Foreign aid, Cashgate and trusting relationships amongst stakeholders: key factors contributing to (mal) functioning of the Malawian health system.

Malawi has a long history of receiving foreign aid, both monetary and technical support, for its health and other services provision. In the past two decades, foreign aid has increased, with the aim of the country being able to achieve its Millennium Development Goals by the end of 2015. It is currently moving towards achieving the sustainable development goals. Despite increased donor support, progress in the Malawian health service has remained very slow. This article discusses how trusting relationships amongst the stakeholders is vital in proper financial management, including of foreign aid and effective functioning of the health system in Malawi. This article is based on a qualitative study, using a range of research approaches: the in-depth case study of foreign aid funded Maternal and Child Health (MCH) projects (n = 4); Key Informant Interviews (n = 20) and reviews of policy documents to explore the issues around foreign aid and MCH services in Malawi. During the study period 2014-16, the country continued to face significant financial and other resource management challenges. The study has identified key factors, notably the issue of financial mismanagement, particularly Cashgate, news of which broke in 2013. This scandal has resulted in a great deal of mistrust amongst key stakeholders in health. The concomitant deterioration of working relationships has had a major impact on the health system resulting in further mal-distribution of resources and programme duplications. After highlighting key issues around foreign aid, Cashgate and trusting relationships amongst stakeholders, this article makes policy suggestions, with the aim of assisting donors and external development partners to better understand Malawian socio-political networks and relationships amongst key stakeholders. This understanding will help all those involved in the effective financial management and dispersal of foreign aid.

Qualitative analysis of multi-disciplinary round-table discussions on the acceleration of benefits and data analytics through hospital electronic prescribing (ePrescribing) systems.

BACKGROUND: Electronic systems that facilitate prescribing, administration and dispensing of medicines (ePrescribing systems) are at the heart of international efforts to improve the safety, quality and efficiency of medicine management. Considering the initial costs of procuring and maintaining ePrescribing systems, there is a need to better understand how to accelerate and maximise the financial benefits associated with these systems. OBJECTIVES: We sought to investigate how different sectors are approaching the realisation of returns on investment from ePrescribing systems in U.K. hospitals and what lessons can be learned for future developments and implementation strategies within healthcare settings. METHOD: We conducted international, multi-disciplinary, round-table discussions with 21 participants from different backgrounds including policy makers, healthcare organisations, academic researchers, vendors and patient representatives. The discussions were audio-recorded, transcribed and then thematically analysed with the qualitative analysis software NVivo10. RESULTS: There was an over-riding concern that realising financial returns from ePrescribing systems was challenging. The underlying reasons included substantial fixed costs of care provision, the difficulties in radically changing the medicines management process and the lack of capacity within NHS hospitals to analyse and exploit the digital data being generated. Any future data strategy should take into account the need to collect and analyse local and national data (i.e. within and across hospitals), setting comparators to measure progress (i.e. baseline measurements) and clear standards guiding data management so that data are comparable across settings. CONCLUSIONS: A more coherent national approach to realising financial benefits from ePrescribing systems is needed as implementations progress and the range of tools to collect information will lead to exponential data growth. The move towards more sophisticated closed-loop systems that integrate prescribing, administration and dispensing, as well as increasingly empowered patients accessing their data through portals and portable devices, will accelerate these developments. Meaningful analysis of data will be the key to realise benefits associated with systems.

Financial and clinical risk in health care reform: a view from below.

OBJECTIVES: This paper examines how the interaction between financial and clinical risk at two critical phases of health care reform in England has been experienced by frontline staff caring for vulnerable patients with long term conditions. METHODS: The paper draws on contracting theory and two interdisciplinary and in-depth qualitative research studies undertaken in 1995 and 2007. Methods common to both studies included documentary analysis and interviews with managers and front line professionals. The 1995 study employed action-based research and included observation of community care; the 2007 study used realistic evaluation and included engagement with service user groups. RESULTS: In both reform processes, financial risk was increasingly devolved to frontline practitioners and smaller organizational units such as GP commissioning groups, with payment by unit of activity, aimed at changing professionals' behaviour. This financing increased perceived clinical risk and fragmented the delivery of health and social care services requiring staff efforts to improve collaboration and integration, and created some perverse incentives and staff demoralisation. CONCLUSIONS: Health services reform should only shift financial risk to frontline professionals to the extent that it can be efficiently borne. Where team work is required, contracts should reward collaborative multi-professional activity.

Learning about patient safety: organizational context and culture in the education of health care professionals.

OBJECTIVES: This study investigated the formal and informal ways pre-registration students from medicine, nursing, physiotherapy and pharmacy learn about keeping patients safe. This paper gives an overview of the study and explores findings in relation to organizational context and culture. METHODS: The study employed a phased design using multiple qualitative methods. The overall approach drew on 'illuminative evaluation'. Ethical approval was obtained. Phase 1 employed a convenience sample of 13 pre-registration courses across the UK. Curriculum documents were gathered, and course directors interviewed. Phase 2 used eight case studies, two for each professional group, to develop an in-depth investigation of learning across university and practice by students and newly-qualified practitioners in relation to patient safety, and to examine the organizational culture that students and newly-qualified staff are exposed to. Analysis was iterative and ongoing throughout the study, using frameworks agreed by all researchers. RESULTS: Patient safety was felt to have become a higher priority for the health care system in recent years. Incident reporting was a key feature of the patient safety agenda within the organizations examined. Staff were often unclear or too busy to report. On the whole, students were not engaged and may not be aware of incident reporting schemes. They may not have access to existing systems in their organization. Most did not access employers' induction programmes. Some training sessions occasionally included students but this did not appear to be routine. CONCLUSIONS: Action is needed to develop an efficient interface between employers and education providers to develop up-to-date curricula for patient safety.

Overseas nurses' experiences of discrimination: a case of racist bullying?

AIM: We present three case studies of discrimination to illustrate how racist bullying as discriminatory practices operates in the workplace. BACKGROUND: Workplace bullying in the British health care sector is reported along with evidence of discrimination towards overseas-trained nurses recruited to work in the United Kingdom (UK). METHODS: The three interviews, which form the basis of the discussion in this paper, were selected purposively from a national study of overseas nurses because they present strong examples of the phenomenon of workplace bullying. The data on which this paper draws were collected through semi-structured, audio-recorded interviews and thematically re-analysed using nvivo V2. RESULTS: The national study showed how racism is entrenched in health workplaces. Our findings in this paper suggest that racism can be understood by the concept of racist bullying. There are four key findings which illustrate racist bullying in the workplace: abusive power relationships, communication difficulties, emotional reactions to racist bullying and responses to bullying. CONCLUSIONS: We argue that the literature on workplace bullying adds a layer of analysis of discrimination at the individual and organizational levels which enables us to further delineate racist bullying. We conclude that racist bullying can be specifically identified as a form of bullying. IMPLICATIONS FOR NURSING MANAGERS: Our data may assist managers to challenge current workplace working practices and support bullied employees. The three interviews show different responses to racist bullying which allow us to explore some implications for management practice.

Provision of continued professional development for non-medical prescribers within a South of England Strategic Health Authority: a report on a training needs analysis.

AIMS: This paper reports on a Training Needs Analysis for Non-Medical Prescribers commissioned by a south of England Strategic Health Authority. BACKGROUND: The aim of the TNA was to inform future policy, educational provision and practice development and provide nurse managers with significant information on the perceived Continuing Professional Development (CPD) needs of the non-medical prescribers. METHODS: Data were collected from a sample of 270 non-medical prescribers using an in-depth questionnaire, and telephone interviews with a purposive sample of 11 key stakeholders. RESULTS: The findings report: * The qualifications that non-medical prescribers possess. * The level of confidence described by the non-medical prescribers in their role. * What non-medical prescribers identify as their present and future CPD requirements in relation to prescribing. * What education and training provision non-medical prescribers have attended in relation to their prescribing role since qualifying. CONCLUSIONS: The findings suggest, first that short courses that were specific to the non-medical prescribers role were considered to be the most popular and useful. However, courses needed to be advertised well in advance. Second, training gaps were identified. IMPLICATIONS FOR NURSING MANAGEMENT: Pharmacology and prescribing are rapidly changing and require regular CPD in order to keep up to date with the latest developments. Non-medical prescribing is a comparatively new innovation to the NHS, therefore those who are not medically qualified need mentorship from experienced prescribers, as well as the encouragement from nurse managers to be confident prescribers themselves and enhance patient care.

Emotions at work: what is the link to patient and staff safety? Implications for nurse managers in the NHS.

AIMS: This paper sets the discussion of emotions at work within the modern NHS and the current prioritisation of creating a safety culture within the service. BACKGROUND: The paper focuses on the work of students, frontline nurses and their managers drawing on recent studies of patient safety in the curriculum, and governance and incentives in the care of patients with complex long term conditions. METHODS: The primary research featured in the paper combined a case study design with focus groups, interviews and observation. RESULTS: In the patient safety research the importance of physical and emotional safety emerged as a key finding both for users and professionals. In the governance and incentives research, risk emerged as a key concern for managers, frontline workers and users. CONCLUSION: The recognition of emotions and the importance of emotional labour at an individual and organizational level managed by emotionally intelligent leaders played an important role in promoting worker and patient safety and reducing workplace risk. IMPLICATIONS FOR NURSE MANAGERS: Nurse managers need to be aware of the emotional complexities of their organizations in order to set up systems to support the emotional wellbeing of professionals and users which in turn ensures safety and reduces risk.

Profession, market and class: nurse migration and the remaking of division and disadvantage.

AIMS AND OBJECTIVES: This article aims to analyse the part played by successive waves of nurse migration in changing patterns of division and disadvantage within nursing. We argue that migration has in part acted to reinforce disadvantage based on class and gender, race and ethnicity and identify the influence of changes in nursing structure and commercialization of care in these processes. BACKGROUND, DESIGN AND METHODS: The historical analysis of division within nursing and the impact of migration are based on secondary sources (literature review) and primary research undertaken by ourselves and colleagues. The paper develops a concept of 'remaking' disadvantage drawing on analysis in social history of the interplay between agency and economic position in the 'making' of class. It uses the extended case method to focus on the residential care sector, showing how global and national influences operate at the frontline of service delivery. RESULTS: We show how social class and gender, race and ethnicity have interacted and are reflected in the division of labour within nursing. We demonstrate how the employment conditions of nurse migrants have reinforced patterns of disadvantage. The case study of the residential care home sector deepens our analysis of intersecting sources of professional disadvantage including aspects of commercialization, in a sector where they have severe effects for vulnerable staff and patients. CONCLUSIONS: In the UK, migrant professional nurses have repeatedly acted both as a highly valued labour force on whom patients and clients rely and as involuntary contributors to remaking disadvantage. This situation is sustained by the current international labour market and rising commercialization which facilitate nurse migration and the segmentation of care work based on a 'pecking order' of specialties that reinforce existing divisions of social class, gender and race within nursing. RELEVANCE TO CLINICAL PRACTICE: Migrant nurses play a key role in the delivery of 'frontline' care to patients. The role many currently play reinforces disadvantage within nursing in ways that are problematic for the profession, patients and clients. The recognition and valuing of their skills is critical to the promotion of their own morale which in turn has an impact on their relationship with colleagues and the delivery of patient and client care.

Trends in length of stay, living setting, functional outcome, and mortality following medical rehabilitation.

CONTEXT: Changes in reimbursement have reduced length of stay (LOS) for patients receiving inpatient medical rehabilitation. The impact of decreased LOS on functional status, living setting, and mortality is not known. OBJECTIVE: To examine changes in LOS, functional status, living setting, and mortality in patients completing inpatient rehabilitation. DESIGN: Retrospective cohort study from 1994 through 2001 using information submitted to the Uniform Data System for Medical Rehabilitation. SETTING AND PARTICIPANTS: Data were analyzed from 744 inpatient medical rehabilitation hospitals and centers located in 48 US states. A total of 148,807 patient records from 5 impairment groups (stroke, brain dysfunction, spinal cord dysfunction, other neurologic conditions, and orthopedic conditions) were examined. Patients' mean age was 67.8 (SD, 15.8) years; the sample was 59% female and 81% non-Hispanic white. MAIN OUTCOME MEASURES: Discharge setting, follow-up living setting, change in functional status, and mortality. RESULTS: Median LOS decreased from 20 to 12 days (P<.001) from 1994 to 2001. The proportional decrease in median LOS was greatest (42%) for patients with orthopedic conditions. Mean days to follow-up remained constant from 89 in 1994 to 90 in 2001. Functional status was clinically stable, while efficiency (functional status change divided by LOS) increased significantly (P<.001). Rates of discharge to home and living at home at follow-up remained stable, ranging from 81% to 93%. However, mortality at 80- to 180-day follow-up increased from less than 1% in 1994 to 4.7% in 2001. CONCLUSIONS: Length of stay for inpatient rehabilitation decreased substantially from 1994 to 2001. Effectiveness as measured by change in functional status did not change clinically, and living setting did not change. Efficiency for functional outcomes improved but mortality at follow-up increased.