutual adaptation between all these domains over time. Our empirical case studies raised a variety of challenges across all 7 domains, each classified as simple (straightforward, predictable, few components), complicated (multiple interacting components or issues), or complex (dynamic, unpredictable, not easily disaggregated into constituent components). Programs characterized by complicatedness proved difficult but not impossible to implement. Those characterized by complexity in multiple NASSS domains rarely, if ever, became mainstreamed. The framework showed promise when applied (both prospectively and retrospectively) to other programs.Peer reviewe

Contextual intelligence and chief executive strategic decision making in the NHS

CEO competence and development is a continuing concern in the NHS. As a key feature of any CEO leadership role is responsibility for organisationally critical decisions, and there is an increasing recognition of the role context plays in effective leadership behaviour. This study examines the role of contextual intelligence in relation to PCT CEO decision making behaviour. To do this, the research addresses four questions: a) what does the literature say about CEO contextual intelligence? b) what factors do PCT CEOs say they take into account in different decision making contexts? c) what contextual factors do they actually take into account? and d) what impact do the contextual factors have on their decision making behaviour. A systematic literature review resulted in a model of CEO contextual intelligence for CEO decision making. Semi-structured interviews with 24 PCT CEOs in a NHS region about factors influencing their decisions on generic strategies, national policies, regional strategies and local plans revealed a hierarchy among contextual factors applying to different decision strata. Semi-structured interviews and analysis of CEO diaries two months later of the same focal decisions show the real critical factors to be:- national policies themselves, the Strategic Health Authority and the decision making process, for regional strategies; and Top Management Team and structure for local plans. Altogether, the research reveals that the PCT CEO’s decision making context is rationally bounded; the relevant contextual factors differed significantly from the literature derived model; the actual factors in practice differed from what were espoused; choice of factors vary depending on decision trigger strata which links to degrees of CEO autonomy; and macro level factors which were indicated as significant from the systematic review were in fact ignored in practice. A PCT CEO model of contextual intelligence is developed together with a two dimensional model of underlying structures guiding PCT CEO decision making behaviour. The findings have implications for governance structures in the NHS, CEO decision making and senior leader development in ii the NHS in the context of the 2012 Health and Social Care Act. Areas for further research in public sector, NHS and contextual intelligence are also identified