This thesis begins with a review of the conflict literature. It continues with an illustration of the nature of intergroup conflict between British health care teams, by presenting results from an interview study using the critical incident technique. Within the theory testing part, drawing upon a sample of 53 British health care teams from five organisations, an empirical test of both intergroup contact and social identity theory is provided. In a next step, a measure of intergroup effectiveness, the effectiveness with which dyads of groups perform on collaborative tasks, is developed. Finally, the moderating role of both resource interdependence and group boundary spanners’ negotiation style for the relationship between intergroup competition and longitudinal change in group and intergroup effectiveness is examined.

Countries in Sub-Saharan Africa share at least three things: cultural heritage, a high burden of disease and a low financial commitment to health care. This thesis asks questions of justice about health care systems in Sub-Saharan Africa, in particular Nigeria. The questions are about access to the available health resources and services within African health care systems. While the sub-region as a whole cannot boast of good health care, certain population groups are relatively more disadvantaged. This suggests either or both of two problems: a) that access to basic health care is not proportionate to the populations’ needs; and/or b) that the distribution of the available health care resources favour some over others. Attempts to improve population health have focused on empirical, economic or social strategies. These tend to overlook the ethical dynamics surrounding access to and the distribution of health care. In view of this moral challenge, Norman Daniels has proposed the ethical framework of Accountability for Reasonableness, which can provide basic guidelines for just health care reforms in Africa. While his approach has been effective in the United States, the theoretical basis has fundamental value differentials from African ideals of justice. Starting from Daniels’ Just Health – Meeting Health Needs Fairly, this PhD study develops an African ethical framework that could inform reforms in African health care systems. Specifically, it establishes four key attributes of the African moral outlook, and three principles of African justice. It further abstracts an African method of ethical analysis: process equilibrium. Against this background, the thesis develops a harmonised framework of just health care. Daniels’ principles are matched with African principles to create a Just Health Theory, which is adapted to the Sub-Saharan Africa context. The resulting African principles are mapped onto the health care sector and finally blended into the Harmonised Framework of Just Health Care. By combining the insights from Daniels with African values and approaches, it is possible that just health care will be attained in Nigeria and beyond.

Innovation and entrepreneurship are dynamic and holistic processes that are not restricted to the initial activity of a new undertaking. Many studies link and draw parallels between, not only corporate entrepreneurship and innovation but also innovation and the ability to enhance an organisation’s competitive positioning and to provide outstanding value to its customers. However, a lack of research has been identified regarding the synergy between innovation and entrepreneurship, noting that the synergy between the two concepts helps organisations to prosper. Likewise, continuous service innovation has been described by many authors as the most valuable means for companies to achieve long-term success and organic growth. It is also suggested that for service firms to achieve even greater success, a customer-orientation perspective should be adopted. Although many studies concerning the service sectors and in particular service innovation have been carried out, they have rarely been conducted in the context of healthcare, and in particular, that of mental healthcare. Also, few studies have focused on the interaction and involvement of patients in the development of new health services. The study contributes to the related literature by providing conceptually developed and exploratory-based research, examining the Greek mental healthcare sector. The study contributes in two significant ways: It develops (1) a useful conceptual framework, which introduces a new perspective to the literature of both innovation and entrepreneurship, and (2) the new business model, which presents the means by which patients contribute to opportunities identification, illustrating their participation in the development process. More specifically, this study investigates the influence of user involvement on new health service development and presents the means by which the outcome can enhance a hospital’s entrepreneurial activity. On one hand, this study advances previous service innovation theory by associating with the entrepreneurship theory, while on the other, extends previous knowledge regarding the benefits of customer participation in new health service development.

Volume I contains a literature review, research paper and a public domain paper. The literature review examines literature on stress management interventions for professionals working in mental health and health care settings. The empirical paper investigates the relationship of self-efficacy and hardiness in trainee clinical psychologists and determines whether either concept mediates the relationship between stressors and well-being. It is intended that both pieces of work will be submitted to the British Journal of Clinical Psychology (see Appendix 2.9 for the instructions for authors). Finally, the public domain briefing paper details the empirical paper. Volume II includes five Clinical Practice Reports (CPR). CPR 1 is a case formulation about a 56 year old gentleman with symptoms of anxiety and depression. CPR 2 is a service evaluation regarding staff perspectives on referring clients with psychosis for psychological therapies. CPR 3 documents a single-case experimental design that assessed the effectiveness of an anxiety intervention with a fifteen year old boy with Chrone’s disease. CPR 4 reports a case study of a nineteen year old gentleman with a severe learning disability. An abstract outlining CPR 5, a clinical presentation about a fourteen year old girl with anorexia nervosa and depression, is also included. In order to ensure anonymity, names and identifying information have been omitted.

This portfolio thesis comprises of three parts: a systematic literature review, an empirical report and supporting appendices. Part one is a systematic literature review in which empirical papers investigating the effectiveness of interventions for cultivating self-compassion in healthcare professionals are reviewed. A systematic database search identified fifteen studies to be reviewed. A narrative synthesis of the findings pertaining to effectiveness is provided alongside a review of the methodological quality of the research in this area. The clinical implications for healthcare services and directions for future research are also discussed. Part two is an empirical paper combining qualitative and quantitative methodologies to explore compassion amongst healthcare professionals. The quantitative component sought to investigate whether the presence of occupational stressors and threats impacts on healthcare professionals’ ability to give compassion to others at work, and whether self-compassion and organisational compassion may moderate this relationship. In addition, thematic analysis was employed to investigate the most prominent troubles that healthcare professionals experience in relation to their work. The findings are discussed in relation to theory and implications for clinical practice and future research. Part three comprises the appendices supporting the systematic literature review and the empirical paper, but also includes a reflective statement focussing on the research process.

This thesis applies a conceptual framework to determine the key insights that complex adaptive system theories provide to the novel challenges facing the introduction of clinical governance in two English Primary Care Trusts (PCTs). It presents empirical research on governance through qualitative case studies of the implementation of clinical governance arrangements within two North West PCTs, during a time of flux and change. The study is located within the English National Health Service (NHS) between 1999 and 2005. The Department of Health (DH) describes clinical governance as an evolving organisational structure and process that: "Provides NHS service organisations and individual health professionals with a framework within which to build a single, coherent local programme for quality improvement." (Department of Health, 1998a p.33). The thesis reviews the literature on governance models, quality improvement frameworks and complexity-based approaches to establish an appropriate theoretical base to the study. The literature relates to the nature of PCTs as a networked structure with autonomous parts. This approach contextualises the origins of clinical governance and related quality concepts. The study encompasses the introduction of the most recent contractual arrangements for primary care in 2004 (NHS, 2004). The research question posed is: "How can governance of quality improvement programmes be managed in a way that is appropriate to the characteristics of English PCTs?" Detailed evidence demonstrates the nature of local clinical governance programmes and the implementation within two North West PCTs, from the perspective of those involved. The results of the analysis show that multiple perspectives were taken into account in the decisions made about the content and delivery of clinical governance programmes. It is suggested that the application of a complex adaptive system conceptual framework helped to provide insight and interpretation of the accounts of those involved in the two case studies. The variation in clinical governance approaches across the two PCTs is explained in part by the strategic and policy orientation of each PCT. The results are consistent with the argument that the characteristics of quality improvement programmes in two PCTs go beyond linear based concepts, and can be thought of as real-world exemplars of the emergent properties of complex adaptive systems. In practice, the lessons learned provide opportunities to inform future management approaches to quality improvement programmes in PCTs.

Background: The drive to incorporate best evidence into clinical practice is supported by health policy. The implementation of best evidence requires professionals to change their practice. It is clear that in a health system where resources are finite, change should be prioritised towards an area of high burden on the NHS and where chnage would make a difference to patients. Stroke fulfils this criteria as it is a major cause of mortality and morbidity and therefore a major health issue. Furthermore, studies have shown that storke care is poor and assessment is often incomplete. Change is a complex process requiring a multifaceted implementation strategy as this is more likely to change practice, although specific combinations still need to be evaluated. Aim: To evaluate the use of a combined strategy (an opinion-leader; guideline; a staff education programme; and a new recording system) for implementing multidisciplonary stroke assessment in an acute hospital setting. Methods: A quasi-experimental study design with a pre-test/post-test group which incorporated an evaluation research approach and elements of action research was implemented. Conducted in five inter-related phases over 38 months this encompassed development, implementation and evaluation of the intervention. In Phase 1 (6 months) a diagnostic analysis was conducted using a multi-method approach to identify barriers and faciliatators to change. Phase 2 (9 months) comprised the development of evidence-based guidelines for the multidisciplinary assessment of stroke patients followed by a comparison of current recording practice with these guidelines. This phase also incorporated the collection of patient outcome data (length of stay, hospital mortality and satisfaction). Phase 3 (9 months) comprised the development and implementation of evidence-based guidelines for stroke assessment. Phase 4 repeated the measures of phase 2. Phase 5 comprised a diagnostic evaluation of the change management process and the modelling of 'context-mechanism-outcome' (CMO) configurations to bring together the resiluts of the phases of the study. Results: The major findings were that the combined strategy had a variable impact on the practice of all the professions. The greatest impact was seen with the nursing profession. Pre-test compliance ranged between 0% and 95% (median 60%); post-test 39% and 72% (median 86%) demonstrating a 26% improvement in compliance. Fourteen of the 20 nursing profession specific guidelines reached statistical significance. Least compliance occurred in the medical profession whre compliance in the pre-test period ranged between 2% and 91% (median 45%); post-test 25% and 27% (median 27%). No measurable impact on patient satisfaction or patient outcomes was recorded. Conclusion: The use of the multifaceted strategy had a variable affect on professional compliance with guidelines. Changing professional practice is a complex process requiring leadership with an opinion-leader and professional staff. Furthermore, a strong commitment is needed from professional staff to enable barriers such as professional power to be addressed. A diagnostic analysis is a useful tool for supporting the implementation of organisational change.

This thesis offers an original contribution to knowledge through providing a rigorous longitudinal examination of a complex intervention known as the ‘Leadership in Compassionate Care Programme' (LCC) which was designed to embed compassionate care within local NHS practice in a large Health Board in Scotland. To date there has been little research into the impact of dedicated programmes aimed at enhancing compassionate care on an organisational basis. Through the use of Pawson and Tilley's (1997) realistic evaluation framework this study takes the form of a critical exploration of what did and did not support a sustained focus on compassionate care within the participating settings. The findings have important implications for both policy and practice, and the thesis culminates in a series of recommendations for healthcare organisations at macro, meso and micro levels. Concern about the delivery of compassionate care in the NHS has become a major focus of political, public and professional debate during the last ten years. There has been long standing recognition of the clinical and financial pressures within the NHS; however, the scandal of poor care in Mid Staffordshire NHS Trust brought the issue of compassionate nursing practice into sharp focus. This study makes reference to the findings of the original Francis Inquiry (2010) and subsequent recommendations (Francis 2013) and there is no doubt that the current and future landscape of compassionate care is very different to the one encountered at the outset of this inquiry in 2007. This longitudinal qualitative study provides insight into nurses' experiences as they engaged with the LCC Programme and it provides an important understanding of how best to recognise and support existing good practice and achieve sustainable improvements. Data collection was conducted over three years and primarily involved 46 semi-structured interviews with 33 key participants. This led to the development of eight detailed case studies of participating wards and the generation of an analytic framework based on ‘level of adoption' of the LCC Programme. The eventual synthesis of findings across all eight study sites permitted the development of a conceptual model for strengthening organisational capacity for the delivery of compassionate care. The ‘compassionate core' of this model recognises compassionate care as focussed on meeting the needs of patients, of relatives and of staff. My findings point to the fact that embedding and sustaining compassionate care demands a strategic vision and investment in a local infrastructure that supports relationship-centred care, practice development, and effective leadership at all levels.

This thesis is concerned with current debates as to the value of patient satisfaction research. The thesis reports two surveys by means of which the scope of patient satisfaction research is considered. Conceptual and methodological problems in this field of research and alternative theories of the social process whereby patients evaluate health care are reviewed. The two surveys are presented in terms of an introduction to the particular field of medicine involved, the methods of enquiry used, survey responses and discussion of results. The first survey is of patients attending outpatient neurological clinics presenting with headache. This study was conducted with intensive interviews, one before the neurological consultation and a second at home, one month later. The problems of making sense of patients' accounts in terms of 'expectations' and 'satisfaction' are outlined. Instead different perceptions of the value of clinic visits are related to four different concerns felt by patients in relation to their headaches, concerns for reassurance, explanation, prevention and symptomatic treatment. The second survey is of patient satisfaction with outpatient care in a department of genito-urinary medicine. This survey was conducted with two questionnaires: one completed whilst patients waited in the clinic for theirconsultation, and a second which was mailed to patients one month later. Survey results are used to examine an interactionist model of patient satisfaction developed by Ben Sira. The data is examined by various methods to suggest limitations of and modifications to the original model. Finally the thesis assesses the contribution of the two surveys to an understanding of how patients evaluate medical care. Alternative models of patient satisfaction are reexamined. It is argued that some perspectives have too restricted a view of patients' abilities. The implications of the two surveys are reviewed in terms of the different interests researchers may have in surveying patients' views.

This interpretive case study investigates the relationship between organisational culture, organisational learning and cultural change in the National Health Service (NHS). Starting from a social constructivist standpoint, it conceives of organisational culture as a dynamic entity, socially and discursively constructed through engagement with surroundings, in contrast to the managerial discourse evident in NHS policy and research literature. The conceptual framework informing the research is based on cultural historical activity theory and a three perspectives theory of organisational culture. This allows exploration of individual and collective learning within the context of organisational social and cultural practice, exploring the organisation at the macro level but also through the lived experiences of individuals. An interprofessional department in an NHS provider organisation was studied for four months as it went through a programme of service improvement. Data was collected and analysed iteratively through a combination of observation, interview, documentary reading and field notes. Analysis using an activity theoretical approach generated a „thick description‟ of the organisation. Organisational stories were analysed to explore meaning making. Findings suggest that organisational culture can be considered a shared epistemic object within fluid networks of activity. Individual and collective learning is linked through practice, mediated by external political motivations and internally generated contradictions. Understandings of professional power play a major part and can lead to unexpected directions of travel. Conceptually, the study shows activity theory to be a useful framework for analysing learning and cultural change in NHS organisations. It adds to the debate on the self and the role of power and contradiction in activity theory through the application of a three perspectives approach to culture. It can help guide practitioners and policy makers in the NHS by encouraging them to rethink their understandings of culture and how cultural change is achieved through mediated practice.