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Article
Publication date: 9 October 2007

Mary T. Westbrook, Jeffrey Braithwaite, Joanne F. Travaglia, Debbi Long, Christine Jorm and Rick A. Iedema

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…

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1293

Abstract

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.

Details

International Journal of Health Care Quality Assurance, vol. 20 no. 7
Type: Research Article
ISSN: 0952-6862

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Article
Publication date: 11 September 2007

Jeffrey Braithwaite, Rick A. Iedema and Christine Jorm

The purpose of the paper is to examine the deep conceptual underpinnings of trust and communication breakdowns via selected health inquiries into things that go wrong…

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2385

Abstract

Purpose

The purpose of the paper is to examine the deep conceptual underpinnings of trust and communication breakdowns via selected health inquiries into things that go wrong using evolutionary psychology.

Design/methodology/approach

This paper explains how this is carried out, and explores some of the adverse consequences for patient care. Evolutionary psychology provides a means of explaining important mental capacities and constructs including theory of mind and the social brain hypothesis. To have a theory of mind is to be able to read others' behaviours, linguistic and non‐verbal cues, and analyse their intentions. To have a social (or Machiavellian) brain means being able to assess, compete with and, where necessary, outwit others. In the tough and complex environment of the contemporary health setting, not too different from the Pleistocene, humans display a well‐developed theory of mind and social brains and, using mental attributes and behavioural repertoires evolved for the deep past in hunter‐gatherer bands, survive and thrive in difficult circumstances.

Findings

The paper finds that, while such behaviours cannot be justified, armed with an evolutionary approach one can predict survival mechanisms such as turf protection, competitive strategies, sending transgressors and whistleblowers to Coventry, self‐interest, and politics and tribal behaviours.

Originality/value

The paper shows that few studies examine contemporary health sector behaviours through an evolutionary psychology lens or via such deep accounts of human nature.

Details

Journal of Health Organization and Management, vol. 21 no. 4/5
Type: Research Article
ISSN: 1477-7266

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Article
Publication date: 3 August 2006

Rick Iedema, Rowena Forsyth, Andrew Georgiou, Jeffrey Braithwaite and Johanna Westbrook

This paper discusses video ethnography as part of a multimethod study of the introduction of information technology to streamline pathology test order entry in hospitals…

Abstract

This paper discusses video ethnography as part of a multimethod study of the introduction of information technology to streamline pathology test order entry in hospitals and its effect on the work of pathology laboratory scientists. The paper opens with an overview of video research in health care settings. After acknowledging the limitations inherent in video data, the paper offers a description of how video footage served to enhance insight in three ways. First, the footage enhanced the researchers’ own appreciation of the significance of particular facets of the data, which led them to reassess information collected through interviewing, focus groups and research field notes. Second, the footage enhanced the pathology laboratory scientists’ appreciation of the problems they experienced when incorporating the new information technology into their daily work practice, by enabling them to articulate these problems to outside researchers. Third, by being watched (by the video camera) and by watching themselves perform their work they were enabled to redesign their practices. The paper suggests that, as a result of interactively performing their work in front of the camera, the scientists came to apprehend their practices ‘from under a different aspect’. The paper concludes that by allowing video ethnography as a research method to remain underdefined and emergent, the modality of engagement and uptake shown by participants in the video research can be considered as a further enriching aspect of video ethnography as a research process.

Details

Qualitative Research Journal, vol. 6 no. 2
Type: Research Article
ISSN: 1443-9883

Keywords

Content available
Article
Publication date: 4 May 2021

Christine Jorm, Rick Iedema, Donella Piper, Nicholas Goodwin and Andrew Searles

The purpose of this paper is to argue for an improved conceptualisation of health service research, using Stengers' (2018) metaphor of “slow science” as a critical yardstick.

Abstract

Purpose

The purpose of this paper is to argue for an improved conceptualisation of health service research, using Stengers' (2018) metaphor of “slow science” as a critical yardstick.

Design/methodology/approach

The paper is structured in three parts. It first reviews the field of health services research and the approaches that dominate it. It then considers the healthcare research approaches whose principles and methodologies are more aligned with “slow science” before presenting a description of a “slow science” project in which the authors are currently engaged.

Findings

Current approaches to health service research struggle to offer adequate resources for resolving frontline complexity, principally because they set more store by knowledge generalisation, disciplinary continuity and integrity and the consolidation of expertise, than by engaging with frontline complexity on its terms, negotiating issues with frontline staff and patients on their terms and framing findings and solutions in ways that key in to the in situ dynamics and complexities that define health service delivery.

Originality/value

There is a need to engage in a paradigm shift that engages health services as co-researchers, prioritising practical change and local involvement over knowledge production. Economics is a research field where the products are of natural appeal to powerful health service managers. A “slow science” approach adopted by the embedded Economist Program with its emphasis on pre-implementation, knowledge mobilisation and parallel site capacity development sets out how research can be flexibly produced to improve health services.

Details

Journal of Health Organization and Management, vol. 35 no. 6
Type: Research Article
ISSN: 1477-7266

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Article
Publication date: 10 April 2017

Rick Iedema, Raj Verma, Sonia Wutzke, Nigel Lyons and Brian McCaughan

To further our insight into the role of networks in health system reform, the purpose of this paper is to investigate how one agency, the NSW Agency for Clinical…

Abstract

Purpose

To further our insight into the role of networks in health system reform, the purpose of this paper is to investigate how one agency, the NSW Agency for Clinical Innovation (ACI), and the multiple networks and enabling resources that it encompasses, govern, manage and extend the potential of networks for healthcare practice improvement.

Design/methodology/approach

This is a case study investigation which took place over ten months through the first author’s participation in network activities and discussions with the agency’s staff about their main objectives, challenges and achievements, and with selected services around the state of New South Wales to understand the agency’s implementation and large system transformation activities.

Findings

The paper demonstrates that ACI accommodates multiple networks whose oversight structures, self-organisation and systems change approaches combined in dynamic ways, effectively yield a diversity of network governances. Further, ACI bears out a paradox of “centralised decentralisation”, co-locating agents of innovation with networks of implementation and evaluation expertise. This arrangement strengthens and legitimates the role of the strategic hybrid – the healthcare professional in pursuit of change and improvement, and enhances their influence and impact on the wider system.

Research limitations/implications

While focussing the case study on one agency only, this study is unique as it highlights inter-network connections. Contributing to the literature on network governance, this paper identifies ACI as a “network of networks” through which resources, expectations and stakeholder dynamics are dynamically and flexibly mediated and enhanced.

Practical implications

The co-location of and dynamic interaction among clinical networks may create synergies among networks, nurture “strategic hybrids”, and enhance the impact of network activities on health system reform.

Social implications

Network governance requires more from network members than participation in a single network, as it involves health service professionals and consumers in a multi-network dynamic. This dynamic requires deliberations and collaborations to be flexible, and it increasingly positions members as “strategic hybrids” – people who have moved on from singular taken-as-given stances and identities, towards hybrid positionings and flexible perspectives.

Originality/value

This paper is novel in that it identifies a critical feature of health service reform and large system transformation: network governance is empowered through the dynamic co-location of and collaboration among healthcare networks, particularly when complemented with “enabler” teams of people specialising in programme implementation and evaluation.

Details

Journal of Health Organization and Management, vol. 31 no. 2
Type: Research Article
ISSN: 1477-7266

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Article
Publication date: 5 April 2011

Rick Iedema and Katherine Carroll

This paper aims to present evidence for regarding reflexive practice as the crux of patient safety in tertiary hospitals. Reflexive practice buttresses safety because it…

Abstract

Purpose

This paper aims to present evidence for regarding reflexive practice as the crux of patient safety in tertiary hospitals. Reflexive practice buttresses safety because it is the precondition for flexible systematization – that is, the process that involves frontline clinicians in designing, redesigning and flexibly enacting care processes.

Design/methodology/approach

The paper presents an account of a collaborative video‐ethnographic project with a multi‐disciplinary team in an acute spinal unit. Video‐ethnography was combined with video‐reflexivity to provide practitioners with the opportunity to become involved in data interpretation and solution generation.

Findings

The study reveals that an outsider analysts/catalyst (or clinalyst) is critical to engaging frontline practitioners in reflexivity. The clinalyst is able to elicit insights and perspectives that assist practitioners in revisiting and revising their processes and practices, principally because video‐based reflexivity connects “what we do” directly to “who we are”.

Practical implications

Because complexity will be an indelible part of health care work, health care organizations should invest in developing “reflexive space” where learning about complexity becomes possible. Instead of continuing to invest in research efforts seeking to derive and test staff compliance with guidelines and protocols, and training centred on simulation, these organization must begin to engage with the lived complexity of clinical work in order to skill up incoming clinicians.

Originality/value

Enhancing clinical practitioners' capability to confront complexity in their practices is currently not a standard component of clinical training or work‐based learning. Video‐reflexive ethnography in tertiary health care is unique in involving clinicians in “making sense” of and deriving solutions from lived complexity.

Details

Journal of Organizational Change Management, vol. 24 no. 2
Type: Research Article
ISSN: 0953-4814

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Article
Publication date: 31 October 2008

Rick Iedema, Christine Jorm and Jeffrey Braithwaite

Increased public awareness of clinical failure and rising levels of litigation are spurring health policy makers in industrialized countries to mandate that clinicians…

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2119

Abstract

Purpose

Increased public awareness of clinical failure and rising levels of litigation are spurring health policy makers in industrialized countries to mandate that clinicians report and investigate clinical errors and near misses. This paper seeks to understand the value of root cause analysis (RCA) recommendations for practice improvement purposes. The paper presents an analysis of interviews with nine senior health managers who were asked about their views on RCA as practice improvement method.

Design/methodology/approach

Interview data were collected as part of a multi‐method evaluation consultancy project investigating a local Health Safety Improvement Program. The interview data were discourse analysed and arranged into over‐arching themes.

Findings

The analysis reveals rather negative views of the improvement potential of RCA: RCA is subject to too many constraints to be able to produce valuable recommendations; RCA recommendations: are perceived to be of “variable quality”; generate considerable extra work for senior management to do with vetting RCA recommendations; are experienced as contributing in only a limited way to organizational and practice improvement.

Research limitations/implications

This study focuses on nine interviewees only and presents an analysis of single (not multiple) interviews. However, these nine interviewees fulfil crucial roles in implementing clinical practice improvement initiatives in their respective geographic areas.

Practical implications

The findings suggest that RCA requires much time and negotiation, and that the recommendations produced may not live up to the philosophy of clinical practice improvement's expectations. It may be necessary to reorient the expectations of the power of RCA, or accept that RCA produces communication about clinical processes that would otherwise not have taken place, and whose effects may not be registering for some time to come.

Originality/value

Besides drawing out the implications for RCA as investigative practice, the analysis argues that interviewees' responses harbour indications to suggest that these officials are finding themselves engaged in increasing levels of communicative and emotional labour, in having to manage and compensate for the ambiguities, incommensurabilities and conflicting goals inscribed into “post‐bureaucratic” initiatives such as RCA.

Details

Journal of Health Organization and Management, vol. 22 no. 6
Type: Research Article
ISSN: 1477-7266

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Article
Publication date: 20 March 2009

Roslyn Sorensen and Rick Iedema

This paper aims to understand the impact of emotional labour in specific health care settings and its potential effect on patient care.

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2811

Abstract

Purpose

This paper aims to understand the impact of emotional labour in specific health care settings and its potential effect on patient care.

Design/methodology/approach

Multi‐method qualitative ethnographic study undertaken in a large ICU in Sydney, Australia using observations from patient case studies, ward rounds and family conferences, open ended interviews with medical and nursing clinicians and managers and focus groups with nurses.

Findings

Clinician attitudes to death and dying and clinicians' capacity to engage with the human needs of patients influenced how emotional labour was experienced. Negative effects were not formally acknowledged in clinical workplaces and institutional mechanisms to support clinicians did not exist.

Research limitations/implications

The potential effects of clinician attitudes on performance are hypothesised from clinician‐reported data; no evaluation was undertaken of patient care.

Practical implications

Health service providers must openly acknowledge the effect of emotional labour on the care of dying people. By sharing their experiences, multidisciplinary clinicians become aware of the personal, professional and organisational impact of emotional labour as a core element of health care so as to explicitly and practically respond to it.

Originality/value

The effect of care on clinicians, particularly care of dying people, not only affects the wellbeing of clinicians themselves, but also the quality of care that patients receive. The affective aspect of clinical work must be factored in as an essential element of quality and quality improvement.

Details

Journal of Health Organization and Management, vol. 23 no. 1
Type: Research Article
ISSN: 1477-7266

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Article
Publication date: 1 August 2005

Rick Iedema, Carl Rhodes and Hermine Scheeres

To examine Hardt and Negri's discussions of immaterial labor in relation to personal identity and sociality at work in a context of the postmodernization of the global economy.

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2049

Abstract

Purpose

To examine Hardt and Negri's discussions of immaterial labor in relation to personal identity and sociality at work in a context of the postmodernization of the global economy.

Design/methodology/approach

Hardt and Negri's discussions of immaterial labor are reviewed in relation to their implications for social interaction and identity at work. Heidegger's idea of “presencing” is then used to examine the dynamic emergence of identity as an effect of the “affectualization” of work.

Findings

Global trends towards an informationalized economy have profound implications for identity at work in that the dynamics of identity are foregrounded and managerial and organizational power structures that seek to define an essential worker identity are destabilized.

Research limitations/implications

Suggests that research into identity at work should include a focus on the immaterial dimensions of work and should consider the implications of this for the dynamic emergence of identity and for future forms of organization and management.

Practical implications

Suggests that the emergence of immaterial labor might provide increasing, albeit complex and contested, opportunities for worker participation; this is on what management relies, and what at the same time has the potential of undermining the legitimacy of management.

Originality/value

Provides an innovative way of examining the dynamics of identity in contemporary organizations.

Details

Journal of Organizational Change Management, vol. 18 no. 4
Type: Research Article
ISSN: 0953-4814

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Article
Publication date: 9 October 2007

Jeffrey Braithwaite, Mary T. Westbrook, Joanne F. Travaglia, Rick Iedema, Nadine A. Mallock, Debbi Long, Peter Nugus, Rowena Forsyth, Christine Jorm and Marjorie Pawsey

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.

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1645

Abstract

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.

Details

International Journal of Health Care Quality Assurance, vol. 20 no. 7
Type: Research Article
ISSN: 0952-6862

Keywords

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