The role of experimenter familiarity in children's eyewitness identification.

Child eyewitnesses show a high false identification rate on target-absent (TA) lineups despite good performance on target-present (TP) lineups. One explanation is that children feel a social pressure to choose when presented with a TA lineup. We investigated whether experimenter familiarity would reduce social pressure and improve accuracy on TA lineups. Children (5-7 years, N = 120) watched a short video of a staged theft; 1-2 days later they completed a TP or TA lineup with a familiar or unfamiliar experimenter. Experimenter familiarity had an impact on lineup response in TA lineups only, with more correct 'not there' and fewer 'not sure' responses when the children were familiar with the experimenter. The results provide further evidence to support the social aspect of eyewitness identification decisions in children and provide a possible strategy to improve identification accuracy for those working with children in the criminal justice system.

Electronic witnessing in the medically assisted reproduction laboratory: insights and considerations after 10 years of use.

STUDY QUESTION: What have we learnt after 10 years of electronic witnessing? SUMMARY ANSWER: When applied correctly, an electronic witnessing system can replace manual witnessing in the medically assisted reproduction lab to prevent sample mix-up. WHAT IS KNOWN ALREADY: Electronic witnessing systems have been implemented to improve the correct identification, processing, and traceability of biological materials. When non-matching samples are simultaneously present in a single workstation, a mismatch event is generated to prevent sample mix-up. STUDY DESIGN, SIZE, DURATION: This evaluation investigates the mismatch and administrator assign rate over a 10-year period (March 2011-December 2021) with the use of an electronic witnessing system. Radiofrequency identification tags and barcodes were used for patient and sample identification. Since 2011, IVF and ICSI cycles and frozen embryo transfer cycles (FET) were included; IUIs cycles were included since 2013. PARTICIPANTS/MATERIALS, SETTING, METHODS: The total number of tags and witnessing points were recorded. Witnessing points in a particular electronic witnessing system represent all the actions that have been performed from gamete collection through embryo production, to cryopreservation and transfer. Mismatches and administrator assigns were collected and stratified per procedure (sperm preparation, oocyte retrieval, IVF/ICSI, cleavage stage embryo or blastocyst embryo biopsy, vitrification and warming, embryo transfer, medium changeover, and IUI). Critical mismatches (such as mislabelling or non-matching samples within one work area) and critical administrator assigns (such as samples not identified by the electronic witnessing system and unconfirmed witnessing points) were selected. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 109 655 cycles were included: 53 023 IVF/ICSI, 36 347 FET, and 20 285 IUI cycles. The 724 096 used tags, led to a total of 849 650 witnessing points. The overall mismatch rate was 0.251% (2132/849 650) per witnessing point and 1.944% per cycle. In total, 144 critical mismatches occurred over the different procedures. The yearly mean critical mismatch rate was 0.017 ± 0.007% per witnessing point and 0.129 ± 0.052% per cycle. The overall administrator assign rate was 0.111% (940/849 650) per witnessing point and 0.857% per cycle, including 320 critical administrator assigns. The yearly mean critical administrator assign rate was 0.039 ± 0.010% per witnessing point and 0.301 ± 0.069% per cycle. Overall mismatch and administrator assign rates remained fairly stable during the evaluated time period. Sperm preparation and IVF/ICSI were the procedures most prone to critical mismatch and administrator assigns. LIMITATIONS, REASONS FOR CAUTION: The procedures and methods of integration of an electronic witnessing system may vary from one laboratory to another and result in differences in the potential risks related to sample identification. Individual embryos cannot (yet) be identified by such a system; this makes extra manual witnessing indispensable at certain critical steps where potential errors are not recorded. The electronic witnessing system still needs to be used in combination with manual labelling of both the bottom and lid of dishes and tubes to guarantee correct assignment in case of malfunction or incorrect use of radiofrequency identification tags. WIDER IMPLICATIONS OF THE FINDINGS: Electronic witnessing is considered to be the ultimate tool to safeguard correct identification of gametes and embryos. But this is only possible when used correctly, and proper training and attention of the staff is required. It may also induce new risks, i.e. blind witnessing of samples by the operator. STUDY FUNDING/COMPETING INTEREST(S): No funding was either sought or obtained for this study. J.S. presents webinars on RIW for CooperSurgical. The remaining authors have nothing to declare. TRIAL REGISTRATION NUMBER: N/A.

LGBTQ+ cultural-competence training effectiveness: Mental health organization and therapist survey outcome results from a pilot randomized controlled trial.

Lesbian, gay, bisexual, transgender, queer/questioning and other sexual and gender diverse (LGBTQ+) persons frequently lack access to mental health service organizations (MHOs) and therapists who are competent with LGBTQ+ clients. Existing continuing education programmes to better equip therapists to work with LGBTQ+ clients are often not widely accessible or skills focused, evaluated for effectiveness and inclusive of MHO administrators who can address the organizational climate needed for therapist effectiveness. A virtual, face-to-face, multi-level (administrators and therapists) and multi-strategy (technical assistance, workshop and clinical consultations) LGBTQ+ cultural competence training-the Sexual and Gender Diversity Learning Community (SGDLC)-was tested in a pilot randomized controlled trial. Ten organizations were randomly assigned to the intervention (SGDLC plus free online videos) or control (free online videos only) group. Pretest/posttest Organization LGBTQ+ Climate Surveys (n = 10 MHOs) and pretest/posttest Therapist LGBTQ+ Competence Self-Assessments (n = 48 therapists) were administered. Results showed that at pretest, average ratings across organization LGBTQ+ climate survey items were low; twice as many items improved on average in the intervention (10/18 items) than control (5/18 items) group organizations. At pretest, therapist average scores (range 0-1) were highest for knowledge (0.88), followed by affirmative attitudes (0.81), practice self-efficacy (0.81), affirmative practices (0.75) and commitment to continued learning (0.69). Pretest/posttest change scores were higher for the intervention relative to the control group regarding therapist self-reported affirmative attitudes (cumulative ordinal ratio [OR] = 3.29; 95% confidence interval [CI] = 1.73, 6.26), practice self-efficacy (OR = 5.28, 95% CI = 2.00, 13.93) and affirmative practices (OR = 3.12, 95% CI = 1.18, 8.25). Average therapist and administrator satisfaction scores were high for the SGDLC. These findings suggest the SGDLC training can affect organizational- and therapist-level changes that may benefit LGBTQ+ clients.

A four-year analysis of US and Canadian academic nurse administrators' job satisfaction and intent to stay.

BACKGROUND: A crisis in vacancies for academic nurse leaders across North American has been recognized. Their role has become increasingly multifaceted, facing rapidly changing responsibilities that must evolve with health care, higher education and leadership. PURPOSE: This retrospective study was conducted to investigate relationships among relevant variables included in the COACHE Faculty Job Satisfaction survey. METHODS: The sample included survey responses from academic nursing administrators (n = 174). Analysis of variance and multiple linear regression modeling were utilized. DISCUSSION: Clarity in the tenure process (F (6, 92) = 2.92, p = .001), collaboration (p =.000) as well as academic leadership decisions of the dean or division chair (p = .006), and work-life balance (p =.005) were found to be significant. CONCLUSIONS: Understanding the factors important to administrators will assist in innovative approaches to attract and retain qualified leaders.

Moral distress in nurse leaders-A scoping review of the literature.

Nurse leaders face immense organizational pressures exacerbating their distress, which has not been prioritized as much as frontline nurses. This review synthesized the literature to examine theoretical models, measures, contributing factors, outcomes, and coping strategies related to moral distress in nurse leaders. PubMed, Embase, CINAHL, and PsycINFO were searched, and 15 articles-2 quantitative and 13 qualitative studies were extracted. The scoping review identified one study using a theoretical model and two measures-the ethical dilemmas questionnaire and the Brazilian moral distress scale. Contributing factors of moral distress include internal and organizational constraints, increased workload, and lack of support impacting physical and emotional well-being and intention to quit. This review did not yield any intervention studies emphasizing the need for research to identify specific predictors of moral distress and examine their relationship to nurse leader retention, so organizations can explore targeted interventions to promote coping and mitigate distress.

Leading Through Loss: Experiences of Nursing Home Administrators-in-Training During the COVID-19 Pandemic.

End-of-life care is a critical aspect of long-term care, yet there is limited understanding of nursing home staff's experiences and preparation in this area, particularly among facility administrators. To address this gap, two cohorts of Administrators-in-Training (2021 & 2022) were interviewed about their knowledge and practices regarding end-of-life care in skilled nursing facilities. Interviews focused on involvement in end-of-life discussions, coping strategies, grief support, and personal perspectives on death. The findings revealed a significant lack of training on death management and end-of-life care for Administrators-in-Training (AITs), with limited grief support mechanisms in place within skilled nursing facilities. Personal experiences with death influenced AITs' approach to end-of-life care, and various coping strategies were observed. The results highlight the need for comprehensive training programs and improved support for AITs to enhance end-of-life care delivery.

A survey of the perceptions of barriers to and facilitators of cardiac rehabilitation in healthcare providers and policy stakeholders.

BACKGROUND: Cardiac rehabilitation (CR) is a prognostic management strategy to help patients with CVD achieve a good quality of life and lower the rates of recurrence, readmission, and premature death from disease. Globally, cardiac rehabilitation is poorly established in hospitals and communities. Hence, this study aimed to investigate the discrepancies in the perceptions of the need for CR programs and relevant health policies between directors of hospitals and health policy personnel in South Korea to shed light on the status and to establish practically superior and effective strategies to promote CR in South Korea. METHODS: We sent a questionnaire to 592 public health policy managers and directors of selected hospitals, 132 of whom returned a completed questionnaire (response rate: 22.3%). The participants were categorized into five types of organizations depending on their practice of PCI (Percutaneous Coronary Intervention), establishment of cardiac rehabilitation, director of hospital, and government's policy makers. Differences in the opinions between directors of hospitals that perform/do not perform PCI, directors of hospitals with/without cardiac rehabilitation, and between hospital directors and health policy makers were analyzed. RESULTS: Responses about targeting diseases for cardiac rehabilitation, patients' roles in cardiac rehabilitation, hospitals' roles in cardiac rehabilitation, and governmental health policies' roles in cardiac rehabilitation were more positive among hospitals that perform PCI than those that do not. Responses to questions about the effectiveness of cardiac rehabilitation and hospitals' roles in cardiac rehabilitation tended to be more positive in hospitals with cardiac rehabilitation than in those without. Hospital directors responded more positively to questions about targeting diseases for cardiac rehabilitation and governmental health policies' roles in cardiac rehabilitation than policy makers, and both hospitals and public organizations provided negative responses to the question about patients' roles in cardiac rehabilitation. Responses to questions about targeting diseases for cardiac rehabilitation, patients' roles in cardiac rehabilitation, and governmental health policies' roles in cardiac rehabilitation were more positive in hospitals that perform PCI than those that do not and public organizations. CONCLUSIONS: Hospitals must ensure timely referral, provide education, and promote the need for cardiac rehabilitation. In addition, governmental socioeconomic support is needed in a varity of aspects.

Work environment, resilience, burnout, intent to leave during COVID pandemic among nurse leaders: A cross-sectional study.

AIMS: The aims of this work are to (1) investigate the work environment, resilience, burnout, and turnover intention and (2) examine how work environment and personal resilience impact burnout and turnover intention among nurse leaders in the midst of the COVID-19 crisis. BACKGROUND: The COVID-19 pandemic introduced tremendous stressors to nurse leaders, for example, managing the complex staffing situation while balancing patients' and family's needs. METHODS: During May to September 2021, an electronic survey was sent out to nurse leaders in Birmingham, Alabama, USA, and surrounding areas. RESULTS: Fifty-six respondents were included in the study. The composite score of the work environment measure was moderately to highly related to resilience [ρ (rho) = .59] and burnout [ρ = -.63 to -.68] but had small association to intent to leave [ρ = -.30]. The resilience was highly correlated to burnout [ρ = -.53 to -.59] and moderately associated to intent to leave [ρ = -.32]. CONCLUSIONS: A better work environment for nurse leaders is related to higher resilience, lower burnout, and lower turnover intention. Resilience impacts burnout and turnover intention among nurse leaders. IMPLICATIONS FOR NURSING MANAGEMENT: Health care organizations and stakeholders should implement effective strategies to improve the work environment, which could lead to enhanced resilience, reduced burnout, and lower turnover intention of their nurse leaders especially during and following this pandemic.

An Examination of Assisted Living Facility Administrator Qualifications Across States.

Resident acuity, Medicaid's increased role in funding assisted living, and the COVID-19 pandemic have brought increased attention to the regulatory environment of assisted living facilities (ALFs) and the responsibilities of ALF administrators (ALFAs) are growing increasingly complex. This study explores, describes, and compares the education (degree and assisted living-specific training), experience, exam (competency), and continuing education requirements for ALFAs across all states, and how states' requirements compare to national assisted living associations' suggested standards for entry-level and ongoing practice. Wide variation in ALFA qualifications are identified, with some states found to have extremely low qualification requirements.

Implementing culturally competent transplant care and implications for reducing health disparities: A prospective qualitative study.

BACKGROUND: Despite available evidence-based interventions that decrease health disparities, these interventions are often not implemented. Northwestern Medicine's® Hispanic Kidney Transplant Program (HKTP) is a culturally and linguistically competent intervention designed to reduce disparities in living donor kidney transplantation (LDKT) among Hispanics/Latinos. The HKTP was introduced in two transplant programs in 2016 to evaluate its effectiveness. OBJECTIVE: This study assessed barriers and facilitators to HKTP implementation preparation. METHODS: Interviews and group discussions were conducted with transplant stakeholders (ie administrators, nurses, physicians) during implementation preparation. The Consolidated Framework for Implementation Research (CFIR) guided interview design and qualitative analysis. RESULTS: Forty-four stakeholders participated in 24 interviews and/or 27 group discussions. New factors, not found in previous implementation preparation research in health-care settings, emerged as facilitators and barriers to the implementation of culturally competent care. Implementation facilitators included: stakeholders' focus on a moral imperative to implement the HKTP, personal motivations related to their Hispanic heritage, and perceptions of Hispanic patients' transplant education needs. Implementation barriers included: stakeholders' perceptions that Hispanics' health insurance payer mix would negatively impact revenue, a lack of knowledge about LDKT disparities and patient data disaggregated by ethnicity/race, and a perception that the family discussion component was immoral because of the possibility of coercion. DISCUSSION AND CONCLUSIONS: Our study identified novel barriers and facilitators to the implementation preparation of a culturally competent care intervention. Healthcare administrators can facilitate organizations' implementation of culturally competent care interventions by understanding factors challenging care delivery processes and raising clinical team awareness of disparities in LDKT.

Teacher Power and the Politics of Union Organizing in the Charter Sector.

Despite the growing media attention paid to charter-school unions, comparatively little empirical research exists. Drawing on interview data from two cities (Detroit, MI, and New Orleans, LA), our exploratory study examined charter-school teachers' motivations for organizing, the political and power dimensions, and the framing of unions by both teachers and administrations. We found that improving teacher retention, and thus school stability, was a central motivation for teacher organizers, whereas, simultaneously, high teacher turnover stymied union drives. We also found that charter administrators reacted with severity to nascent unionization drives, harnessing school-as-family metaphors and at-will contracts to prevent union formation. As the charter sector continues to grow, understanding why teachers want unions and how those unions differ from traditional public school unions is crucial to analyzing the long-term viability of these schools and the career trajectories of the teachers who work in them.

Can Lineup Administrators Blind to the Suspect's Identity Influence Witnesses' Decisions?

It is advocated that police lineup administrators should be blind to the identity of suspects to prevent them from influencing witnesses' decisions. Yet, it has been found that a lineup administrator who is blind to the suspect's identity may bias a witness's decision if he or she has previously administered the lineup to another witness to the same crime. In the present two experiments these findings are examined and expanded upon. Administrators blind to the suspect's identity presented a sequential lineup to a confederate and then a naïve witness under the manipulations of the confederate witness's decisiveness, confidence and decision speed. The findings of the previous study were not replicated; however, the second witness identifications matched the confederate's selection significantly more often when the confederate's decision was rapid rather than slow. Given the potentially dire consequences of such an effect, it is argued that different blind lineup administrators should be used for each witness to a crime.

Malaysian Journal of Medical Sciences' Performance Status in 2017 and the Challenges.

This report presents a review of the Malaysian Journal of Medical Sciences' (MJMS) performance status throughout 2017, which covers the submission pattern of original manuscripts by month, the geographical distribution of submitting authors, the types of manuscripts and overall acceptance/rejection rates. As the years progress, MJMS continues to receive an escalating number of manuscript submissions. This contributes to an ever-increasing workload, which makes administrative tasks continually more challenging. Although the manuscript submission platform seeks to minimise the pre-publication workload of the journal administrator, it is still a time-consuming task, particularly when authors seek exclusive attention for their submitted manuscripts.

[The Modern Characteristics of Anti-Tuberculosis Care Support of Population of the Chechen Republic].

Despite a steady tendency of decreasing of indices of morbidity of tuberculosis of population of the Chechen Republic, the problems related to early diagnosis of tuberculosis and organization of specialized medical care of patients continue to be unresolved. The questionnaire survey of administrators of anti-tuberculosis medical organizations of the Chechen Republic was carried out with the purpose of establishing difficulties in medical care support of patients with tuberculosis and determining main directions of their overcoming. The results of study demonstrated that main problems are asocial behavior of patients, inadequate staffing of institutions with medical and paramedical personnel, absence of proper relationship with other medical organizations, inadequate level of financing. The administrators indicated as main directions of solving problems increasing of remuneration of labor of medical personnel of anti-tuberculosis medical organizations, development of social defense of patients, physicians and population, alteration of actual normative legal base according to modern social economic conditions, enhancement of preventive direction of work, optimization of manning table and standards of work load of physicians and also development of tactics of treatment and re-organization of dispensary observation of patients with tuberculosis.

The Behavioral and Social Sciences: Contributions and Opportunities in Academic Medicine.

The Association of American Medical Colleges plays a leading role in supporting the expansion and evolution of academic medicine and medical science in North America, which are undergoing high-velocity change. Behavioral and social science concepts have great practical value when applied to the leadership practices and administrative structures that guide and support the rapid evolution of academic medicine and medical sciences. The authors are two behavioral and social science professionals who serve as academic administrators in academic medical centers. They outline their career development and describe the many ways activities have been shaped by their work with the Association of American Medical Colleges. Behavioral and social science professionals are encouraged to become change agents in the ongoing transformation of academic medicine.

Challenges to the provision of community aged care services across rural Australia: perceptions of service managers.

INTRODUCTION: The Australian community aged care sector is facing a growing workforce crisis, particularly in rural and regional areas. Its predominantly female workforce is ageing, and recruiting younger, skilled workers is proving difficult. The service sector, too, is proving highly complex and diverse as a result of contemporary aged care service reforms as well as ongoing difficulties in providing services to the growing numbers of older people living in Australia's rural areas. Despite these multiple challenges, there is a gap in research that explores how rural aged care services manage their day-to-day requirements for skilled workers across the diverse service sector. To address this gap, this article reports on the experiences and perceptions of a small sample of service managers whose organisations represent this diversity, and who are accountable for care provision in regional and rural locations. In such areas, recruitment and skill needs are contoured by disproportionate aged populations, distance and reduced service availability. METHODS: Eleven service managers were interviewed as part of a larger project that examined the skill and training needs of community aged care workers within the Riverina, a rural region in New South Wales. Qualitative data drawn from semi-structured interviews were thematically analysed to identify the managers' individual needs for workers and skills in the context of location, service parameters and availability of other health and community services. RESULTS: Thematic analysis of the interview data elicited three themes: services, roles and skill deployment; older workers and gendered roles; and barriers to recruitment. The findings illustrate the complexities that characterise the community aged care sector as a whole and the impact of these on individual services located in regional and rural parts of Australia. The participants reported diverse needs for worker skills in keeping with the particular level of service they provide. Significantly, their varying perceptions and practices reflect their preference for older, female workers; their reluctance to take on younger workers is negatively skewed by a lack of capacity to compete for, recruit and retain such workers and to offer incentives in the form of enhanced roles and career development. CONCLUSIONS: The findings highlight the conceptual ambiguities inherent in definitions of community aged care work as broadly skilled and uniformly sought across the sector. On the one hand, demands for more and better trained workers to meet growing client complexity locate care work as skilled. On the other, managers of narrowly defined service activities may rely on a diminishing workforce whose skills they downplay in gendered and lay terms. This contradiction corresponds with long-held conclusions about the gendered, exploitative reputation of care work, a characterisation discursively constructed by privileging the moral dimensions of the job over the technical skills required for it. Significantly, the findings raise questions about the capacity of services, as they are currently structured and differentiated, to reshape and redefine aged care work as a 'good job', one that holds appeal and tangible rewards for new and younger skilled workers.

Promoting colorectal cancer screening through a new model of delivering rural primary care in the USA: a qualitative study.

INTRODUCTION: Despite the known benefits of colorectal cancer (CRC) screening, rural areas have consistently reported lower screening rates than their urban counterparts. Alternative healthcare delivery models, such as accountable care organizations (ACOs), have the potential to increase CRC rates through collaboration among healthcare providers with the aim of improving quality and decreasing cost. However, researchers have not sufficiently explored how this innovative model could influence the promotion of cancer screening. The purpose of the study was to explore the mechanism of how CRC screening can be promoted in ACO-participating rural primary care clinics. METHODS: The study collected qualitative data from in-depth interviews with 21 healthcare professionals employed in ACO-participating primary care clinics in rural Nebraska. Participants were asked about their views on opportunities and challenges to promote CRC screening in an ACO context. Data were analyzed using a grounded theory approach. RESULTS: The study found that the new healthcare delivery model can offer opportunities to promote cancer screening in rural areas through enhanced electronic health record use, information sharing and collaborative learning within ACO networks, use of standardized quality measures and performance feedback, a shift to preventive/comprehensive care, adoption of team-based care, and empowered care coordinators. The perceived challenges were found in financial instability, increased staff workload, lack of provider training/education, and lack of resources in rural areas. CONCLUSIONS: This study found that the innovative care delivery model, ACO, could provide a well-designed platform for promoting CRC screening in rural areas, if sustainable resources (eg finance, health providers, and education) are provided. This study provides 'practical' information to identify effective and sustainable intervention programs to promote preventive screening. Further efforts are needed to facilitate delivery system reforms in rural primary care, such as improving performance evaluation measures and methods.

Nurse administrators' intentions and considerations in recruiting inactive nurses.

AIMS: To understand nurse administrators' intentions and considerations in recruiting inactive nurses and to examine predictors of intent to recruit. BACKGROUND: Few studies have provided insight into employer intentions and considerations in recruiting inactive nurses. METHODS: A census survey collected data from 392 nurse administrators via a mailing method. RESULTS: Overall, 89.0% of nurse administrators were willing to recruit inactive nurses. Stepwise regression analysis revealed that the only predictor of nurse administrators' intention to recruit was nurse turnover rate at the hospital. Nurse administrators perceived the most important recruiting considerations were inactive nurses' cooperation with alternating shifts, health status and nursing licence. The most frequent reasons for not recruiting were an inactive nurse's lack of understanding of the medical environment and poor nursing competence. CONCLUSIONS: Most hospital nurse administrators were willing to recruit inactive nurses. Inactive nurses who wish to return to work should be qualified, willing to work both day and night shifts, and in good health. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse administrators can reduce the nursing shortage by recruiting inactive nurses. Re-entry preparation programmes should be implemented that will provide inactive nurses with knowledge of the current medical environment and the skills required to improve their nursing competence.

Early elective delivery and vaginal birth after cesarean in rural US maternity hospitals.

INTRODUCTION: The purpose of this study was to describe policies on early elective delivery (EED) and vaginal birth after cesarean (VBAC) in rural US maternity hospitals and to measure whether hospital policies differ by staffing, facilities, or birth volume. METHODS: Data came from a telephone survey, conducted among all rural maternity hospitals in nine US states from November 2013 to March 2014, to report on EED and VBAC at the hospital level. The associations between EED and VBAC and hospital characteristics were analyzed using χ2 and Fisher's exact tests. RESULTS: Most rural maternal hospitals (70.1%) had a 'hard stop' EED policy, whereby elective delivery before 39 weeks gestation was prohibited. Less than half of the rural hospitals surveyed allowed VBACs (38.1%). Rural hospitals with a higher birth volume (p=0.001), with a dedicated obstetric operating room (p<0.001), and where obstetricians and certified nurse-midwives attended deliveries (p=0.010 and p=0.030, respectively) were more likely to allow VBAC deliveries. Hospitals where family physicians and general surgeons attended deliveries were less likely to allow VBAC deliveries (p=0.002 and p=0.040, respectively). CONCLUSIONS: Most rural US maternity hospitals have a hard stop EED policy, consistent with evidence and guideline recommendations. Access to VBAC varies across rural settings, possibly owing to capacity limitations to provide this option. Further research is needed to determine whether and how best to safely implement national recommendations for EED and VBAC policies across a range of rural settings.

Doctors as street-level bureaucrats in a rural hospital in South Africa.

INTRODUCTION: In the perspectives of implementation of policy, the top-down and bottom-up perspectives of policy-making dominate the discourse. However, service delivery and therefore the experience of the policy by the citizen ultimately depend on the civil servant at the front line to implement the policy. Lipsky named this street-level bureaucracy, which has been used to understand professionals working in the public sector throughout the world. The public sector in South Africa has undergone a number of changes in the transition to a democratic state, post 1994. This needs to be understood in public administration developments throughout the world. At the time of the study, the public sector was characterized by considerable inefficiencies and system failures as well as inequitable distribution of resources. The context of the study was a rural hospital serving a population of approximately 150 000. RESULTS: An insider-ethnography over a period of 13 months explored the challenges of being a professional within the public sector in a rural hospital in South Africa. Data collection included participant observation, field notes of events and meetings, and documentation review supplemented with in-depth interviews of doctors working at a rural hospital. Street-level bureaucracy was used as a framework to understand the challenges of being a professional and civil servant in the public sector. RESULTS: The context of a resource-constrained setting was seen as a major limitation to delivering a quality service. Yet considerable evidence pointed to doctors (both individually and collectively) being active in managing the services in the context and aiming to achieve optimal health service coverage for the population. In the daily routine of the work, doctors often advocated for patients and went beyond the narrow definitions of the guidelines. They compensated for failing systems, beyond a local interpretation of policy. However, doctors also at times used their discretion negatively, to avoid work or to contribute to the inefficiencies of healthcare delivery. CONCLUSIONS: While appearing to be in conflict, the merging of the roles of the health professional and the bureaucrat is required to be able to function effectively within the healthcare system. Being a doctor and being a civil servant are synergistic in daily work, and as a result it is difficult to neatly differentiate professional and civil servant roles in decision-making. It is in the discretion of both roles that considerable flexibility within the roles is possible. Such freedom to act is critical for being able to find local solutions and thereby improve healthcare services. The findings resonate strongly with studies from other parts of the world and offer a window into making sense of the local decision making of doctors. Street-level bureaucracy remains an important lens to view the work of healthcare professionals in the public sector. In the tension between the top-down policy-making and the bottom-up pressure, street-level bureaucracy acts as an important terrain for improving the implementation of services and therefore advocacy and health system improvement.