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In the 1950s the term community care was associated with the movement of people with mental health problems from longstay institutions into the community. More recently, however, the term has applied to services to a much wider range of groups including older people. The thesis is concerned with community care services for this group and in particular, domiciliary care. It seeks to evaluate claims made in the White Paper: 'Caring for People' that its preferred model of community care can provide both increased service effectiveness for consumers and cost control. The thesis argues that community care policy was shaped by 'managerialist' assumptions and that improved performance could be delivered by organisational change, in particular the quasi-market and the use of managerialist techniques. Thus, the two phenomena of 'managerialism' and 'quasi markets' are conjoined, the latter offering to the former the possibility of competition between providers, which in turn is seen to provide greater user choice and value for money. Two key reports from the Audit Commission are analysed as exemplars of managerialism and community care. The connection between the reports and government policy is discussed and the evidence presented in them for community care, as a cost containment policy, is scrutinised. The consumer effectiveness argument for community care is examined by considering, in particular, the relationship between consumer choice and the market model of community care advocated in the Griffiths report: 'Community Care: Agenda for Action' (1988) and the White Paper: Caring for People (1989). It is argued that both the government proposals and much of the critical academic commentary fail to examine various underlying premises, in particular, the salience of 'choice' as a universally desirable objective. The themes outlined above are explored in empirical work undertaken in the case study local authority. The consumer effectiveness issue is analysed with reference to a survey of users of domiciliary care services. The survey is used to examine how far the assumptions made by both government and many academic commentators, with regard to user satisfaction, correspond to those of users. The analysis questions these assumptions showing that 'consumerist' notions of choice of service are much less significant than personal aspects of the service such as 'caring manner' and continuity of relation with carer. Cost control issues are examined by considering an example of 'value for money' auditing in the authority. Analysis of this project suggests the difficulties which such exercises have in generating appropriate norms for service provision in domiciliary care. The thesis concludes by relating the themes explored to current problems in community care policy, in particular the increasing significance of rationing and eligibility criteria.

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The aim of this study is to identify the ways in which nurses can be effective in helping anxious patients to feel calmer or more secure. This subject is important to all nurses who work in close day-to-day contact with people under stress. The study uses the Inferential Model of Communication as its main theoretical foundation, emphasising the value of identifying the intentions of the communicator and the inferences made by the respondent. It establishes a Nursing definition of the verb "to reassure" as "an attempt by nurses to communicate with patients who are anxious, worried or distressed with the intention of inducing them to predict that they are safe or safer than they presently believe or fear". The literature review reveals few research-based studies which explicitly refer to "reassurance", but many experimental studies of interventions designed to calm anxious patients. The inferential model helps to highlight the theoretical inadequacies of interventions based on "information-giving", and demonstrates the importance of the distinction between prediction and control in aversive situations. Grounded Theory methods were used to collect and analyse a total of 351 Critical Incidents reported in writing by 202 nurses, and in tape-recorded interviews by a further fifty-one nurses and fifty-one patients. The incidents were drawn from the experience of nurses and patients in a wide variety of clinical settings, including general hospital, community, psychiatric and mental handicap settings. A set of descriptive categories was developed from this database to code all the incidents collected. The classification scheme was tested for inter-rater coding reliability, yielding agreement levels of ninety per cent or higher in most categories. The results show that the nurses used five helping strategies - prediction, support, patient control, distraction and direct action. Of these, only the first two are always forms of "reassurance" as defined above. It appears that rational choice of a helping strategy requires nurses to compare their views of the aversiveness of patients' situations with the views of the patients themselves. Out of this comparative assessment, the study suggests that it is possible to predict which helping strategies are most likely to be effective in inducing patients to feel calmer, and which ones may have undesirable side-effects. The study concludes by offering some suggestions for further research, arguing that the inferential model of communication has demonstrated its potential as a powerful tool for the analysis of nurse-patient communication.

The development of computer systems in UK hospitals has in recent years been focused on the provision of hospital-wide information systems, known as Hospital Information Support Systems (HISS). This development has been motivated by National Health Service reforms and a realisation that earlier fragmented systems were not meeting the requirements of clinical and nursing staff in the most effective way. Such systems were often developed by external, centralised agencies using systems analysis techniques appropriate to the development of information systems in product orientated organisations. However, the hospital ward, an environment existing at the 'sharp end' of health care, in which many diverse and non-computer related activities take place, presents the system designer with many of the classic problems with which the discipline of Human Computer Interaction (HCI) is concerned. Although a HISS has the potential to improve both the work conditions of clinical staff and the delivery of health care, this may be impeded by many of the common obstacles associated with the introduction of a large and complex computer system into a work environment where tasks are ill defined. This thesis reports on a project that is based upon the application of HCI methods to the health care environment and their contribution to the solution of the problems that such an environment presents. Requirements for the users' interface to the potential HISS are derived using a task analytic approach, involving Task Analysis for Knowledge Descriptions (TAKD). A prototype system has been designed and subsequently evaluated in a hospital ward. The contribution of TAKD to the design and its further applicability to the environment are assessed. The research represents an original application of a formal task analysis method to the design of ward based computer systems, and as such makes a valuable contribution to the areas of medical informatics and HCI. It shows that TAKD has real but limited applicability in this sphere, in that its use can lead to the design of more usable interfaces, while there is a need to combine it with methods aimed at broader systems design if these benefits are to accrue in the development of a HISS. The potential for the integration of task analysis with Design Rationale methods is also demonstrated.

As a discipline Management Information System (MIS) is relatively new. Its short history has been characterised with epistemological dialectism. The current conflict and debate about MIS inquiry is broadly between the advocates of the social systems and technical systems perspectives. Few authors have made positive contributions toward clarifying the meaning and nature of MIS, and the appropriate design framework for MIS development. This thesis adds to their effort by using a MIS designed and implemented through action research at the North Western Regional Health Authority. There are seven Chapters in this thesis. Chapters One and Two examine the nature of the problem addressed by this research; the project history, ontological assumptions and research strategy. Chapter Three examines the debate, nature and conflicting views about MIS. It defines the theoretical problem addressed by this thesis and proposes a new concept of MIS. The theoretical problems are dealt with in Chapter Four. In Chapter Five the application of the theoretical concepts developed in Chapter Four is demonstrated in the design of MIS. Chapter Six relates some of the findings of this thesis to the work of other authors. It also examines the problem of human inquiry and the suitability of action research for MIS research. The main findings of this research summarised in Chapter Seven provide a new perspective of MIS as a purposeful system; the taxonomy of purposeful systems; primary context and secondary context of MIS; context analysis and context evaluation of MIS.

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