Managing between the agendas: implementing health care reform policy in an acute care hospital.

Purpose: This paper aims to assess administrative and clinical manager stances on health system reform. Understanding these stances will help to identify cultural differences and competing agendas between these two key health service stakeholders and contribute to developing strategies to improve organisational performance.

Design/methodology/approach: A qualitative methodology was used comprising in-depth open-ended interviews conducted in 2007 with 26 administrative and clinical managers who managed clinical units.

What prevents incident disclosure, and what can be done to promote it?

Background: Adverse-event incident disclosure is gaining international attention as being central to incident management, practice improvement, and public engagement, but those charged with its execution are experiencing barriers. Findings have emerged from two large studies: an evaluation of the 2006-2008 Australian Open Disclosure Pilot, and a 2009-2010 study of patients' and relatives' views on actual disclosures. Clinicians and patients interviewed in depth suggest that open disclosure communication has been prevented by a range of uncertainties, fears, and doubts.

Accounting for health-care outcomes: implications for intensive care unit practice and performance.

The aim of this study was to understand the environment of health care, and how clinicians and managers respond in terms of performance accountability. A qualitative method was used in a tertiary metropolitan teaching intensive care unit (ICU) in Sydney, Australia, including interviews with 15 clinical managers and focus groups with 29 nurses of differing experience. The study found that a managerial focus on abstract goals, such as budgets detracted from managing the core business of clinical work.

Emotional labour: clinicians' attitudes to death and dying.

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.

Patients' and family members' experiences of open disclosure following adverse events.

Objective: To explore patients' and family members' perceptions of Open Disclosure of adverse events that occurred during their health care.

Design: We interviewed 23 people involved in adverse events and incident disclosure using a semi-structured, open-ended guide. We analyzed transcripts using thematic discourse analysis.

Beyond profession: nursing leadership in contemporary healthcare.

Aim(s): To examine nursing leadership in contemporary health care and its potential contribution to health service organization and management.

Background: As the nursing profession repositions itself as an equal partner in health care beside medicine and management, its enhanced nursing standards and clinical knowledge are not leading to a commensurate extension of nursing's power and authority in the organization.

Method(s): An ethnographic study of an ICU in Sydney, Australia, comprising: interviews with unit nursing managers (4); focus groups (3) with less experienced, intermediate and experienced nurses (29 in total); and interviews with senior nurse manager (1).

The National Open Disclosure Pilot: evaluation of a policy implementation initiative.

Objective: To determine which aspects of open disclosure "work" for patients and health care staff, based on an evaluation of the National Open Disclosure Pilot.

Design, Setting And Participants: Qualitative analysis of semi-structured and open-ended interviews conducted between March and October 2007 with 131 clinical staff and 23 patients and family members who had participated in one or more open disclosure meetings. 21 of 40 pilot hospital sites, in New South Wales, South Australia, Victoria and Queensland, were included in the evaluation.

Redefining accountability in health care: managing the plurality of medical interests.

Conflict in health service delivery is common. It is often attributed to disputes between clinicians and patients or their families about treatment decisions and is particularly common in intensive care units (ICUs), in the form of ;futility disputes' between families and medical clinicians about decisions to terminate the active treatment of a dying family member. More common, but less prominent in the literature, is conflict within the medical profession about patient care goals and treatment.

Integrating patients' nonmedical status in end-of-life decision making: structuring communication through 'conferencing'.

This paper considers the nonmedical status of patients in end-of-life decisions. Considering nonmedical factors is not yet routine, particularly in decisions to withhold or withdraw treatment. The paper advocates that non-medical factors-the capacity and willingness to withstand continuing treatment-are essential to ensure that decisions taken are in the patient's best interest.

Advocacy at end-of-life research design: an ethnographic study of an ICU.

Background: Clinicians worldwide are being called upon to reconcile accountability for patient outcomes with the resources they consume. In the case of intensive care, contradictory pressures can arise in decisions about continuing treatment where benefit is diminishing. As concern grows about the cost effectiveness of treatment at end-of-life, nursing expertise and advocacy become significant factors in decision making.

Managing quality in cancer services: why improvement isn't easy.

Optimising the quality of care is an imperative for health services worldwide, including in Australia. Recognition that poor quality often has its roots in system failures is beginning to shift strategies for improvement to the systems of care, although the tendency remains to focus on eliminating the practice variations of individual clinicians. In those instances where systems improvement is addressed, strategies tend to be generic and technical, and often unrelated to the context in which they are applied.

Management of delirium: a clinical governance approach.

This study assessed the management of delirium in the Acute Care of the Elderly unit (ACE) at a tertiary referral hospital as a case study of the application of clinical governance principles. The environment was found to be supportive of ongoing clinical governance activities, both in clinical organisation of work processes and orientation of management. However, patient involvement, dissemination and use of clinical pathways, performance measurement and feedback, and maintaining stability of care are areas requiring further development.

The teleo-affective limits of end-of-life care in the intensive care unit.

This paper explores the relevance of a specific kind of sensed connectedness or 'teleo-affectivity' to the organisation and enactment of end-of-life care. Referred to as heedful inter-relating, this teleo-affective connectedness has been found to occur among employees as they carry out their highly complex and dangerous work. This paper focuses on the proposals put in the literature for confronting the complexity of end-of-life care in the intensive care unit (ICU), and inquires into the positionings incurred in and around end-of-life care in one specific unit, with the aim of gauging the pertinence of heedful inter-relating to end-of-life care in ICU.