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The literature is dominated by prescriptive accounts of the application of Continuous Quality Improvement and care pathways in the acute hospital services sector. The authors assume that the organisation is a designed artefact (Scapens, Otley and Lister, 1984): goals can be achieved. This thesisr eports on the nature, processa nd consequenceso f a Nurse Manager introducing care pathways in a Children's Hospital It believes, in opposition to the conventional view, that the organisation is a culture. The actions and interactions of individuals and groups shape initiatives. This is within context and within time. The research investigation was conducted over a twenty-five month period, from February 1996 to April 1998. It was ethnographic in nature. Interviews were conducted with managers, nurses and doctors, formal meetings and activity in the Children's Emergency Department observed, and documentation collected. The findings are, however, presented from the nurses' perspective using their words. Files for newspaper clippings were created and maintained. The thesis contributes to the literature in three ways. In the main, it represents the first contextual and critical account of the implementation of care pathways than that believed to be contained in the literature. Further, it purposefully utilises for the first time two conceptualf rameworks in order to explicate the changep rocessesin the Children's Hospital. These are Watson's (1994) Strategic Exchange Perspective and Dawson's (1994) Processual Framework. It presents the descriptive part of the findings in the form of a narrative. The Nurse Manager established a project to multiskill experienced nurses in the diagnosis and treatment of minor conditions using care pathways as the vehicle. Her role changed during the process of implementation, but the project had little, if no, impact on power structures between and decision making of doctors and nurses

No description available.

No description available.

This thesis is concerned with the issues of managerial effectiveness, organizational change and cultures in the National Health Service. Using the micropolitical and cultural perspectives it is concerned to offer an approach which builds on existing organization, management and change theory in order to further an understanding of these issues in relation to National Health Service organizations as well as other contexts. The focus of attention is on the relationship between structure and culture at both the official and unofficial levels of the organization. The three case studies of organizations undergoing organizational change have allowed the opportunity to understand the complexity of the relationship between the official and unofficial arrangements in the organization and the impact of this on managerial effectiveness and organizational change. The main finding of the thesis is that within organizations, structure and culture are inextricably bound and their consonance at both official and unofficial levels of the organization is a necessary condition for managerial effectiveness. The types of organizational culture developed during the investigation indicate how the plurality of interests, beliefs and cultures within an organization make it difficult to achieve this condition. Concerning National Health Service organizations, the researcher argues that the recommendations contained within the Griffiths Report (1983) have offered a model of management which is based on cultural assumptions which are different to those which have traditionally underpinned the managerial process in the NHS. Following this, the researcher demonstrates via the cases, that the introduction of these recommendations has served to offer greater scope for a diversity of managerial style and philosophy at Unit level. They have also served to raise conflict between cultures, in particular the medical and managerial, to the point that the conditions needed for achieving managerial effectiveness do not exist.

This qualitative study IS underpinned by interpretive-constructionist methodological governing principles, and took shape around a developing research focus and aim rather than in relation to pre-existing research questions. The focus of the research is on clinical supervision activity. This refers to formal and informal research encounters with participants and significant others in the organization in which the study was carried out, about: the experience of the practice of clinical supervision; attempts to translate textual prescription and description of clinical supervision into organizational reality; finally, the meaning endowment placed on both of the above by myself, my participants, and significant others associated with my research. In order to address an important gap in the literature, the aim of the research developed as the need to unpack and clarify the meaning, and the affective and organizational theoretical implications of clinical supervision activity. Part one of the ethnographic report is constructed around three overlapping categories: owning, resisting and feeling. These categories are developed around the proposition that the bureaucratic rationality inscribed within both the literature on clinical supervision, and in organizational attempts to implement it, fails to take account of both the emotional underlife of the organization and otherorganizational factors. Specifically, I argue that clinical supervision activity, and my inscription within it as 'insider' researcher', was influenced, shaped and constrained by the pre-existing interpersonal rules and norms of the organization in which my research was conducted. Those governed what could and could not be done or said in or about clinical supervision activity, arguably undermining organizational goals to implement it. Part two of the ethnography explores the maIn theoretical and conceptual implications an sIng from the preceding ethnographic construction, around structural organizational power and politics. This addresses a significant gap in the contemporary literature in clinical supervision in nursing and mental health nursing. I conclude with a critical auto-critique of the study itself, around a discussion of its strengths and limitations and possible future research directions

This study investigates the ways in which nurses socially construct their health value systems and the ways in which they interpret their nursing practices. On the basis of the contradictions uncovered by the research, a new approach to health education is suggested, structured around a Lived Experience Model of Health Education the core of which is an intensified reflective practice. The model seeks to build the capacity for critical practice, closely integrating theory and practice, into nurses' modes of constructing a lay ideology based on their clinical and personal experience. Herein lies a fundamental difference between this model and other health education models, which have tended to be too narrowly focused on the individual and as a result have perpetuated a victim blaming ideology. The thesis begins with a desk study of the British dimension of a coming international crisis in the funding of public health, to which the general response has been a shift away from state support for bio-medically dominated health systems to systems based on the central concepts of health promotion and health education. The desk study argues that in Britain this has become as much an ideological issue as a practical one, with liberal notions of free market individualism prominent in public policy, and relevant sociological findings played down. Before embarking on the field study, the thesis considers whether or not a Health Locus of Control study might give enough insight into the basis for nurses' health education practices to explain why many nurses seem resistant to change, and therefore why perhaps they have had so little effect on patterns of social morbidity. This was rejected partly because of the methodological problems uncovered in a range of prior Locus of Control studies, but mainly because the method offers no way of engaging with sociologically identified inequities in morbidity and mortality rates. Nor was it felt that standard quantitative methods of research would enable the study to explore the complex ideological issues involved in nurses' social constructions of health. The decision was taken to employ a methodology based around qualitative interviews using the method of hierarchical focusing, which allows the interviewer to probe seamlessly matters at different levels of generality and specificity. In the field work study the general ideological tendency revealed in the desk study is shown to have a marked effect on nurses' constructions of their roles as health practitioners. The subjects, a group of experienced nurses, were asked a number of questions concerning their views of what constituted good and poor health and the causes for this. When the transcripts of the interview recordings were analysed using content analysis, it was clear that much of what was said was logocentric and heavily influenced by bio-medical discourse in spite of the subjects talking freely about holistic nursing. In fact there were contradictory and anomalous messages throughout the transcripts, so it was decided to subject these to a form of discourse analysis which revealed the existence of two opposing value positions held without any feeling of contradiction by a number of respondents: a holistic view - the public account, and a victim-blaming view - the private account. In order to gauge the effect of such views on nursing practice a further group of experienced nurses was given a series of nursing vignettes to analyse. The results showed that there appear to be two types of nurses: a reflexive group that is able to take on the complex issues involved in caring in the postmodern context and one, much the larger group, whose members have failed to resolve the contradictions in the prevailing ideology, who tend to fall back on victim-blaming and on bio-medical perspectives. Of course, this needs much more research to establish as a general pattern. However, there was enough clear evidence of ideological influences blocking the development of nurses' understanding and health practices to suggest the need for a new way of working with trainee nurses, much more sharply aimed at the development of critical consciousness in the practice situation. All the lessons of the research have been incorporated in the design of the new model.

There is a long-standing shortage of occupational therapists (OT's) in the United Kingdom. Commentators suggest that this is partly due to the withdrawal of qualified practitioners, but the contribution to this situation of such therapists' withdrawal early in their career seems to have been largely ignored to date. This study explored junior occupational therapists' withdrawal from practice, within one year of qualification and their likelihood of withdrawing within the following year. The focus was on the early work experience of 206 newly-qualified British occupational therapists. It investigated the potential influence of a number of independent variables which have been associated with the retention, turnover and attrition of other health care workers. These included workers' age, gender, occupational stress and trait anxiety levels, as well as a discrepancy between their expected and actual practice. The study was longitudinal in nature collecting data from respondents both before, and one year' after, qualification. A range of purpose-designed questionnaires and a semi-structured interview were used. A variety of factors were found to be of influence. Respondents' retention in practice was linked to issues of support, resources, success with clients, job satisfaction, the desire to make use of and increase their skills and the extent to which work matched their personal values. Their likelihood of leaving practice within two years of qualification was associated with both their level of occupational stress, and a perception that practice had failed to meet their expectations. Respondents' tumover level was linked to issues of support, autonomy, respondents' desire to increase their skills, and a perceived discrepancy between their expected and actual practice. Finally, attrition was linked to this same discrepancy, as well as to issues of support, autonomy, respondents' health, job dissatisfaction, level of responsibility and unmet expectations of practice. Those who left practice also noted longstanding uncertainty about the wisdom and permanence of occupational therapy as a career. These results provided both fuel for discussion and the opportunity to make recommendations for future occupational therapy policy, education and practice.

Arguably, in common with many other nation states, Jordan could be said to have drifted into different ways of paying for health services without always foreseeing the long run consequences of taking the strategic direction necessary. In part, of course, as in many developing countries, the financing of Jordan's health care services has been influenced by its colonial past. This partly explains why, historically, Jordan has attempted not only to provide wholly free services, but to provide privileged access to medical services, not only to the military personnel but also to public servants in general. With world economic instability and recent economic difficulties, notwithstanding the opportunities created by Jordan signing the peace treaty with Israel, and the unclear but likely stark future conditions facing the Jordanian economy, it is highly improbable that Jordan will continue to be in a position to sustain, from central government monies, a health system which currently consumes about7percent of the GDP. Financing strategies will, therefore, have to address the heightened expectations for rising health expenditures. Options under active consideration at this time include: introducing or extending the present system of user charges; community financing (participation ); (increased) use of the private sector; public or private health insurance; and, improving efficiency in the use of hospital and community resources. These are all financing options open to the Jordanian government to adopt, whether singly or in combination, to generate more resources for the health system and to make better use of existing resources. Examining the range of different modalities of health services' financing reveals, not surprisingly, that there are advantages and disadvantages in each financing scheme. Nevertheless, depending on Jordan 's circumstances, some of the approaches may be more appreciated than others: that is from a political, cultural, socio-economic, or strictly fiscal point of view. This thesis focuses upon one particular health financing approach, "National Health Insurance (NU)", and is aimed to lead the government of Jordan to rigorously explore the concept, consider the options, and develop an implementation strategy benefiting, where appropriate, from other countries' experiences with systems of NHI. Specifically, the thesis first provides an overview (or situation analysis) of the healthiness of the Jordanian economy, its key demographic and epidemiological characteristics, and salient features of the Jordanian health sector. This is followed by a largely theoretical discussion of the principles of insurance, and its potential relevance to the unpredictability and uncertainty of health and disease. Methodological problems inherent in public or private health insurance schemes are highlighted, and then considered in a comparative context, drawing on lessons and experience around the globe. The thesis considers as its basic premise that a system of national health insurance is both desirable and feasible for Jordan as it faces the next millennium. To test that premise, the study is conducted by means of a series of investigations emphasising both secondary and primary sources of data, and a range of quantitative and qualitative research methods including: content and document analysis; experimental and survey methods; interviews; and questionnaires. The conclusions drawn from the evidence supports the contention that the introduction of NM is potentially both desirable and feasible in Jordan but subject to meeting very strict conditionalities, not least government ownership of the scheme, and the willingness to address the present choice and diversity in health service provision through health sector reform. These matters are as much political as technical matters. On the more technical front, nonetheless, the design of an appropriate NHI is shown to raise critical issues regarding: coverage; benefits; organisation and management; costing and financing; and, provider payment mechanisms. Various technical options are discussed in the thesis, and were consulted upon with key decision makers in Jordan. Further directions of research and development are also identified, which likely have applicability beyond the specifics of Jordan itself.

American Recommended Dietary Allowances (RDAs) and British Dietary Reference Values (DRVs) are used as the scientific benchmarks in a number of policies and surveys relating to food, nutrition and welfare. In the USA the RDAs have a number of statutory and regulatory involvements, particularly with respect to food assistance programmes and the definition of the poverty level. In the UK, although DRVs have no statutory role, they are the benchmarks against which diets of population groups are assessed or food supplies are determined, and hence they indirectly influence various policy decisions. Although RDAs and DRVs are often presented and used as if they were solely scientific standards, the thesis is premised upon the assumption that they are in fact a mixture of scientific, social and political factors. The thesis examines the way in which RDAs and DRVs are constructed, both the process and the products, by particular reference to the allowances for vitamin C in the USA and UK, and the controversy that surrounded the publication of the tenth edition of the RDAs in the USA in the 1980s. In particular, it focuses on what constitutes scientific evidence in the RDA arena, where and why boundaries are drawn between scientific and non-scientific evidence, and what are the judgements and interpretations included in the process and products of RDA and DRV construction. Research was carried out by means of a critical analysis of the literature to identify the relevant scientific evidence and areas of interpretation and selection. This was followed by in-depth interviews with key individuals who were involved in the most recent RDA and DRV report processes or in the disputed 1985 RDA report, or who have been advocates or critics of these standards over the years. The thesis shows that the science underlying the recommended figures is incomplete and the theoretical methods outlined for determining an RDA/DRV were not followed in practice. Even though the standards could be improved by strengthening the scientific evidence, they will always be subject to value judgements over the question of 'adequacy'. Influencing such judgements and also underlying the 1985 RDA controversy are the conflicting certainties and interests of different cognitive groups within science. With scientific credibility and scientific authority at stake, the boundary between science and non-science moves to suit the interests and beliefs of the different scientific groups. At the same time external groups align themselves with the cognitive evidence which reinforces their own position.