This study was prompted by the reflective essays submitted by paramedics in which they recounted traumatic experiences from work which seemed unprocessed. I subsequently became interested in how paramedics maintained their resilience and ‘survived’ their work as measured by for example, job satisfaction, morale, attrition and mental and physical well-being. A qualitative research design was adopted which used a psycho-social interview technique called ‘free association narrative interviewing’ (FANI) as the means of data collection. Data collection included a one hour biographical interview initially and a second follow up 45 minute semi structured interview with seven participants recruited from a trust in England. In all instances data was collected at the university or participant’s home and interviews were digitally recorded. The interviews were transcribed and analysed thematically. The study was approved by UWE and NHS ethics committees. The analysis explored the key findings within the context of contemporary resilience theory drawing on psychological, sociological and psycho-social literature. However the main focus of the work was from a psycho-social perspective which is psycho-dynamically informed and uses psychoanalytic concepts and principles to explore core issues. The themes captured respondents’ motivations to become a paramedic, which embraced notions of gender differences and the ‘wounded healer’. The hidden toll of the work in relation to health, and the impact of recent performance targets and changes to skill mix which appeared to threaten traditional protective methods of support, emerged as other themes. Support from within the organisation was explored, focusing on the role of management, debriefing, peer support, humour, time out and the culture of shame and denial within the organisation. Outside support explored the role of friends, family and referral to outside agencies. In dealing with unprocessed encounters, paramedics appeared to use other strategies including emotional detachment, dissociation, displays of anger and inappropriate professional behaviour. Despite limitations to the study, the findings unveil a unique account of how paramedics survive and become resilient.

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Aims: This study explored why patients seek unplanned follow up after treatment in an emergency department, if participants could identify the healthcare professional they were treated by, and whether the patient’s perception of, and confidence in, the healthcare professional had an impact on their subsequent decision to seek follow up. Methods: A mixed method pragmatic approach was used in order to quantify and explore the aims of the study. Participants were followed up two weeks later by telephone and finally invited to take part in a focus group to explore their experience and perceptions of their visit to the emergency department. Results: 18% of patients sought unplanned follow up in the 2 weeks following their initial visit, with no statistically significant difference between healthcare professional groups. 19% of patients incorrectly identified the healthcare professional treating them, with evidence of a gender bias. Discussion: The qualitative elements of the study explored the quantitative results. Participants were more likely to believe the healthcare professional was a doctor if they were male and had effective communication skills. A number of practical issues were identified in reducing unplanned follow up rates. The most common were issuing fitness to work certificates, explaining the trajectory of an illness or injury and addressing specific pain management issues. A change in policy would be required for non –medical health care professionals to be able to issue fitness to work certificates but in this study it was found to be the single most effective strategy to reduce reconsultantion rates. Conclusion: Patients seek unplanned follow up for a variety of reasons. This study shows that non-medical HCPs do not have a higher planned or unplanned follow-up rate, and they may have some advantages over junior medical staff in terms of effective consultation skills, high patient satisfaction and reduced reconsultation rates.

Overcrowding in Emergency Departments (ED) results in increased Lengths of Stay (LOS) and longer Waiting Times (WTs) for patients. These are ever-growing concerns in all hospitals around the world. Published literature shows many causes of this problem. This study, explores and identifies that one of the prominent causes can be attributed to human behaviour within EDs. It appears that patient behaviour has not been included in previous work as a cause of overcrowding. This thesis aims to present a method referred to as Discrete Event Simulation (DES) in an effort to explore and understand the effects of patient behaviour in the overcrowded ED of Tripoli Medical Centre (TMC). Firstly, a descriptive study was adopted, which collected data from different hospital sources, i.e. ED reports, ED's services time, staff and managers‘ opinions, and the observations of patients attending the ED of TMC. This identified the most significant behaviours impacting LOS and WT. Secondly, four different DES models were developed and analysed. Ultimately a hybrid model comprising of DES logic and Bayesian Network (BN) modelling was developed to capture and analyse a more accurate occurrence of human behaviour. Analysis of the hospital data reveals four behavioural factors are responsible for increasing WTs and LOS, leading to disruptions in patient flow. These factors include confrontation, challenges, passivity and illness belief. These behaviours are often appearing amongst the minor and non-urgent patients, who represent approximately 75% of all ED patients. The examination area within ED was found to be the place most commonly impacted by difficult behaviours, which is shown by the prolonged WTs in this area. A new strategy termed as Patient Behavioural Control (PBC) has been devised, developed and modelled. The PBC strategy aims to detect patient behavioural problems early and implements a revised patient flow procedure that results in overall reductions in LOS and WTs. This thesis contributes to the knowledge in this arena through consideration being directed towards patient behaviours from an operational perspective, utilising DES models in an effort to establish cause and effects, thus helping to devise a new approach in the healthcare sector. This new approach is not restricted in terms of application in only the healthcare arena, but can be adopted across other sectors for the management of human behaviours.

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This thesis looks to use a variety of statistical methods to investigate the performance of hospitals for patients who receive trauma care. Our main motivation comes from data provided by the Trauma Audit Research Network (TARN). Trauma centre performance as measured by the Ws score of Hollis et al. (1995) was formulated from the TRISS (Trauma Injury Severity Score) methodology and is part of an ongoing study to improve trauma care across the UK. However, ring institutional performance and ranking hospitals is a difficult process, particularly in the presence of missing data and for hospitals with few trauma patient records. There are also many political issues arising when using ranking and compiling league tables, see Goldstein and Spiegelhalter (1996). One way to ensure that our assessment of institutional performance is as precise as possible is to make sure that we have quality data, i.e. complete and that our predictions are accurate.

This research develops a comprehensive model for evaluating the efficiency and productivity of the sector of head trauma injury (HTI) care in England and Wales, in order to reduce the costs associated with trauma care. After assessing the advantages and disadvantages of various efficiency measurement approaches, the data envelopment analysis (DEA) methodology is chosen for this research, including both the DEA-based Malmquist index model and the bootstrapping DEA model. Since the variables selected for these models include some missing data, the approach known as multiple imputation by chained equations (MICE) is proposed to deal with such missing data situations, in order to ensure the accuracy of the inferential and predictive results that our analyses generate. In addition, an experimental study is provided to simulate this approach, in order to investigate its validity as a methodology for replacing such missing values within DEA applications. This experimental study is based on a real data set of 66 hospitals provided by the Trauma Audit and Research Network (TARN), within Salford Royal NHS Foundation Trust. The results of this experimental study show that MICE works well and gives an acceptable estimate of true efficiency. Furthermore, this research introduces a framework that combines DEA with structural equation modelling (SEM) in order to investigate the effects of uncontrollable variables on efficiencies. While the use of DEA provides valuable results, our SEM analysis reveals additional findings that were not identified in previous studies. For example, unlike previous second stage analysis studies in DEA that focused on only the direct effects of environmental factors on the efficiency scores, this study uses SEM to investigate further any indirect effects and the total effects of these uncontrollable factors on the efficiencies. This additional information is shown to be more useful and more informative than the results generated by the previous studies. The methodologies proposed and developed in this thesis are then applied to the full set of available TARN data in order to measure the efficiency and productivity of HTI care, demonstrating real possibilities for reducing the costs of head trauma care.

In recent years safety in medicine has been high on the agenda, both for government and for healthcare providers. This thesis starts by describing the evolution of patient safety and then goes on to explore error specifically in the Emergency Department (ED). Focus is drawn to the role of non-technical skills for improving safety. The initial broad aim of this research was to learn how the ED team could function better to improve patient care. An interview study is developed to investigate how ED staff change their behaviour during periods of high demand and to determine the direction of future research. This study highlights that staff would benefit from increased awareness of the nontechnical skills that contribute to effective teamwork and enhanced patient safety. The interviews also reveal the leadership role of the registrar is of particular importance. Therefore, a series of studies are developed to identify and describe the non-technical skills required by Emergency Medicine trainees, with a specific focus on leadership. The process of developing a provisional assessment tool for assessing non-technical skills in the ED is described. This draws on published literature and curricula as well as considering existing methods of assessment. The assessment tool is revised using re-analysis of staff interviews and a series of preliminary observations in the ED. Content validity of the tool is measured using a survey of expert opinion and this helps to further refine the tool components. An experimental study reveals that whilst adequate levels of inter-rater reliability are achievable, rater accuracy appears to be more problematic. Various sources or rater error are also explored and this leads onto a larger, multicentre observational study investigating use of the tool in the workplace. Further data for reliability is collected and field notes are analysed to provide a detailed description of the non-technical skills displayed by ED registrars. Findings of the studies are summarised and limitations, applications and further research are discussed.