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This suggests that a focus on getting the work done transactional may fail to pick up on the health and stress impacts of working environments. In an organisation that is directed to achieving work targets rather than worker satisfaction this might not matter in the short term. However a transformational leader will have this in mind. Work and Health. The less control one has the more likely one is to suffer serious illness in later life.

The study showed that men in the lowest employment grades were much more likely to die prematurely than men in the highest grades, having less autonomy over their role. Furthermore, these socio-economic inequalities in health did not appear to be fully accounted for by differences in well-known risk factors, such as smoking. A Finnish study was conducted in a cohort study similar to Whitehall, but with greater analysis of the worker's stress. Others argue that because there is a strong correlation between low employment grade and domestic stress, stress from a lack of control at work cannot be the whole story Yarnell Those with fewer resources have a harder time making ends meet, a situation that can be a tremendous source of chronic anxiety.

Comparative psycho-social stress and social inequalities have been strongly implicated in a range of unequal health outcomes between socio- economic groups in many countries Marmot , Wilkinson and Pickett That is to say that important work factors can impact on your health and wellbeing. The core standards have been designed to help employers improve the mental health of their workplace and enable individuals with mental health conditions to thrive.

By taking action on work-related stress, either through using the HSE Management Standards or an equivalent approach, employers will meet parts of the core standards framework, as they will: 1. The research, which surveyed 1, organisations across the UK referencing 3. Alienation in the workplace. Health care professionals are increasingly experiencing their work as a commodity bought and sold in a marketplace, over which they have less and less control as managerial practices focusing on non clinical criteria are imposed from above.

From this perspective , we would expect more workplace stress and alienation, and ill health as control is removed from daily practices. The plebeians needed distraction to prevent them from seeing the true nature of their subjugated existence.

Soap operas, Sport and celebrity culture may have a similar function today. Other ways of ameliorating this alienation is through organised religion or a spiritual quest, or one can resort to easing the anomic pain with drugs and alcohol. We might also engage in art or philosophical musings to escape the feelings of disconnection from ourselves, our work, each other and from nature.

So far we have discussed leadership from the perspective of the individuals themselves. However there is a need to consider the organisation itself and ask whether organisational cultures support or hinder the exercise of good leadership. Do organisations need to change? Is it reasonable or fair to expect individuals to become leaders in poorly run organisations. Leadership Development and Organisational Change. In the UK and the US there has been a drive for developing and improving leadership within healthcare organisations especially focusing on the development of skills for nurses.

The goal of course is to improve the quality of patient care. Has this worked? Large et al conducted an evaluation of a large Clinical Leadership Programme the Clinical Leadership Programme started in They gathered data from 16 healthcare organisations.

A clinical leader at each of the 16 locations was selected for the study. In addition, 36 service users from the clinical areas of these leaders were selected, along with 14 directors of nursing and 15 local facilitators, to help assess the effectiveness and impact of clinical leadership development.

In total, key stakeholder interviews were undertaken at case study sites. This was illustrated in the team goal setting and action planning described by clinical leaders, colleagues and directors of nursing. Their new leadership strategies promoted better alignment of the team, which in turn helped increase team effectiveness. As a practice-based development programme, the CLP provided a toolkit of interventions to support experiential learning for the programme participants.

However much of this is rooted in assumptions that producing effective leaders will result in improvements in management and organisation. I think this is too simplistic and does not take account of the evidence. The need to establish baseline measures of leadership effectiveness. The need to clarify the link between changed behaviours e. Is it possible to identify clear links between inputs CLPs and outputs various? Do we have to change assumptions about identifying what works?

If we do, how will this sit with managers charged with delivering measurable targets? In , the evidence is still not robust that attendance in CLPs actually result in long term changes or better patient outcomes. It is also to the nature of organisations in which people work that requires attention.

Consider your own experiences: How would you best describe your relationship to senior management: 1. How are strategic decisions made?

To what degree do you feel that establishing of order and control over work patterns and decision making is important for managers? To what degree do you have a shared vision for the organisation? Is it explicit, is it communicated to you by management? How important is it that you conform to organisational practices, how is challenge to current organisational practices dealt with?

To what degree is learning new methods of care organisation and delivery and cultures encouraged? How quickly does you organisation react to change and handle differences? What levels of proactivity by staff are encouraged?

What metaphor would you use to describe how your organisation works? For example, an oil tanker, slow to turn around when directional change is needed and on which the captain is in charge. Leadership as already argued operates in a context. This context includes organisational cultures and practices. So we need to think about what types of organisation we work and how we can affect changes in culture and practices. Leadership within my organisation is generally driven by senior management to establish order and control.

Strategic decisions are made through a formal planning process. Change is planned and programmatic. Employees�feel like a cog in a wheel. The Choir 2. My organisation has a shared direction about the future. The organisation encourages conformity but discourages challenging and learning. The Living organisation. My organisation acknowledges unpredictability and difference and constantly adapts to the environment in which staff are encouraged to challenge and progress.

Some Issues: 1. Work culture may inhibit leadership development: have we got the respect of the public, politicians, policy makers and other professional groups?

The ratio of professional staff to nonprofessional staff requiring training, supervision and regulation by clinical leaders.

Health care organisations may be risk averse and heavily regulated which counters leadership development that encourages risk and creativity e. Healthcare organisations must create the conditions which support and enhance new models of leadership. Is this too simplistic a question? There is a view that there are competing ideas about what clinical leadership is, what professional values and assumptions it is based on, and how this contrast with notions of managerial leadership.

Managerial leadership may have very different assumptions and values about how healthcare is delivered. What is meant by clinical leadership as opposed to managerial leadership?

Discuss the notion of the disconnected hierarchy. What are the problems of general management? To what degree is the argument presented applicable to your context? This section has addressed the context in which people have to work and considered leadership operating in certain types of organisation. We need to consider whether leadership training is linked to better patient outcomes, we need to think about the organisations leaders have to work in and we have to consider if clinicians and mangers have different goals, values and assumptions?

Next we examine address the idea of self awareness as a part of developing your professional skills and knowledge. Importantly, is it possible to understand why you think how you do, and what you can do to change? All good stuff. This is central to the task of many social sciences and should apply especially in health theory, education and practice. It may be that one has been so socialized into that practice that it never comes up for critical examination.

Who, and what, we are arises socially, as well as from our physical biological selves, as well as from our psychological thinking and motivations. Society structures who we are without determining who we are.

Family life structures us � giving language, culture, hopes and aspirations but does not determine these aspects of ourselves. There is room for agency. A clinical setting structures us � giving us a language, a discourse, acceptable modes of professional behaviours and explicit values.

The way anyone thinks about a course of action in any given clinical context will be manifest in what they do, what aims they set themselves and based in how they see their abilities, options and constraints.

So we need to see that agency works within a context, e. This happens in the following way: 1. The agent does not have a choice about this.

This objective situation operates in relation to Family Centred? Professionals determine their choices of practical action in relation to their objective circumstances.

This will include their clinical guidelines, working practices and resources. We may then critique whether effective action is possible before we act. One considers such things as gendered patterns of thinking, or class based patterns of thinking, or the possibility of heuristic thinking and our propensity to use emotion when reasoning. For an MR , one may think about such things as professional and organisational patterns of thinking and how this shapes one's own thoughts and actions.

Taken to extreme this may lead to self-doubt and inaction. They will seek out an understanding of power structures and ethical positions. The MR leaders may then appear as indecisive because they are weighing up options and considering options from a variety of positions. Socratic questioning would be an unaffordable luxury. In educational settings that focus on competency and skill acquisition, rooted in instrumental rationality and biomedicine, MR runs counter to the need for learning procedures, processes and facts.

It also runs counter to the epistemology of much of evidence based practice rooted as it is in often taken for granted empiricism. They may well delude themselves it is for the good of others. They are outcomes driven, over and above issues of value and consensus.

These outcomes must align however with their own interests. They do not consider it useful to think about what other people think of them or their action. If the AR does not have this political-philosophical 'bank' they operate within their own interests and ethical standpoints that support them.

The AR can be a leader for change, they can be disruptive of social orders, they don't consider the emotional needs of others necessarily as relevant.

They do not require the validation of others before they act. Their thinking is self- referential, that is they refer to themselves for judgment as to the worth of acting. They may use manipulative measures to steer other people into action that meets the AR's interests.

Coaching and counselling skills would be very useful to the AR in meeting their own ends in this regard. Students who display AR may have experienced criticism, and chastening during their education, as they don't play by the rules just because they are rules. The AR may have developed a thick skin, and may act according to whatever rules they see as right.

They will require validation by other people before acting. They consider how any action will affect other people, and the opinions of other people become very important.

They are consensus seekers and value this over and above outcomes or values. They refer and may defer to others' thinking and action and will not readily rock the boat. Mentors may look favourably upon a CR if the boat is not being rocked. They are particularly open to professional socialisation and developing the consensus of professional identity. A person working in a toxic clinical environment may well feel unease, but if their CR is dominant they may be very reticent to challenge and fall back on post hoc rationalisation for action that may be sub optimal.

Values, consensus or outcome thinking is secondary to personal survival in an uncertain world. The FR requires someone to lead them, to look after them, to tell them what is right. If they are 'high functioning', self caring and independent living, they may require a good deal of supervision and control to prevent harm to themselves and to others. Internal Conversations. So, we have internal conversations.

Our inner speech is rapid and often contracted into single words or phrases that contain a rich complexity of meaning. This eases the sharing of inner conversations because we all share that idiosyncratic meaning. Hence we talk in short cuts, in jargon, half sentences. This might be what Tuckman referred to as the norming and performing stage of team dynamics.

For a young professional confronted with new decisions, such as her role and function in a new clinical placement, this contextual continuity is a resource. How should I speak to patients or seniors? For those who learn that their inner conversations make sense only to themselves, attempts at expressing inner conversations may then be rebuffed by incomprehension or misunderstanding.

Efforts at making oneself clear may involve self exposure, continued failure to communicate may well be hurtful and result in defensiveness. One may resort to withdrawal. It might well be that the AR will resist the misunderstanding and the rebuffs and continue to answer her inner conversations in her own way albeit within the very real constraints of power, not the least of the mentor.

What is your inner voice saying? Positive comments of the student's practice by mentors are not necessarily, and always, oriented to evaluations of the students' leadership capacities. For example, already mentioned is a consideration of status, role set and organisational context. When exercising clinical leadership, it may assist personal and professional development to consider what their inner conversations actually are, to lead them rather than be led. Similarly, if there is a tendency to act without the consideration about the impact of that action on others and self, then personal development may be required.

Are we able to identify educational practices and practices in the clinical environment that foster certain modes? Are student nurses able to develop self analysis of this nature and then work on this understanding to communicate better in the clinical and personal environment?

To what degree do you agree with the following statements? I often act before really thinking about how my actions will be interpreted. I often think about how my gender should act in a situation. When I know how my colleagues interpret my actions, I still go ahead.

I really value what my colleagues, peers and family think of me and this can restrain my action. I often wonder why colleagues say and do the things they do. It is very important that the team gets along and works together.

MR AR CR AR These questions are for discussion only. Gender issues. It is a truth too obvious to mention, except that it needs thinking about. Health care teams are a mix of people who come with different class backgrounds, different nationalities, ethnicities, religions and of course of gender.

They are characterised by a variety of cultural assumptions and of values. These assumptions and values can impact on professional interaction in subtle and not so subtle ways. We have to note the gendered nature of professions. Historically, medicine has been a male occupation, while nursing still is dominated by females.

In the UK women are as numerous in the junior doctor ranks but as seniority increases, the numbers of men increases.

It is the same in hospital management, and for nursing management. Class, ethnicity, nationality and gender intersect to create a complex social milieu. Porter used participant observation to study doctor-nurse interaction in an intensive care unit and a medical ward. Unproblematic subordination: 2. Informal overt decision 4. Models 1, 2 and 4 were rarely seen. As this study is old and was small scale, further research is needed to establish whether model 4 in the current era is any more common.

Is medicine a dominant profession because it is superior in its approach and knowledge, more highly valued than nursing by society why? A few studies from seem to support the contention that interaction between nurses and doctors retain elements of game playing and the positioning of nurses into subordinate roles especially when it comes to decision making. Changes in the nursing profession has not been as far reaching as hoped by many in their attempts to professionalise it, and thus game playing arises still Tame We need to consider whether the situation has changed in the past 4 years.

Many factors could come into to play to change the nature of discussions and interactions that doctors and nurses experience. Interprofessional education could be one of those factors, The changing balance of males to females in medicine could be another.

Subject Positions Theory. At least a possibility of notional choice is inevitably involved because there are many and contradictory discursive practices that each person could engage in Davies and Harre, , p. There can be interactive positioning in which what one person says positions another. This can be done through agenda setting and the acceptance of certain words, ideas and concepts as more valuable than others. Note that it is very easy to project superiority in discussing clinical cases or when discussing management processes, by using exact medical and management terminology.

Just think about what that means. Of course, the other person can accept that position or reject it and through language try to claim a different status. We also use larger discursive frames which also position who we think we are and what we think the proper course of action should be. We can frame Public Health within a biomedical frame of reference e. The self is then positioned in relation to the stories that we use for those categories for example as wife, not husband, or good wife and not bad wife.

Note how the language changes when teams go out to socialize and different subject positions are adopted. Thus the language used by medical staff can position nurses, and other people, into subordinate positions. See Grant and Goodman for a fuller discussion on the nature of communication, especially chapter The reason symptoms are not easily recognised as cardiac in women, is that the language of cardiac symptomology e.

This could explain the statistical over representation of mental health problems of BME people. Poststructuralism discusses how decisions are made through language use and the relationship between knowledge and power. It studies how we construct meaning in an encounter with each other, how the power relationship between the professional and the person can affect what meaning is constructed by us.

Feminist Poststructuralism adds the gender dimension to this in that is suggests that there are patriarchal discourses, patriarchal social institutions and power relationships that can marginalise and even oppress women and their perspectives.

There is an argument that there are gendered dimensions to knowledge and understanding and clinical practice Sundin Huard There are differing epistemologies, that there is a feminine psychology e.

Gilligan These differences also affect what the goals of care are. Men can adopt female thinking and vice versa. An argument is that two main health care professions are gendered in their epistemologies and this is mirrored in the management � nursing relationship. We're not stagnant beings. That is to say, keep picking up his socks and someday he might just pick up yours.

There is a suggestion that men and women approach leadership from very different values and behaviour patterns. Two basic constructs to describe leadership behaviour based on the Ohio State approach are: 1. Consideration: friendly and interpersonally supportive supervisory behaviour.

Creating a supportive environment of warmth, friendliness and helpfulness, by being approachable, looking out for the welfare of the group, doing little things for subordinates and giving advance notice of change.

Initiating structure: emphasis on assigning tasks, specifying procedures to be followed, clarifying expectations of subordinates, scheduling work to be done. It is suggested that leaders can be placed on a continuum between consideration and initiating behaviour Stogdill in van Emmerik et al There is belief that women adopt consideration behaviour and men adopt initiating behaviour.

Women may adopt more interpersonal styles but only in female industries, in male industries they may adapt their behaviours or because they are selected by men in those industries. They found that where there are relatively higher numbers of female managers this is associated positively with consideration behaviours, male managers in organisations with more female managers tend to engage less in initiating structure, but this does not hold for women.

They conclude that individual differences gender are more important than organisational societal differences when explaining leadership behaviours. However care has to be taken not to extrapolate to all cultures and more work has to be done to explore other variables modernity, economic wealth, political systems.

The argument here tends to focus on those positions where authority in established leadership positions are formally acknowledged a form of managerial leadership. Clinical leadership exercised at peer to peer levels may not manifest as quite so gendered. Killeen et al focuses on aspirations and how men and women see themselves as leaders.

The study uses the auto industry as an exemplar of a male industry and clothing as a female industry. In line with 'Role Congruity theory', females regarded managerial careers more positive in the clothing industry and males the reverse. This does not extend to the CEO level where either gender would regard this as positive although unlikely.

In Spain, where they suggest that the status of women as employees is not as high as in the US, men evaluated the managerial roles more positively than women, whereas in the US there was no difference. They conclude that women in both countries have a weaker sense of possibility, rooted in a belief that leadership roles may cause problems for close relationships which they value more highly.

In both cases women took into account the future changing world as giving women more opportunities and access to leadership roles in an era of increasing gender equality. There, however, remains a sense for women that there is a trade-off between powerful occupational roles and achieving good close relationships.

And that this probably represents other Spanish hospitals. In a medical context women are underrepresented: 1. On research ethics committees 3. On editorial boards of major medical journals In a law was passed for gender equality to enable opportunities for both genders. This paper suggests that there is a long way to go still. Van Edwards argues that men and women tend to have two distinctly different leadership styles that shape how they manage there teams: Females are Transformational Leaders while men are indeed Transactional Leaders Burke and Collins Why is there this difference?

This is put down to physiological differences as well as social expectations. How men and women lead differently? It describes the structuring of a society the basis of the family. Traditional families pass on lineage through fathers.

On this basis fathers are considered have primary responsibility for the welfare of the family. There is a hierarchy in the family and thus in society. Sweet and Norman undertook a selective literature review of the nurse-doctor relationship in the context of the history of patriarchal relationships.

They concluded that, while much has been written generating anecdote and opinion, there had been little empirical work to establish an evidence base around the impact of patriarchy on this relationship. They cite some empirical work, Heenan and Mackay , which suggested dissatisfaction and poor working relationships amongst nurses resulting in negative consequences for patients, but much is of this is over 20 years old since publication.

They argue that the relationship is characterised by each profession having ideal expectations of each other which are not always met.

A rather outspoken friend theorises that they have to be either perverts or women haters. Misogyny has always run rife in medicine, says she, because of a patriarchal society that suppressed women. Physicians were traditionally men with power and status not much change there, then. Women, when not keeping house and churning out offspring, did the grotty jobs like cleaning, laying out the dead, and of course, nursing.

Today I saw nine women in morning surgery, all harping on about fairly nebulous symptoms. There was nothing to get your teeth into and actually treat, like good old conjunctivitis or an ingrowing toenail. At a bit of a loss, it was all too convenient to cop out: "It's your hormones, luv, we're all slaves to them.

My busy, practical side wanted to deal with these patients sharpish and get on, but my feminist side was ashamed at trivialising their complaints. For, as my friend points out, demanding women are easily dismissed as hormonal. Medical statistics show that women make up the vast majority of patients attending general practice.

So are women a bunch of hypochondriacs with too much time on our hands? The Ancient Greeks blamed everything on the uncontrollable, wandering womb and then that crackpot Freud came along and diagnosed all women as hysterical.

Women probably do come to surgery more than men, but not necessarily because they are ill. They frequently consult for health-related matters, like contraception or smears. Often they are the only adult who is available to accompany a child, so indeed we do see many female customers in this job. If unwell, women often request female doctors.

Perhaps they expect them to naturally be more empathetic, especially with matters "down below". Not necessarily so. A female GP I know totally rejects the possibility of PMS, considers post-natal depression to be the punishment of wimps and generally hates seeing women patients. And are these decisions purely based on medical science?

Does culture play a part? Theobold et al raise the importance of gender analysis and of understanding patriarchal values and assumptions. They examine gender across a range of health policy and system contexts. Do we therefore have to retrain, re educate, men and women about male assumptions and values in health care management? There is a large literature on the nature of team and team working and so it is to this topic we now turn. Teamworking As just stated this topic appears a good deal in the literature, the focus is on ensuring good team work to improve patient outcomes.

There are descriptions about what makes a team, what holds teams back from working effectively, how we develop a team and what the proper role for team members may be.

However we also need to think critically about our teams in actual practice. Is teamworking myth or reality in clinical practice? Chase had previously examined teamworking in critical care environments and observed two parallel hierarchies consisting of medics and nurses. The suggestion here is that clinical teams may divide along professional lines and are not teams at all but are merely groups.

Does it matter that we are a group rather than a team? The theory about team working, rather than just being a group, is that we get better outcomes, creativity and productivity�what is the evidence?

Can you think of examples of good or poor team working that led to better or worse patient outcomes? Team Dynamics Within health care teams, and their relationship with other professions and management, there are various barriers to team development. Tuckman outlined a typology for group dynamics and argued that teams went through various stages of development.

The implication here is that if a team gets stuck at one stage they will not get to optimum performance. He believed as is a common belief today that these stages are inevitable in order for a team to grow to the point where they are functioning effectively together and delivering high quality results.

The adjourning stage is when the team is completing the current project. They will be joining other teams and moving on to other work in the near future. For a high performing team, the end of a project brings on feelings of sadness as the team members have effectively become as one and now are going their separate ways.

How are new members integrated into the team - by being proactive or passive? Social dynamics implies that it is the everyday experience of working with people that individuals get to know what is required and what their place is. How do you help to get your team to the performing stage?

Team Role Theory Meredith Belbin. Belbin suggested various team roles which if brought together will support effective team working. Consider then how we overcome barriers and move from being a group to becoming a team. What individual and group, organisational actions need taking?

So far we have examined how cultures shape working practices, how individual professionals work together and how gender may shape leadership. Team working is seen as an important aspect of care delivery. We now turn to a goal of care delivery, enhancing or improving the quality of patient care. Quality 1. Clinical leadership might be focused on improving service delivery and the quality of patient care.

In order to do this leaders need some tools to help them. How do we go about Quality Improvement? Brocklehurst has suggested a number of approaches to quality improvement. Data Based approaches: Data collected and used to construct quantitative indicators of performance. League tables being the commonest. Tend to be negative and can be de-motivating 4. System or Process Focused Approaches. Quality is also a function of organisational rather than individual performance.

The concept of Total Quality Management TQM stresses the importance of leadership and organisational culture to quality improvement, and focuses on the use of a range of tools to examine and change processes of care. These have much in common, may overlap or be used concurrently.

Provide a brief description of examples of each in your clinical area. Identify your role in any of these approaches. Think about the provision of personal care and the food offered to people when they are in-patients. You already know what is important to people from talking and listening to them. Does your clinical environment identify clearly what people might consider to be a quality service? Continuous Quality Improvement. CQI has been found to work effectively in manufacturing industries and now also in healthcare.

The core concepts of CQI are: 1. CQI aims to improve process and system. CQI aims to eliminate unwanted outcomes 5. PDSA So, how might we put this into practice?

This includes 3 key questions and then a process for testing change using Plan Do Study Act PDSA cycles Answering the questions helps bring the problem or issue into FOCUS Find a process that needs improvement Organise a team that knows the process Clarify the current knowledge of the process Understand the variation in the process Select a process for improvement The model starts with 3 basic questions: 1.

Then, the PDSA cycle: Plan � set the objective, make predictions, plan to answer the questions who, where, when collect data to answer the questions. Do � carry out the plan, collect the data, begin analysis of the data. Study - Act � want changes are to be made to the next cycle.

Can the change be implemented? The aviation industry provides a model for health care, based on the fact that errors can very quickly result catastrophe. Critical care environments may share similar experiences in that errors could lead quickly to even more severe illness or death.

Quality 2. Accidents will happen? So how do we go about eliminating errors that could lead to serious harm and death? There are at least two approaches that leaders can take: 1. Person � this is when we look at unsafe acts themselves, including errors and procedural mistakes made by healthcare staff. Take a drug error for example. This has often been the approach adopted by managers.

It is easy to focus on the failing of the person rather than an analysis of the system which allowed that error to occur. System - here we know that errors will occur, and that they are consequences rather than causes of harm. This accepts the fallibility of humans in their work and so we need to change the working systems in which people work rather than a focus on trying to change people.

We try to design a system that defends against errors and focus on the person, the team, the task, the workplace and the organisation itself. Errors happen often because either the barriers to prevent them do not exist or that the various steps all line up to allow the error to take place. For example in the aviation industry a pilot cannot land an aircraft with its wheels up because there are barriers preventing that.

In many accidents and failures there are technical failures in the system that can be found, often however it is the human factors that count! What defence mechanisms are in place to prevent errors? The patient dies 3 weeks later. Error wisdom may include mental preparedness Reason : 1. Quality 3. Care, Quality and Soft Metrics. Are we doing the right things? In this section, clinical leaders are challenged to consider how they know what quality care looks like and if we are indeed doing the right things by collecting the right data?

The failings over 10 years at Alexandra Hospital in Worcester BBC indicate the pervasive nature of not only poor quality care but actual abuse. Although failings in basic day-to-day care in Worcester were highlighted by a CQC report, this should not lead us to complacency about the robustness of quality and audit reporting mechanisms. One of the most pertinent is that, given the extent of the poor care, how did staff and systems charged with evaluating the quality of clinical placements miss what was going on?

The university charged with placing students at Mid Staffordshire NHS Trust had to address the serious issues that arose in clinical practice and presented some of their insights. Are Mid Staffs and Worcester outliers or are other Trusts currently harbouring their own dark secrets? Abuse at the levels described might, or should be, easy to spot. If we cannot see it we might ask ourselves is that because it does not exist or is it because our tools lack precision and validity?

However, it is clear that they were not robust enough to predict and prevent individual abuse and managerial failures. One may ask what indicators were being looked at? What metrics are being used to make judgements about quality? A University might review its educational and placement audits and reporting mechanisms in the light of evidence of poor quality care. Universities and Trusts may have regular meetings to discuss concerns and then develop action plans to address them.

Audits and joint meetings are important pillars in upholding the quality of care provision and the student experience, but what other pillars are there, and which ones can Universities address? There is no shortage of frameworks and mechanisms in existence and yet all of the weight of published literature on quality did not prevent Mid Staffs and Worcester. Antecedents to poor care Have we investigated in enough depth both the antecedents to poor care and the social process of collecting evidence of it?

That being said, the antecedents to suboptimal care might teach us something about poor care. They may provide pointers, or places to look and research. Quirke et al identify 4 categories of the antecedents for SOC: 1. Junior doctors hours, rotations. To apply these categories to an analysis of poor quality care in non-acute settings is a short step.

Elderly patients with long term conditions have complex nursing as well as medical needs and often will be prescribed a long list of medications. This should alert us already to the need to ensure that whosoever is responsible and accountable for that care requires education, support, supervision and on-going development.

To this category I would add the leadership and management skills of nurses in clinical areas which if not properly developed and supported, compounds the above categories. Education is of course university core business. The organisational issues are Trust business and can again only be addressed through partnership. Many of the antecedents for poor care might be picked up by appropriate hard metrics, e. It remains the case though that hard data still might not provide valid measures of good quality care.

Hard metrics include data such as share price, sales and number of customer service complaints. They may construct the tacit knowledge individuals have about their workplace. They may include the physical appearance and environment of a clinical area.

Although I am passing theory and practice I dont feel like the practice experience is particularly thorough my emphasis. Please forgive me if that sounds arrogant as I obviously dont know what the nurses perspective is. This has led to me feeling like I can get away with not reading or doing much more than turn up and be nice to people, say nice things make them feel good my emphasis.

This can be easily dismissed as the view of one student only, and the fault for her feeling about practice in this way lies within herself. To do this may be a mistake. Shields et al , Goodman , Morrall and Goodman This is an example of soft metrics that would not appear in quality processes and yet might be telling us something vital. Two processes � hard and soft Therefore two processes are in operation. There are formal educational and placement audits on the one hand, and a host of evaluative comments, feelings and intangibles, on the other.

If the results of the formal process do not match the results being generated by soft metrics then the possibility remains that a false picture emerges about the quality of a service, placement or organisation. Students already discuss among themselves which wards are to be avoided or tolerated.

Quality is often an elusive concept and yet patients know when they are receiving poor quality care. As with all technologies great care has to be exercised to avoid thinking that the results of measurements are valid and not mere constructs of the technology themselves. There are risk implications from relying on technologies to provide data.

We already know for example that relying on task oriented vital signs assessments recorded by machines actually require patient assessment using sensory skills as well Wheatley Listening to soft intelligence or identifying soft metrics could provide an adjunct to better predict failing areas.

Universities and Trusts should consider independent review of their internal audit processes to engage in critical appraisal of the validity of measurement metrics. The independent review could be undertaken by another Faculty within the University or by collaborative partnerships established between Universities. Trusts and AWPs should consider independent review of their own clinical placement audits.

Clinical leaders should understand and be open to the soft intelligence they encounter every day. It has been rooted in a private sector, managerial context with not a little male bias in its understandings. To begin you will have to understand yourself before you can lead others.

You will have to know the power games and ethical positions of various actors and organisations. Care settings bring their own cultures, pressures and issues. However, a unifying focus for all who work in care is patient safety and comfort. Identifying your personal and organisational vision to address this overall goal may be a good start.

Farrell Ed. Newbury Park, CA: Sage. Appleby, J. BMJ e Archer, M. Cambridge University Press. M Making our way through the world. Archer, M. Cambridge; Cambridge University Press. Austin, W. Chapter 3 in Tschudin, V. Bandura, A. New York: W. Freeman and Company. Banks, C.

Nursing Standard 17 10 p 96 Bateman, T. Job satisfaction and the good soldier: the relationship between affect and employee citizenship. The Academy of Management Journal 26 4 : � San Francisco. Jossey Bass Bennis, W. Harper business. New York. Nursing Standard 13 52 p Bolman, L. Reframing Organizations: Artistry, Choice, and Leadership.

San Francisco: Jossey-Bass. Nursing Standard. The health and security perspectives of climate change. Huczynski, A Organisational Behaviour 3rd ed. Prentice Hall Calas, M. Nord Ed. Thousand Oaks: Sage Publications.

Chapman, J. C, Goleman. Jacob, S Contemporary Nursing: Issues, trends and management 3rd ed. St Louis. Elsevier Mosby Churchman, J. June th 24 Cole, G Management: Theory and practice 2nd ed. DP Publications Collier, P. Oxford University Press. Managing the effects of Climate change. Harvard Business Publishing Newsletters Jan 1st. Polity Press. Cunningham, G and Mackenzie, H. Curtis, K. Politics and Poor nursing care. The Cloister House Press. Donabedian A. Ginter, P. Blackwell Dunning, D. Journal of Personality and Social Psychology 77 6 : � Eagly, A.

Psychological Review, 3 , Economist, The. Left behind. September 10th. Edmonstone, J. Journal of Management in Medicine. International Journal of Health Planning and Management.

Journal of Nursing Management. Advances in Psychiatric treatment 10 pp doi Nursing Management. Mcnamara, M.

Fletcher, J. Gilligan, C. Harvard University Press. Goodman, B. Nursing in Critical Care, 9 6 pp Goodman B. London, Earthscan. Chapter 4. Learning Matters. See the bigger picture. May 4th. The need for a sustainability curriculum in nurse education. Intellectual craftsmanship in an age of instrumentalism Nurse Education Today [accepted for publication September Goodman, B.

Goleman, D. Why it can matter more than IQ. Hagell, E. A sociological perspective. Journal of Advanced Nursing. Hasson, F. McKenna, H and Keeney, S. Journal of Advance Nursing. Journal of Health Organisation and Management. Nursing Times Nov Bailliere Tindall. Hutchinson, M. Harvard Business Review, 71 March-April , Health Case Studies is composed of eight separate health case studies. Each case study includes the patient narrative or story that models the best practice at the time of publishing in healthcare settings.

Associated with each case is a set of specific learning objectives to support learning and facilitate educational strategies and evaluation. Open Access healthcare administration textbook pdf. The U. It is run like a business, increasingly focused on generating income for insurers and providers rather than providing care for patients. It is supported by investors and private markets seeking to grow revenue and resist regulation, thus contributing to higher costs and lessened public accountability.

This book is a clarion call not just to politicians and patients but to the medical profession to evolve a new structure for healthcare, based on voluntary private contracts between individuals and not-for-profit, multi-specialty groups of physicians.

Healthcare administration book pdf. More than three hundred entries explain the history, politics, and terminology of the health care debate. Contents include profiles of government agencies, nonprofit organizations, and congressional committees responsible for making health care policy, plus contact information on the most influential groups; definitions of the terms and concepts essential for understanding health policy; history and analysis of important health care policies and policy debates involving programs such as Medicare, Medicaid, and the uninsured; Reports on medical advances, new drugs and technologies, policy debates, and recent trends in health care delivery; appendixes, including a time line and suggested readings.

Healthcare administration books pdf free download. In this moving, terrifying, and often hilarious book he tells how his residency in a city hospital nearly ground his high principles into dust. Bone-weary from endless hours of duty, aghast at the treatment of helpless patients, Dr. Sacco saw his enthusiasm turn to cynicism. He started to write down the pathos and greed, humor and horror that surrounded him.

Drawing on years of original research and reporting in Africa and Asia, Shah examines how the multinational pharmaceutical industry, in its quest to develop lucrative drugs, has begun exporting its clinical research trials to the developing world, where ethical oversight is minimal and desperate patients abound.

Health care administration book pdf. In his blunt assessment of the state of public health in America, Alfred Sommer argues that human behavior has a stronger effect on wellness than almost any other factor.

Despite exciting advances in genomic research and cutting-edge medicine, Sommer explains, most illness can be avoided or managed with simple, low-tech habits such as proper hand washing, regular exercise, a balanced diet, and not smoking. Health care management book pdf. Descriptions of the detailed procedures and methods used in trials that have been conducted in the past have generally not been published.

As a consequence, those planning such trials have few guidelines available and little access to previously accumulated knowledge. Winner of the Pulitzer Prize and the Bancroft Prize in American History, this is a landmark history of how the entire American health care system of doctors, hospitals, health plans, and government programs has evolved over the last two centuries.

Health Service magaement book pdf download. Beginning in the s in the United States, scores of patients with severe psychiatric disorders were discharged from public mental hospitals. At the same time, activists forced changes in commitment laws that made it impossible to treat half of the patients that left the hospital. The combined effect was profoundly destructive. Today, among homeless persons, at least one-third are severely mentally ill; among the incarcerated, at least one-tenth.

Torrey takes full stock of this phenomenon, exploring the causes and consequences as he weaves together narratives of individual tragedies in three states with sobering national data on our failure to treat the mentally ill. Think your body is your own to control and dispose of as you wish? Think again. The United States Patent Office has granted at least 40, patents on genes controlling the most basic processes of human life, and more are pending. If you undergo surgery in many hospitals you must sign away ownership rights to your excised tissues, even if they turn out to have medical and fiscal value.

Life itself is rapidly becoming a wholly owned subsidiary of the medical- industrial complex. Health care book pdf.

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