An integrative review of research evaluating organisational culture in residential aged care facilities.

BACKGROUND: Evidence suggests that the culture of healthcare organisations, including residential aged care facilities (RACFs), is linked to the quality of care offered. The number of people living in RACFs has increased globally, and in turn, attention has been placed on care quality. This review aimed to identify how organisational culture is studied, sought to elucidate the results of previous studies, and aimed to establish what interventions are being used to improve organisational culture in RACFs. METHODS: We employed an integrative review design to provide a comprehensive understanding of organisational culture. Five academic data bases were searched (Ovid Medline, Scopus, PsycInfo, CINAHL, Embase). Articles were included if they were empirical studies, published in peer reviewed journals in English, conducted in a RACF setting, and were focused on organisational culture/climate. RESULTS: Ninety-two articles were included. Fifty-nine studies (64.1%) utilised a quantitative approach, while 24 (26.0%) were qualitative, and nine used mixed methods (9.8%). Twenty-two (23.9%) aimed to describe the culture within RACFs, while 65 (70.7%) attempted to understand the relationship between culture and other variables, demonstrating mixed and indeterminate associations. Only five (5.4%) evaluated an intervention. CONCLUSIONS: This review highlights the heterogenous nature of this research area, whereby differences in how culture is demarcated, conceptualised, and operationalised, has likely contributed to mixed findings. Future research which is underpinned by a sound theoretical basis is needed to increase the availability of empirical evidence on which culture change interventions can be based.

What do consumer and providers view as important for integrated care? A qualitative study.

BACKGROUND: Integrated care is a model recognised internationally, however, there is limited evidence about its usability in the community. This study aimed to elicit community and provider views about integrated care and how implementation could meet their healthcare needs in a new hospital. METHODS: Using a qualitative approach, consumer and provider views on the strengths, barriers and enablers for integrated care were collected via a series of online workshops and supplementary interviews. RESULTS: A total of 22 consumers and 49 providers participated in 11 focus groups; all perceived integrated care to be an accessible and efficient model that offers a high level of care which enhanced staff and patient well-being. Providers expressed concerns about longer waiting times and safety risks associated with communication gaps and insufficient staff. Enablers include supporting consumers in navigating the integrated care process, co-ordinating and integrating primary care into the model as well as centralising patient electronic medical records. DISCUSSION: Primary, tertiary and community linkages are key for integrated care. Successful interoperability of services and networks requires an investment in resources and infrastructure to build the capability for providers to seamlessly access information at all points along the patient pathway. CONCLUSION: Integrated care is perceived by consumers and providers to be a flexible and patient-focused model of healthcare that offers benefits for a hospital of the future.

Determining the role and responsibilities of the community epilepsy nurse in the management of epilepsy.

AIMS AND OBJECTIVES: The aim of this study is to enhance the understanding of the core elements and influencing factors on the community-based epilepsy nurse's role and responsibilities. BACKGROUND: Internationally, epilepsy nurse specialists play a key role in providing person-centred care and management of epilepsy but there is a gap in understanding of their role in the community. DESIGN: A national three-stage, mixed-method study was conducted. METHODS: One-on-one, in-depth semi-structured qualitative interviews were conducted online with 12 community-based epilepsy nurses (Stage 1); retrospective analysis of data collected from the National Epilepsy Line, a nurse-led community helpline (Stage 2); and focus group conducted with four epilepsy nurses, to delve further into emerging findings (Stage 3). A thematic analysis was conducted in Stages 1 and 3, and a descriptive statistical analysis of Stage 2 data. Consolidated Criteria for Reporting Qualitative studies checklist was followed for reporting. RESULTS: Three key themes emerged: (1) The epilepsy nurse career trajectory highlighted a lack of standardised qualifications, competencies, and career opportunities. (2) The key components of the epilepsy nurse role explored role diversity, responsibilities, and models of practice in the management of living with epilepsy, and experiences navigating complex fragmented systems and practices. (3) Shifting work practices detailed the adapting work practices, impacted by changing service demands, including COVID-19 pandemic experiences, role boundaries, funding, and resource availability. CONCLUSION: Community epilepsy nurses play a pivotal role in providing holistic, person-centred epilepsy management They contribute to identifying and addressing service gaps through innovating and implementing change in service design and delivery. RELEVANCE TO CLINICAL PRACTICE: Epilepsy nurses' person-centred approach to epilepsy management is influenced by the limited investment in epilepsy-specific integrated care initiatives, and their perceived value is impacted by the lack of national standardisation of their role and scope of practice. NO PATIENT OR PUBLIC CONTRIBUTION: Only epilepsy nurses' perspectives were sought.

An exploratory survey study of disorder and its association with safety culture in four hospitals.

BACKGROUND: Signs of disorder in neighbourhoods (e.g., litter, graffiti) are thought to influence the behaviour of residents, potentially leading to violations of rules and petty criminal behaviour. Recently, these premises have been applied to the hospital context, with physical and social disorder found to have a negative association with patient safety. Building on these results, the present study investigates whether physical and social disorder differ between hospitals, and their relationship to safety culture. METHODS: We conducted a cross sectional survey with Likert-style and open response questions administered in four Australian hospitals. All staff were invited to participate in the pilot study from May to September 2018. An analysis of variance (ANOVA) was used to examine differences in disorder by hospital, and hierarchical linear regression assessed the relationship of physical and social disorder to key aspects of safety culture (safety climate, teamwork climate). Open responses were analysed using thematic analysis to elaborate on manifestations of hospital disorder. RESULTS: There were 415 survey respondents. Significant differences were found in perceptions of physical disorder across the four hospitals. There were no significant differences between hospitals in levels of social disorder. Social disorder had a significant negative relationship with safety and teamwork climate, and physical disorder significantly predicted a poorer teamwork climate. We identified five themes relevant to physical disorder and four for social disorder from participants' open responses; the preponderance of these themes across hospitals supported quantitative results. CONCLUSIONS: Findings indicate that physical and social disorder are important to consider in attempting to holistically understand a hospital's safety culture. Interventions that target aspects of physical and social disorder in a hospital may hold value in improving safety culture and patient safety.

Advancing Australian public health initiatives targeting dementia risk reduction.

Public health initiatives aim to improve health outcomes for populations by preventing disease and ill-health consequences of environmental hazards and natural or human-made disasters. Whilst public health initiatives have been used successfully to modify behaviours for chronic diseases, many initiatives targeting reduced dementia risk in older adults suffer from conceptual and statistical flaws that greatly limit their usefulness. The limited success in modifying lifestyle dementia risk factors has led us to fall short in building a successful roadmap to dementia risk reduction. Here we argue for adopting a population-level, holistic approach to dementia risk reduction strategies across the lifespan. This approach is supplemented by 10 strategies that focus on improving social policies, harnessing existing policy, legislature and incentive schemes, and identifying feasible approaches to increase recreational and transport-related physical activity to creating best practice health care that supports healthy brain ageing for all.

The COVID-19 System Shock Framework: Capturing Health System Innovation During the COVID-19 Pandemic.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has resulted in over 2 million deaths globally. The experience in Australia presents an opportunity to study contrasting responses to the COVID-19 health system shock. We adapted the Hanefeld et al framework for health systems shocks to create the COVID-19 System Shock Framework (CSSF). This framework enabled us to assess innovations and changes created through COVID-19 at the Sydney Children's Hospitals Network (SCHN), the largest provider of children's health services in the Southern hemisphere. METHODS: We used ethnographic methods, guided by the CSSF, to map innovations and initiatives implemented across SCHN during the pandemic. An embedded field researcher shadowed members of the emergency operations centre (EOC) for nine months. We also reviewed clinic and policy documents pertinent to SCHN's response to COVID-19 and conducted interviews and focus groups with stakeholders, including clinical directors, project managers, frontline clinicians, and other personnel involved in implementing innovations across SCHN. RESULTS: The CSSF captured SCHN's complex response to the pandemic. Responses included a COVID-19 assessment clinic, inpatient and infectious disease management services, redeploying and managing a workforce working from home, cohesive communication initiatives, and remote delivery of care, all enabled by a dedicated COVID-19 fund. The health system values that shaped SCHN's response to the pandemic included principles of equity of healthcare delivery, holistic and integrated models of care, and supporting workforce wellbeing. SCHN's resilience was enabled by innovation fostered through a non-hierarchical governance structure and responsiveness to emerging challenges balanced with a singular vision. CONCLUSION: Using the CSSF, we found that SCHN's ability to innovate was key to ensuring its resilience during the pandemic.

Unravelling the truth: Examining the evidence for health-related claims made by naturopathic influencers on social media - a retrospective analysis.

Background: Social media platforms are frequently used by the general public to access health information, including information relating to complementary and alternative medicine (CAM). The aim of this study was to measure how often naturopathic influencers make evidence-informed recommendations on Instagram, and to examine associations between the level of evidence available or presented, and user engagement. Methods: A retrospective observational study using quantitative content analysis on health-related claims made by naturopathic influencers with 30000 or more followers on Instagram was conducted. Linear regression was used to measure the association between health-related posts and the number of Likes, and Comments. Results: A total of 494 health claims were extracted from eight Instagram accounts, of which 242 (49.0%) were supported by evidence and 34 (6.9%) included a link to evidence supporting the claim. Three naturopathic influencers did not provide any evidence to support the health claims they made on Instagram. Posts with links to evidence had fewer Likes (B=-1343.9, 95% CI=-2424.4 to -263.4, X=-0.1, P=0.02) and fewer Comments (B=-82.0, 95% CI=-145.9 to -18.2, X=-0.2, P=0.01), compared to posts without links to evidence. The most common areas of health were claims relating to 'women's health' (n=94; 19.0%), and 'hair, nail and skin' (n=74; 15.0%). Conclusion: This study is one of the first to look at the evidence available to support health-related claims by naturopathic influencers on Instagram. Our findings indicate that around half of Instagram posts from popular naturopathic influencers with health claims are supported by high-quality evidence.

A dynamic systems view of clinical genomics: a rich picture of the landscape in Australia using a complexity science lens.

BACKGROUND: Clinical genomics represents a paradigm shifting change to health service delivery and practice across many conditions and life-stages. Introducing this complex technology into an already complex health system is a significant challenge that cannot be managed in a reductionist way. To build robust and sustainable, high quality delivery systems we need to step back and view the interconnected landscape of policymakers, funders, managers, multidisciplinary teams of clinicians, patients and their families, and health care, research, education, and philanthropic institutions as a dynamic whole. This study holistically mapped the landscape of clinical genomics within Australia by developing a complex graphic: a rich picture. Using complex systems theory, we then identified key features, challenges and leverage points of implementing clinical genomics. METHODS: We used a multi-stage, exploratory, qualitative approach. We extracted data from grey literature, empirical literature, and data collected by the Australian Genomic Health Alliance. Nine key informants working in clinical genomics critiqued early drafts of the picture, and validated the final version. RESULTS: The final graphic depicts 24 stakeholder groups relevant to implementation of genomics into Australia. Clinical genomics lies at the intersection of four nested systems, with interplay between government, professional bodies and patient advocacy groups. Barriers and uncertainties are also shown. Analysis using complexity theory showed far-reaching interdependencies around funding, and identified unintended consequences. CONCLUSION: The rich picture of the clinical genomic landscape in Australia is the first to show key stakeholders, agencies and processes and their interdependencies. Participants who critiqued our results were instantly intrigued and engaged by the graphics, searching for their place in the whole and often commenting on insights they gained from seeing the influences and impacts of other stakeholder groups on their own work. Funding patterns showed unintended consequences of increased burdens for clinicians and inequity of access for patients. Showing the system as a dynamic whole is the only way to understand key drivers and barriers to largescale interventions. TRIAL REGISTRATION: Not applicable.

Unfinished Care in Residential Aged Care Facilities: An Integrative Review.

BACKGROUND AND OBJECTIVES: When workload demands are greater than available time and resources, staff members must prioritize care by degree of importance and urgency. Care tasks assigned a lower priority may be missed, rationed, or delayed; collectively referred to as "unfinished care." Residential aged care facilities (RACFs) are susceptible to unfinished care due to consumers' complex needs, workforce composition, and constraints placed on resource availability. The objectives of this integrative review were to investigate the current state of knowledge of unfinished care in RACFs and to identify knowledge gaps. RESEARCH DESIGN AND METHODS: We conducted a search of academic databases and included English-language, peer-reviewed, empirical journal articles that discussed unfinished care in RACFs. Data were synthesized using mind mapping techniques and frequency counts, resulting in two categorization frameworks. RESULTS: We identified 17 core studies and 27 informing studies (n = 44). Across core studies, 32 types of unfinished care were organized under five categories: personal care, mobility, person-centeredness, medical and health care, and general care processes. We classified 50 factors associated with unfinished care under seven categories: staff member characteristics, staff member well-being, resident characteristics, interactions, resources, the work environment, and delivery of care activities. DISCUSSION AND IMPLICATIONS: This review signifies that unfinished care in RACFs is a diverse concept in terms of types of unfinished care, associated factors, and terminology. Our findings suggest that policymakers and providers could reduce unfinished care by focusing on modifiable factors such as staffing levels. Four key knowledge gaps were identified to direct future research.

The patient died: What about involvement in the investigation process?

Patient and family involvement is high on the international quality and safety agenda. In this paper, we consider possible ways of involving families in investigations of fatal adverse events and how their greater participation might improve the quality of investigations. The aim is to increase awareness among healthcare professionals, accident investigators, policymakers and researchers and examine how research and practice can develop in this emerging field. In contrast to relying mainly on documentation and staff recollections, family involvement can result in the investigation having access to richer information, a more holistic picture of the event and new perspectives on who was involved and can positively contribute to the family's emotional satisfaction and perception of justice being done. There is limited guidance and research on how to constitute effective involvement. There is a need for co-designing the investigation process, explicitly agreeing the family's level of involvement, supporting and preparing the family, providing easily accessible user-friendly language and using different methods of involvement (e.g. individual interviews, focus group interviews and questionnaires), depending on the family's needs.

Staff members' prioritisation of care in residential aged care facilities: a Q methodology study.

BACKGROUND: When healthcare professionals' workloads are greater than available resources, care activities can be missed, omitted or delayed, potentially leading to adverse patient outcomes. Prioritisation, a precursor to missed care, involves decision-making about the order of care task completion based on perceived importance or urgency. Research on prioritisation and missed care has predominantly focused on acute care settings, which differ from residential aged care facilities in terms of funding, structure, staffing levels, skill mix, and approaches to care. The objective of this study was to investigate how care staff prioritise the care provided to residents living in residential aged care. METHODS: Thirty-one staff members from five Australian residential aged care facilities engaged in a Q sorting activity by ranking 34 cards representing different care activities on a pre-defined grid from 'Least important' (- 4) to 'Most important' (+ 4). Concurrently, they participated in a think-aloud task, verbalising their decision-making processes. Following sorting, participants completed post-sorting interviews, a demographics questionnaire and semi-structured interviews. Q sort data were analysed using centroid factor analysis and varimax rotation in PQMethod. Factor arrays and data from the think-aloud task, field notes and interviews facilitated interpretation of the resulting factors. RESULTS: A four-factor solution, representing 22 participants and 62% of study variance, satisfied the selection criteria. The four distinct viewpoints represented by the solution were: 1. Prioritisation of clinical care, 2. Prioritisation of activities of daily living, 3. Humanistic approach to the prioritisation of care, and 4. Holistic approach to the prioritisation of care. Participants' prioritisation decisions were largely influenced by their occupations and perceived role responsibilities. Across the four viewpoints, residents having choices about their care ranked as a lower priority. CONCLUSIONS: This study has implications for missed care, as it demonstrates how care tasks deemed outside the scope of staff members' defined roles are often considered a lower priority. Our research also shows that, despite policy regulations mandating person-centred care and the respect of residents' preferences, staff members in residential aged care facilities tend to prioritise more task-oriented aspects of care over person-centredness.

Assessing the appropriateness of the management of upper respiratory tract infection in Australian children: a population-based sample survey.

OBJECTIVE: To assess the proportion of Australian children aged 0-15 years that received care in line with clinical practice guidelines (CPGs) for upper respiratory tract infections (URTIs). DESIGN: Retrospective medical record review using a multistage sampling strategy. SETTING: General practices, hospital emergency departments and hospital inpatient service providers in three Australian states. PARTICIPANTS: Children aged up to 15 years who received care for URTI in 2012 and 2013. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary assessment was estimated adherence with 14 indicators of appropriate care as documented in medical records. Indicators were extracted from national and international CPGs and ratified by experts. Secondary assessment was adherence to two bundles of indicators (diagnostic symptoms and medical history taking), where all indicators must be adherent for the bundle to be scored as adherent. RESULTS: There were 1653 children with one or more assessments of URTI care to CPG adherence. Over half of the children were under 3 years of age, with roughly equal numbers of males and females. Three indicators had fewer than 25 visits so were not reported. Overall adherence ranged from 0.5% for 'documented advice around antibiotics' to 88.3% for 'documentation of medical history'. Adherence with Bundle A (documentation of all three definitive symptoms) was 43.1% (95% CI 32.8% to 54.0%) and Bundle B (documentation of all four indicators of medical history) was 30.2% (95% CI 20.9% to 40.9%). CONCLUSIONS: URTIs in children are common, usually self-limiting, conditions that are allocated considerable resources. The results suggest that there may be a need for more thorough holistic assessment of the patient and improved documentation. Since inappropriate prescription of antibiotics for URTIs is still a known problem in Australia, there is a need for consistent, clear communication around antibiotics' lack of impact on symptoms and a high association with undesirable side effects.

Are we on the cusp of a fourth research paradigm? Predicting the future for a new approach to methods-use in medical and health services research.

BACKGROUND: The dominant medical and health research paradigm continues to be quantitative. While the authors sense a sea-change in opinion about mixed-method research, underpinned by two decades of highly-cited publications in medical journals, much of the medical literature still widely favours the Randomised Control Trial. MAIN BODY: This debate article examines whether it is the beginning of the end of the dominant quantitative paradigm and the interest this holds for researchers and clinicians at the forefront of care delivery. It examines the Third Research Paradigm, signifying the importance of mixed-methods, and discusses the power of the patient voice and person-focused research activity. The authors discern the coming of age of a Fourth Research Paradigm integrating mixed-methods with data collected 'on the hoof'. Within this new paradigm, the article explores the power of available, real time, and emergent data - from smart phones, wearable devices, and social media, as well as more creative approaches to data collection. The Fourth Research Paradigm will require the support of multi-disciplinary teams, moving through the world alongside their research subjects. The impact of a Fourth Research Paradigm on the health researcher is assessed, as the researcher's gaze moves away from considerations of methodological superiority to re-considerations of their role in the brave new world of research multiplicity. CONCLUSION: The Fourth Research Paradigm offers extensive opportunities to tell more complete research stories in real-time settings. It concentrates on contextual notions of everyday happenings within the ever-changing world of healthcare delivery. There will be challenges ahead, not least the management of large, complex datasets and adaptive study designs. But rigorous planning will enable unique insights into the relationships played out in the world of the patient and healthcare provider. Better care and new delivery models are likely to result, but how this will manifest is not yet clear.

The comparative performance of the Canadian and Australian health systems.

Using three data sets, each providing an overview of health service delivery in high-income countries, this article provides a high-level comparative analysis of health system performance against specified key performance indicators in two jurisdictions: Canada and Australia. Several variations, nuances, and points of comparison between delivery and organization of care are discussed. The article examines three policy and structural differences that may help explain the comparatively superior performance of the Australian system on most indicators, and two key areas of improvement for the Canadian system were illuminated: a stronger central government role and a national pharmaceutical plan. It is hoped that this article will empower health leaders to take action in these areas.

Strengthening the capacity of nursing leaders through multifaceted professional development initiatives: A mixed method evaluation of the 'Take The Lead' program.

BACKGROUND: Effective nursing leadership is necessary for the delivery of safe, high quality healthcare. Yet experience and research tells us that nursing leaders are commonly unprepared for their roles. Take The Lead (TTL), a large-scale, multifaceted professional development program was initiated in New South Wales, Australia, to strengthen the capacity of Nursing/Midwifery Unit Managers (N/MUMs). The aim of this study was to examine the effects of TTL on job performance, nursing leadership and patient experience. METHODS: Nursing/Midwifery Unit Managers (n = 30) and managers of N/MUMs (n = 30) who had completed the TTL program were interviewed between August and December 2010. The semi-structured interviews included a combination of open-ended questions and questions that required respondents to rate statements using a Likert scale. Data from the open-ended questions were thematically analysed to identify and categorise key concepts. The responses to the Likert items were analysed via descriptive statistics. RESULTS: Nursing/Midwifery Unit Managers' participation in TTL engendered improvements in job performance and leadership skills, as well as some improvement in patients' experiences of care. The program facilitated role clarification and helped foster peer-support and learning networks, which were perceived to provide ongoing professional and personal benefits to participants. CONCLUSIONS: Our study revealed a consensus about the beneficial outcomes of TTL among those involved with the program. It supports the significant and ongoing value of widely implemented, multifaceted nursing leadership development programs and demonstrates that participants value their informal interactions as highly as they do the formal content. These findings have implications for delivery mode of similar professional development programs.

Experimenting with clinical networks: the Australasian experience.

PURPOSE: Australian states have embraced clinical networking as a mechanism for managing, organising and improving the quality of care. Using these individualised state approaches to clinical networks, in this paper the authors aim to examine this Australasian "experimentation" and present lessons for other health systems. DESIGN/METHODOLOGY/APPROACH: The paper draws on current knowledge from the literature on clinical networks. The 2010 Inaugural Australasian Clinical Networks Conference also serves as a primary resource, as well as the authors' extensive discussions with policy-makers, managers and clinicians in Australasian systems. FINDINGS: Key themes from the literature include: network type (mandated or natural, and hybrids); network purpose; the importance of network objectives; drivers of network success and barriers; the need for consumer engagement; and the difficulty of evaluating network effectiveness. Policy challenges include the establishment of networks for some specialty areas and not others; how to develop common standards across networks; and the need for performance metrics to assess network impact on patient outcomes. Australian networks report difficulties with achieving greater involvement of rural clinicians and indigenous populations, and with private sector clinical engagement. There are challenges too with implementation, at service level, of models of care and recommendations. ORIGINALITY/VALUE: Clinical networks are becoming a fundamental vehicle for clinical improvement and change across complex organisational and professional boundaries. How to nurture and sustain effective clinical networks is of import to every health system and the authors invite stakeholders in health systems to network and share their empirical research on clinical networks to assist with distinguishing the evidence from the rhetoric.

Professional conceptualisation and accomplishment of patient safety in mental healthcare: an ethnographic approach.

BACKGROUND: This study seeks to broaden current understandings of what patient safety means in mental healthcare and how it is accomplished. We propose a qualitative observational study of how safety is produced or not produced in the complex context of everyday professional mental health practice. Such an approach intentionally contrasts with much patient safety research which assumes that safety is achieved and improved through top-down policy directives. We seek instead to understand and articulate the connections and dynamic interactions between people, materials, and organisational, legal, moral, professional and historical safety imperatives as they come together at particular times and places to perform safe or unsafe practice. As such we advocate an understanding of patient safety 'from the ground up'. METHODS/DESIGN: The proposed project employs a six-phase data collection framework in two mental health settings: an inpatient unit and a community team. The first four phases comprise multiple modes of focussed, unobtrusive observation of professionals at work, to enable us to trace the conceptualisation and enactment of safety as revealed in dialogue and narrative, use of artefacts and space, bodily activity and patterns of movement, and in the accomplishment of specific work tasks. An interview phase and a social network analysis phase will subsequently be conducted to offer comparative perspectives on the observational data. This multi-modal and holistic approach to studying patient safety will complement existing research, which is dominated by instrumentalist approaches to discovering factors contributing to error, or developing interventions to prevent or manage adverse events. DISCUSSION: This ethnographic research framework, informed by the principles of practice theories and in particular actor-network ideas, provides a tool to aid the understanding of patient safety in mental healthcare. The approach is novel in that it seeks to articulate an 'anatomy of patient safety' as it actually occurs, in terms of the networks of elements coalescing to enable the conceptual and material performance of safety in mental health settings. By looking at how patient safety happens or does not happen, this study will enable us to better understand how we might in future productively tackle its improvement.

Integrated care in the emergency department: a complex adaptive systems perspective.

Emergency clinicians undertake boundary-work as they facilitate patient trajectories through the Emergency Department (ED). Emergency clinicians must manage the constantly-changing dynamics at the boundaries of the ED and other hospital departments and organizations whose services emergency clinicians seek to integrate. Integrating the care that differing clinical groups provide, the services EDs offer, and patients' needs across this journey is challenging. The journey is usually accounted for in a linear way - as a "continuity of care" problem. In this paper, we instead conceptualize integrated care in the ED using a complex adaptive systems (CAS) perspective. A CAS perspective accounts for the degree to which other departments and units outside of the ED are integrated, and appropriately described, using CAS concepts and language. One year of ethnographic research was conducted, combining observation and semi-structured interviews, in the EDs of two tertiary referral hospitals in Sydney, Australia. We found the CAS approach to be salient to analyzing integrated care in the ED because the processes of categorization, diagnosis and discharge are primarily about the linkages between services, and the communication and negotiation required to enact those linkages, however imperfectly they occur in practice. Emergency clinicians rapidly process large numbers of high-need patients, in a relatively efficient system of care inadequately explained by linear models. A CAS perspective exposes integrated care as management of the patient trajectory within porous, shifting and negotiable boundaries.

Promoting safety: longer-term responses of three health professional groups to a safety improvement programme.

PURPOSE: Patient safety has been addressed since 2002 in the health system of New South Wales, Australia via a Safety Improvement Programme (SIP), which took a system-wide approach. The programme involved two-day courses to educate healthcare professionals to monitor and report incidents and analyse adverse events by conducting root cause analysis (RCA). This paper aims to predict that all professions would favour SIP but that their work and educational histories would result in doctors holding the least and nurses the most positive attitudes. Alternative hypotheses were that doctors' relative power and other professions' team-working skills would advantage the respective groups when conducting RCAs. DESIGN/METHODOLOGY/APPROACH: Responses to a 2005 follow-up questionnaire survey of doctors (n = 53), nurses (209) and allied health staff (59), who had participated in SIP courses, were analysed to compare: their attitudes toward the course; safety skills acquired and applied; perceived benefits of SIP and RCAs; and their experiences conducting RCAs. FINDINGS: Significant differences existed between professions' responses with nurses being the most and doctors the least affirming. Allied health responses resembled those of nurses more than those of doctors. The professions' experiences conducting RCAs (number conducted, leadership, barriers encountered, findings implemented) were similar. RESEARCH LIMITATIONS/IMPLICATIONS: Observational studies are needed to determine possible professional differences in the conduct of RCAs and any ensuing culture change that this may be eliciting. PRACTICAL IMPLICATIONS: There is strong professional support for SIPs but less endorsement from doctors, who tend not to prefer the knowledge content and multidisciplinary teaching environment considered optimal for safety improvement education. This is a dilemma that needs to be addressed. ORIGINALITY/VALUE: Few longer-term SIPs' assessments have been realised and the differences between professional groups have not been well quantified. As a result of this paper, benefits of and barriers to conducting RCAs are now more clearly understood.

Are health systems changing in support of patient safety? A multi-methods evaluation of education, attitudes and practice.

PURPOSE: The purpose of this study is to evaluate the effects of a health system-wide safety improvement program (SIP) three to four years after initial implementation. DESIGN/METHODOLOGY/APPROACH: The study employs multi-methods studies involving questionnaire surveys, focus groups, in-depth interviews, observational work, ethnographic studies, documentary analysis and literature reviews with regard to the state of New South Wales, Australia, where 90,000 health professionals, under the auspices of the Health Department, provide healthcare to a seven-million population. After enrolling many participants from various groups, the measurements included: numbers of staff trained and training quality; support for SIP; clinicians' reports of safety skills acquired, work practices changed and barriers to progress; RCAs undertaken; observation of functioning of teams; committees initiated and staff appointed to deal with adverse events; documentation and computer records of reports; and peak-level responses to adverse events. FINDINGS: A cohort of 4 per cent of the state's health professionals has been trained and now applies safety skills and conducts RCAs. These and other senior professionals strongly support SIP, though many think further culture change is required if its benefits are to be more fully achieved and sustained. Improved information-handling systems have been adopted. Systems for reporting adverse incidents and conducting RCAs have been instituted, which are co-ordinated by NSW Health. When the appropriate structures, educational activities and systems are made available in the form of an SIP, measurable systems change might be introduced, as suggested by observations of the attitudes and behaviours of health practitioners and the increased reporting of, and action about, adverse events. ORIGINALITY/VALUE: Few studies into health systems change employ wide-ranging research methods and metrics. This study helps to fill this gap.