Background: CATs is a hospital admission triage tool for influenza and pneumonia, and comprises of 7 criteria (6 objective and 1 subjective); any one of which is expected to trigger hospital admission in adults and children. As the CATs was only recently developed, its performance has only been assessed in the United Kingdom using data from the 2009 A (H1N1) flu pandemic. An external validation study is thus required to assess the generalisability of the CATs in a new patient population before it is recommended for adoption in practice. Aim: The primary aim of this thesis was to prospectively evaluate the predictive performance of the Community Assessment Tools across a range of acute lower respiratory tract infections in a new geographical setting. Five studies were included in this thesis, each addressing a specific objective in order to achieve the primary aim of this research: • The first study examined the predictive performance of individual CATs criteria with regard to the need for hospital based care and mortality, • The second study examined the performance of CATs as unweighted and weighted scoring indexes for assessing these outcomes in adults and children with ALRTI, • The third study compared the performance of the unweighted CATs scoring index and the well-established pneumonia severity score –CRB65 in two separate sensitivity analyses involving cases of suspected ALRTI and pneumonia in adults. • The fourth study sought to investigate the value of clinical intuition in medical decision-making by comparing the performance of the CATs as an unweighted scoring index with or without the inclusion of its subjective criterion (causing other clinical concern). • The fifth study was a qualitative exploration of critical care practices in Nigerian hospitals, conducted to provide contextual interpretation of findings related to the performance of the CATs in predicting the need for critical care and mechanical ventilation. Methods: Data specific to the CATs and CRB65 were recorded at the initial consultation of patients with symptoms suggestive of an acute lower respiratory tract infection. The performance of the tools with regard to predicting the need for hospital admission , acute care interventions (supplemental oxygen, IV antibiotics and IV fluids), or any deaths on admission were assessed using specificity, sensitivity, negative and positive predictive values, Area under Receiver Operating Characteristic Curves (AUROC) with 95% confidence intervals and Hosmer-Lemeshow goodness-of-fit test. The qualitative study was conducted within a pragmatic paradigm and a semi-structured guide was used to for individual interviews with key hospital staff. Thematic analysis was used for analysing interview data. Results: Data were obtained for 1016 (809 children < 16years) consecutive patients from four hospitals in Lagos Nigeria. In the univariate analysis each CATs criterion significantly predicted an outcome which indicated the need for hospital care or mortality, also none of these criteria were redundant in the multivariable analysis. Criterion C representing low oxygen saturation levels of 92% or less and Criterion G –clinicians’ intuition or gut feelings ,were the best predictors of the need for hospital based care and risk of death in both children and adults. The predictive accuracy of the individual criteria was generally low in terms of AUROC values, but this improved when they were combined to create scoring indexes. An unweighted CATs threshold score of three points or more was appropriate for identifying both adults and children who would potentially benefit from hospital based care and therapeutic interventions. In the comparison between CRB65 and the unweighted CATs score, the latter was seen to have better discrimination and calibration qualities for predicting all outcomes in adults with ALRTI, and although both the unweighted CATs and CRB65 scores demonstrated good predictive ability for the outcome ‘in-hospital mortality’ in adults with pneumonia, the unweighted CATs score outperformed the CRB65 in terms of AUROC values, however, the difference was marginal and statistically insignificant. This thesis provided evidence to support considering clinical intuition or gut feelings in the assessment of patients with ALRTI, as the predictive performance of the unweighted CATs score was significantly better with the inclusion of subjective criterion G (causing other clinical concern) than when this criterion was omitted. Due to insufficient data it was not possible to assess the performance of the CATs in regard to the outcome ‘need for critical care’. Findings from the qualitative study revealed that ALRTI was not a common indication for ICU admission in these hospitals, also that clinical predictions tools were not generally used in this regard, rather decisions regarding ICU admissions were determined by the ability to pay and bed availability. Conclusion: the CATs criteria showed geographical generalisability despite differences in case-mix and geographical variations. When combined to create an unweighted scoring system, CATs showed good potential for guiding decisions to admit adults and children with ALRTI to hospital for further care. Although CATs was developed for use during an influenza pandemic, the unweighted CATs score could be a useful tool for guiding admission decisions in adults with interpandemic pneumonia, as it performed reasonably well when compared with a widely validated and established pneumonia severity score.

The incidence of Heath Care Associated Infection is a major patient safety concern in the United Kingdom and reducing the morbidity and mortality associated with this has become a National Health Service priority. It is generally accepted that this objective will require a multi-factorial approach where infection prevention and control is seen as everybody’s business. However, some strategies receive greater exposure than others and hand hygiene is widely touted as a common sense solution to a complex problem. This discourse based study combined the techniques of Corpus Linguistics with Critical Discourse Analysis to explore the Textual, Discursive and Sociocultural features of hand hygiene discourse. This took place across three language domains, the Academy, the Newspaper Media and Organisational Policy Makers. These three cultural elites take a consistent account of the problem and the solution. Broadly hand hygiene is portrayed as effective, compliance is basic, performance is poor and Health Care Workers should be held to account through zero tolerance policies and if necessary disciplinary action. However, not only does this background the messy, contextual factors of implementing a hand hygiene policy it imposes a one size fits all approach and measurement programme on compliance that hides the true nature of performance and this ultimately impacts on patient care. This study calls for junior clinicians for whom policy has the greatest impact to become more engaged in the policy making process. In a spirit of openness trusts should adopt linguistic devices that recognise the dynamic nature of practice and a more educational, sophisticated approach to audit.

In the UK the National Health Service (NHS) faces the challenge of securing £20 billion in savings by 2014. Improving healthcare productivity is identified by the state as essential to this endeavour, and critical to the long-term future of the NHS. However, healthcare productivity remains a contentious issue, with some criticizing the level of professional engagement. This thesis explores how contemporary UK policy discourse constructs rights and responsibilities of healthcare professionals (HCPs) in terms of productive healthcare, how this is made manifest in practice, and the implications for professional autonomy/identity. Using analytical lenses from the sociology of professions, identity formation and the Foucauldian concept of governmentality, it is proposed that policy discourse calls for a new flavour of professionalism, one that recognises improving healthcare productivity as an individualised professional duty, not just for an elite cadre but for all healthcare professionals. Adopting an ethnographic approach (participant observation, semi-structured interviews, focus group and document analysis), data is presented from a large UK Emergency Department (ED), exploring the extent to which this notion of self-governance is evident. The study elucidates the ways in which: professional notions of productivity are constructed; productive work is enacted within the confines of the organisational setting; and tensions between modes of governance are negotiated. The findings of this study suggest that HCPs perform identity work via their construction of a multidimensional notion of healthcare productivity that incorporates both occupational and organisational values. Whilst responsibility for productivity is accepted as a ‘new’ professional duty, certain ethical tensions are seen to arise once the lived reality of ‘productive’ work is explored within the organisational field. The complex interplay of identity work and identity regulation, influenced by the co-existence of two differing modes of governance, results in a professional identity which cannot be represented by a static occupational/organisational hybrid, but rather one that is characterised by continual change and reconstitution. Understanding healthcare productivity from this perspective has implications for professional education, patient care, service improvement design and the academic field of the sociology of professions.

Studies were conducted in Nottingham, UK to assess quality of discharge summary communication sent from secondary to primary care using updated processing methods. Objectives (1) Assess available evidence on effectiveness of interventions aiming to improve discharge information communication specifically introducing computerised discharge summaries (2) Assess differences in discharge summary quality using new processing methods (3) Obtain perspectives of secondary care on discharge communication issues, identifying points of weakness and primary care views on discharge information communicated from hospital. Methods (1) Systematic review of literature on effectiveness of interventions aiming to improve discharge summary information communication (2) Before and after studies of two different discharge summary types in three departments within Nottingham University Hospitals NHS Trust (3) Qualitative interviews with key stakeholders (N=27) and observations in 3 sites. Results The systematic review returned 21 interventions with emphasis on the introduction of computerised systems to improve quality (timeliness and completeness of discharge summaries). Nine studies significantly improved the completeness of the discharge summary. Ten studies significantly increased the timeliness of the generation of the document and the transfer of information. The three before and after studies produced varying results; the HCOP findings suggested improvements post-intervention in completeness of summaries; this was not statistically significant. In Nephrology, computerisation significantly speeded up the timeliness of discharge summaries but there was no significant difference in completeness between the two types. In Paediatrics, computerisation increased the number of summaries not completed, and the handwritten summary was significantly faster. Computerised discharge summaries contained more information- this was statistically significant. The qualitative study identified issues with understanding the concept of discharge, the purpose and importance of the discharge summary, and organisational issues around the ability to balance the demands for completeness and timeliness, a lack of leadership and user-centred design of the electronic discharge system. Conclusions The literature reviewed found examples of the potential computerisation has on discharge documentation quality. The research studies conducted showed that the introduction of computerisation into the discharge documentation process produced mixed results in quality (completeness and timeliness) of discharge summaries communicated from secondary to primary care. Slight improvements were found in the before and after studies and staff feedback was positive. The success of such interventions depends largely on increased clinical leadership and user-centred design. An established link to patient safety is needed to increase awareness of the importance of discharge summary communication and justify major system change.

Introduction Studies have shown that a proportion of patients admitted to hospital do not require the intensity of services they provide. Also, the admission of patients can be for an inappropriate duration. Methods Three studies were conducted. The first study was a record review to determine the appropriateness of patient admissions and inpatient stays. The second examined the wider causes of inappropriate admissions/inpatient stays as perceived by clinicians, and identified interventions to reduce such admissions/stays. Data were collected using focus groups. The final study explored barriers to service use from the perspectives of clinicians and patients. Data were collected from clinicians via an online questionnaire and from both clinicians and patients using semi structured in-depth interviews. Results Of 119 patients, 32 were admitted inappropriately and 83 were admitted for an inappropriate duration. Risk factors for an inappropriate admission included living in the community compared to a nursing/residential home, and for an inappropriate length of stay included the number of presenting complaints, number of long term neurological conditions and whether the participant lived alone in their own home or with others. In the second study, the limited knowledge and a lack of health and social care resources in the community, were perceived as causes of inappropriate admission/lengths of stay. Interventions to prevent inappropriate admissions/lengths of stay included: sub-acute care facilities and patient held summaries of specialist consultations, among others. The final study found that the main barriers to use of services were out of hour's access and unfamiliarity of clinicians with local service provision. Conclusions The causes of inappropriate admissions/lengths of stay related, in main, to communication problems and accessibility of services. Interventions to improve transference of information and knowledge regarding long term condition management and service provision may be warranted.

This study explores women's experiences of critical illness in Jordanian intensive care units. A narrative approach was employed to access Jordanian women's stories of their critical illness and to study how these accounts changed during the period following their discharge from intensive care. The study was conducted in two hospitals in a major Jordanian city. A purposive sample of 16 women who had spent at least 48 hours in intensive care was recruited over a period of six months, with each woman taking part in between one and three interviews during the six month period. Two focus group discussions were also conducted with 13 ICU nurses drawn from the hospitals in which the women had been patients. These had the aim of encouraging discussion about the development of new supportive care strategies for critically ill women in Jordanian intensive care units. The study findings revealed three main areas: the women's experiences of suffering and pain; their experience of body care; and the impact of the ICU experiences on their lives after discharge home. Experiences of suffering were pervaded with physical, emotional, social and temporal dimensions, interlinked with pain that was often severe, overwhelming, and disturbing to their sleep. The notion of 'nafsi' suffering was employed to describe emotional and social losses, such as loss of family support, which the women experienced. The notion of 'vicarious death' was used to explain the mortal fear women experienced in witnessing the death of others. Loss of body control, the unfamiliar ICU environment, and the sudden onset of illness made it difficult for the women to make sense of their experiences. This study shows that cultural norms and religious beliefs shape the ways in which these Muslim women made sense of their bodies. An analysis of the concept of 'bodywork' is presented: the 'dependent body' captures the women's experiences of changes of their physical status, which meant that from being care providers, they became those in need of care. This involved the experience of a sense of paralysis or disablement, and a complete dependence on their family or nurses. The 'social body' describes the women's feelings and emotions toward their family members. The latter assisted in the care of the women's bodies, but distress, frustration and a sense of loneliness were experienced by the women as a result of the loss of verbal communication with their relatives. The 'cultural body' describes the effect of cultural norms and Islamic religious beliefs on the women's interpretation of their experiences, and the interpretation of male nursing care in the ICU. The 'mechanical body' describes the women's experiences of the ICU machines as extensions of their bodies, and the senses of limbo and ambiguity they encountered during their ICU stay. The recovery period raised many physical, emotional, social, and spiritual issues, which in turn impacted on the women's experiences of their everyday lives. Weakness and tiredness accompanied with difficulties in eating and sleeping made some women feel frustrated and uncertain about their health. Some felt they were a burden upon their families. The meaning of the critical illness experiences were interpreted by some women as an opportunity to value family unity and neighbours' support. For other women, the illness experiences gave them lessons which strengthened their role as mothers and helped them to think positively about their future. This study highlights the importance of considering the cultural and religious preferences among Muslim women in critical care settings. The study recommendations focus on the need to base nursing care on an understanding of the physical, emotional, social, and religious elements of suffering, by exploring the potential of a palliative care approach for nursing critically ill people.

The impact of line manager (supervisor) behaviour on employee well-being, work attitudes, performance and perceptions of organizational culture are assessed using a sample of specialist unit (S-Unit) ambulance personnel. Underpinning line manager behaviour was a 10 item, two-factor structure: supportive (six items) and unsupportive (four items) manager behaviour (see chapter 3). Analysis of manager behaviour on outcome variables was performed using cross-sectional (n = 473) and longitudinal, matched-cases, analysis (n = 242). Cross-sectional analysis (see chapter 5) revealed that supportive manager behaviour was significantly related to increased proximal and distal collective capability, individual capability (efficacy; see chapter 4), work engagement, attitudes towards patient care, organizational commitment, perceived organizational support and job satisfaction; and negatively related to symptoms of ill-health, burnout and intentions to quit. Unsupportive manager behaviour was observed to be significantly related to increased symptoms of ill-health and burnout. It was also found to be marginally related to symptoms of post-traumatic stress disorder. Longitudinal analysis (see chapter 6) revealed that supportive manger behaviour was linked to greater proximal collective capability and reduced intentions to quit. Unsupportive manager behaviour was found to be significantly related to increased reporting of symptoms of post-traumatic stress disorder and ill-health. Reverse causality testing was employed on the longitudinal data and results showed that symptoms of ill-health may influence perceptions of unsupportive manager behaviour. The factor structure of manager behaviour is discussed and relationships (significant and non significant) are assessed against other research.