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PurposeThis viewpoint article discusses and analyses the need and benefits of a patient safety definition within the context of nursing.Design/methodology/approachThis viewpoint article is supported by literature review, statutory documents and expert knowledge evidence. All these sources provided a unified narrative of the background, current aspects and future needs of patient safety.FindingsThe need for strengthening patient safety and the nurses' role within healthcare's actions towards patient safety are discussed. The predominant role of nurses due to the proportionate size and significant role along with the need for clarification of patient safety in nursing terms is recognised. Research evidence of nursing areas with safety issues and relevant nursing interventions are presented. Based on all findings, a research-based nursing specific patient safety definition is proposed. This definition includes three axes: what is patient harm, how this harm can be eliminated or reduced and which are the areas of nursing practice that are identified to provide opportunity for patient harm. These axes include nursing specifications of the patient safety definition.Originality/valueIt is the first time that a nurse specific patient safety definition is proposed. This definition strives to enhance nurse practitioners' understanding and engagement with patient safety by clarifying aspects of patient safety within everyday nursing practice.

PurposeThe impact of population ageing is significant, multifaceted and characterised by frailty and multi-morbidity. The COVID-19 pandemic has accelerated care pathways and policies promoting self-management and home-based care. One under-researched area is how patients and family caregivers manage the complexity of end-of-life therapeutic medicine regimens. In this position paper the authors bring attention to the significant strain that patients and family caregivers experience when navigating and negotiating this aspect of palliative and end-of-life care.Design/methodology/approachFocussing on self-care and organisation of medicines in the United Kingdom (UK) context, the paper examines, builds on and extends the debate by considering the underlying policy assumptions and unintended consequences for individual patients and family care givers as they assume greater palliative and end-of-life roles and responsibilities.FindingsPolicy makers and healthcare professionals often lack awareness of the significant burden and emotional work associated with managing and administering often potent high-risk medicines (i.e. opioids) in the domiciliary setting. The recent “revolution” in professional roles associated with the COVID-19 pandemic, including remote consultations and expanding community-based care, means there are opportunities for commissioners to consider offering greater support. The prospect of enhancing the community pharmacist's medicine optimisation role to further support the wider multi-disciplinary team is considered.Originality/valueThe paper takes a person-focused perspective and adopts a holistic view of medicine management. The authors argue for urgent review, reform and investment to enable and support terminally ill patients and family caregivers to more effectively manage medicines in the domiciliary setting. There are clear implications for pharmacists and these are discussed in the context of public awareness, inter-professional collaboration, organisational drivers, funding and regulation and remote care delivery.

Purpose Ireland’s physicians have a legal and an ethical duty to protect confidential patient information. Most healthcare records in Ireland remain paper based, so the purpose of this paper is to: assess the protection afforded to paper records; log highest risk records; note the variations that occurred during the working week; and observe the varying protection that occurred when staff, students and public members were present. Design/methodology/approach A customised audit tool was created using Sphinx software. Data were collected for three months. All wards included in the study were visited once during four discrete time periods across the working week. The medical records trolley’s location was noted and total unattended medical records, total unattended nursing records, total unattended patient lists and when nursing personnel, medical students, public and a ward secretary were visibly present were recorded. Findings During 84 occasions when the authors visited wards, unattended medical records were identified on 33 per cent of occasions, 49 per cent were found during weekend visiting hours and just 4 per cent were found during morning rounds. The unattended medical records belonged to patients admitted to a medical specialty in 73 per cent of cases and a surgical specialty in 27 per cent. Medical records were found unattended in the nurses’ station with much greater frequency when the ward secretary was off duty. Unattended nursing records were identified on 67 per cent of occasions the authors visited the ward and were most commonly found unattended in groups of six or more. Practical implications This study is a timely reminder that confidential patient information is at risk from inappropriate disclosure in the hospital. There are few context-specific standards for data protection to guide healthcare professionals, particularly paper records. Nursing records are left unattended with twice the frequency of medical records and are found unattended in greater numbers than medical records. Protection is strongest when ward secretaries are on duty. Over-reliance on vigilant ward secretaries could represent a threat to confidential patient information. Originality/value While other studies identified data protection as an issue, this study assesses how data security varies inside and outside conventional working hours. It provides a rationale and an impetus for specific changes across the whole working week. By identifying the on-duty ward secretary’s favourable effect on medical record security, it highlights the need for alternative arrangements when the ward secretary is off duty. Data were collected prospectively in real time, giving a more accurate healthcare record security snapshot in each data collection point.

Choosing Health is the first government public health white paper since Saving Lives: Our Healthier Nation, published in 1999. It aims to make the NHS ‘a health service, not a sickness service,’ and is strongly influenced by the Wanless reports. This paper presents a critical review of the main elements of the white paper that relate to mental health, and sets out the actions that policy makers and service delivery organisations need to take to build genuinely mental health promoting public services within a mentally healthy society.

Purpose – The paper aims to assess the quality (content and legibility) of handwritten operation notes and the reader's interpretation of legibility by clinical seniority. Design/methodology/approach – Consecutive elective and emergency general surgical operations over a six-week period from September 2011 at one hospital were retrospectively collected. Non-retrieval of operation notes, typed notes and endoscopies were excluded. The content of each operation note was assessed against a 26-item checklist. Legibility was assessed by 4 readers (2 Foundation Doctors and 2 Registrars in General Surgery) using an original objective scoring system. Findings – A total of 404 operations were identified; 45 were excluded following review of operation notes. Operation notes were derived from 12 consultants and 11 registrars. Analysis of the content score suggested that time of procedure (1 per cent), ASA grade (1 per cent) and blood loss (5 per cent) were poorly reported. Clinical indication and post-operative instructions were documented in only 52 per cent and 66 per cent of operation notes respectively. Registrar notes had a higher content score compared with consultant notes (15.8 vs 13.5, ppp Research limitations/implications – The quality of handwritten notes varies. Registrar-written notes are more content-rich and legible. Practical implications – Clinical seniority and specialty training may improve the interpretation of handwritten operation notes. This study adds to growing evidence supporting the widespread adoption of a computerized immediate operation note. Originality/value – An objective scoring system to assess legibility of operation notes written as freehand was used. Also, legibility according to the reader's seniority in clinical training was evaluated.

PurposeThe aim of the paper is to compare the computer administration method (touch‐screen) with the original paper‐and‐pen approach when measuring patients' perceptions of care quality.Design/methodology/approachThe study group consisted of 199 patients who responded to touch‐screen and 219 who responded to paper‐and‐pen questionnaires, receiving care between January and March 2003 at two out‐patient clinics in one county in Sweden. The response rate was 75 per cent. A modified version of the quality from the patient's perspective questionnaire was used.FindingsTwo main findings emerged: first, both methods yielded almost identical results in quality of care ratings, and second, the touch‐screen method was perceived to be easier to use and to take less time to complete.Originality/valueThe paper shows that both methods are acceptable, but the touch‐screen method appears to be preferred by patients.

Reviews the present contracting arrangements in general practice. Outlines recent Government White Papers, leading to a discussion of the future opportunities for general practice. Demonstrates the reality of primary‐care‐ led NHS with quality of care plus cost containment.

Purpose Organisations within healthcare increasingly operate in rapidly changing environments and present wide variation in performance. It can be argued that this variation is influenced by the capability of an organisation to improve: its improvement capability. However, there is little theoretical research on improvement capability. The purpose of this paper is to set out the current diverse body of research on improvement capability and develop a theoretically informed conceptual framework. Design/methodology/approach This paper conceptualises improvement capability as a dynamic capability. This suggests that improvement capability is comprised of organisational routines that are bundled together, and adapt and react to organisational circumstances. Existing research conceptualises these bundles as three elements (microfoundations): sensing, seizing and reconfiguring. This conceptualisation is used to explore how improvement capability can be understood, by inductively categorising eight dimensions of improvement capability to develop a theoretically informed conceptual framework. Findings This paper shows that the three microfoundations which make up a dynamic capability are present in the identified improvement capability dimensions. This theoretically based conceptual framework provides a rich explanation of how improvement capability can be configured. Originality/value Identifying the component parts of improvement capability helps to explain why some organisations are less successful in improvement than others. This theoretically informed framework can support managers and policy makers to identify improvement capability dimensions in need of development. Further empirical research, particularly in non-market settings, such as publicly funded healthcare is required to enhance understanding of improvement capability and its configuration.

PurposeIn this paper, we contribute to the theorizing of patient involvement in organizational improvement by exploring concepts of “learning from patients” as mechanisms of organizational change. Using the concept of metaphor as a theoretical bridge, we analyse interview data (n = 20) from participants in patient engagement activities from two case study organizations in Ontario, Canada. Inspired by classic organizational scholars, we ask “what is the organization that it might learn from patients?”Design/methodology/approachPatient involvement activities are used as part of quality improvement efforts in healthcare organizations worldwide. One fundamental assumption underpinning this activity is the notion that organizations must “learn from patients” in order to enact positive organizational change. Despite this emphasis on learning, there is a paucity of research that theorizes learning or connects concepts of learning to organizational change within the domain of patient involvement.FindingsThrough our analysis, we interpret a range of metaphors of the organization, including organizations as (1) power and politics, (2) systems and (3) narratives. Through these metaphors, we display a range of possibilities for interpreting how organizations might learn from patients and associated implications for organizational change.Originality/valueThis analysis has implications for how the framing of the organization matters for concepts of learning in patient engagement activities and how misalignments might stymie engagement efforts. We argue that the concept and commitment to “learning from patients” would be enriched by further engagement with the sociology of knowledge and critical concepts from theories of organizational learning.

Purpose The purpose of this paper is to share insights, research findings and discuss key issues related to graduate experiences with transnational nursing education (TNE). Design/methodology/approach The authors used a qualitative approach and sampled national and international nurse graduates to identify challenges and best operating practices in cross-border nursing program facilitation. Findings This research paper has provided a platform for graduates to lend their voices to the promotion of effective cross-border nursing education delivery and suggests that although international collaborations endeavor to maintain high academic standards in TNE, there is still a need to re-engineer, revise and adapt curricular content, learning, teaching and assessment practices to aid the nursing student. Research limitations/implications Identified challenges affecting the facilitation and delivery of cross-border nursing education programs can act as levers to improving service quality of present and future cross-border programs to the nursing student. This will assist future nursing students to recognize culture shock and embrace their decision to pursue nursing. Practical implications The experience of being involved in TNE for nursing students may not be that much different than students of other disciplines. While not able to be generalized to the entire population, the reports by the nursing students in this sample appear to be valuable and worthwhile to continue supporting and encouraging other TNE opportunities. Originality/value This paper explores cross-border nursing education experiences from national and international perspectives. The authors were able to explore inherent TNE challenges from diverse population and cultural backgrounds.

PurposeAttempts to transform health systems have in many countries involved starting to pay healthcare providers through a DRG system, but that has involved managerial workarounds. Managerial workarounds have seldom been analysed. This paper does so by extending and modifying existing knowledge of the causes and character of clinical and IT workarounds, to produce a conceptualisation of the managerial workaround. It further develops and revises this conceptualisation by comparing the practical management, at both provider and purchaser levels, of hospital DRG payment systems in England, Germany and Italy.Design/methodology/approachWe make a qualitative test of our initial assumptions about the antecedents, character and consequences of managerial workarounds by comparing them with a systematic comparison of case studies of the DRG hospital payment systems in England, Germany and Italy. The data collection through key informant interviews (N = 154), analysis of policy documents (N = 111) and an action learning set, began in 2010–12, with additional data collection from key informants and administrative documents continuing in 2018–19 to supplement and update our findings.FindingsManagers in all three countries developed very similar workarounds to contain healthcare costs to payers. To weaken DRG incentives to increase hospital activity, managers agreed to lower DRG payments for episodes of care above an agreed case-load ‘ceiling' and reduced payments by less than the full DRG amounts when activity fell below an agreed ‘floor' volume.Research limitations/implicationsEmpirically this study is limited to three OECD health systems, but since our findings come from both Bismarckian (social-insurance) and Beveridge (tax-financed) systems, they are likely to be more widely applicable. In many countries, DRGs coexist with non-DRG or pre-DRG systems, so these findings may also reflect a specific, perhaps transient, stage in DRG-system development. Probably there are also other kinds of managerial workaround, yet to be researched. Doing so would doubtlessly refine and nuance the conceptualisation of the ‘managerial workaround’ still further.Practical implicationsIn the case of DRGs, the managerial workarounds were instances of ‘constructive deviance' which enabled payers to reduce the adverse financial consequences, for them, arising from DRG incentives. The understanding of apparent failures or part-failures to transform a health system can be made more nuanced, balanced and diagnostic by using the concept of the ‘managerial workaround'.Social implicationsManagerial workarounds also appear outside the health sector, so the present analysis of managerial workarounds may also have application to understanding attempts to transform such sectors as education, social care and environmental protection.Originality/valueSo far as we are aware, no other study presents and tests the concept of a ‘managerial workaround'. Pervasive, non-trivial managerial workarounds may be symptoms of mismatched policy objectives, or that existing health system structures cannot realise current policy objectives; but the workarounds themselves may also contain solutions to these problems.

Purpose Neo-liberal “reform” has in many countries shifted services across the boundary between the public and private sector. This policy re-opens the question of what structural and managerial differences, if any, differences of ownership make to healthcare providers. The purpose of this paper is to examine the connections between ownership, organisational structure and managerial regime within an elaboration of Donabedian’s reasoning about organisational structures. Using new data from England, it considers: how do the internal managerial regimes of differently owned healthcare providers differ, or not? In what respects did any such differences arise from differences in ownership or for other reasons? Design/methodology/approach An observational systematic qualitative comparison of differently owned providers was the strongest feasible research design. The authors systematically compared a maximum variety (by ownership) sample of community health services; out-of-hours primary care; and hospital planned orthopaedics and ophthalmology providers (n=12 cases). The framework of comparison was the ownership theory mentioned above. Findings The connection between ownership (on the one hand) and organisation structures and managerial regimes (on the other) differed at different organisational levels. Top-level governance structures diverged by organisational ownership and objectives among the case-study organisations. All the case-study organisations irrespective of ownership had hierarchical, bureaucratic structures and managerial regimes for coordinating everyday service production, but to differing extents. In doctor-owned organisations, the doctors’, but not other occupations’, work was controlled and coordinated in a more-or-less democratic, self-governing ways. Research limitations/implications This study was empirically limited to just one sector in one country, although within that sector the case-study organisations were typical of their kinds. It focussed on formal structures, omitting to varying extents other technologies of power and the differences in care processes and patient experiences within differently owned organisations. Practical implications Type of ownership does appear, overall, to make a difference to at least some important aspects of an organisation’s governance structures and managerial regime. For the broader field of health organisational research, these findings highlight the importance of the owners’ agency in explaining organisational change. The findings also call into question the practice of copying managerial techniques (and “fads”) across the public–private boundary. Originality/value Ownership does make important differences to healthcare providers’ top-level governance structures and accountabilities and to work coordination activity, but with different patterns at different organisational levels. These findings have implications for understanding the legitimacy, governance and accountability of healthcare organisations, the distribution and use power within them, and system-wide policy interventions, for instance to improve care coordination and for the correspondingly required foci of healthcare organisational research.

Purpose The purpose of this paper is to describe Karen refugee women’s experience of resettlement and the factors which structured community capacity to support their mental health and well-being. Design/methodology/approach A postcolonial and feminist standpoint was used to bring Karen women’s voice to the knowledge production process. Data were collected through ethnographic field observation, in-depth semi-structured individual and focus group interviews with Karen women as well as healthcare and social service providers. Findings Three interrelated themes emerged from the data: Karen women’s construction of mental health as “stress and worry”; gender, language and health literacy intersected, shaping Karen women’s access to health care and social resources; flexible partnerships between settlement agencies, primary care and public health promoted community capacity but were challenged by neoliberalism. Research limitations/implications Karen women and families are a diverse group with a unique historical context. Not all the findings are applicable across refugee women. Practical implications This paper highlights the social determinants of mental health for Karen women and community responses for mitigating psychological distress during resettlement. Social implications Public health policy requires a contextualized understanding of refugee women’s mental health. Health promotion in resettlement must include culturally safe provision of health care to mitigate sources of psychological distress during resettlement. Originality/value This research brings a postcolonial and feminist analysis to community capacity as a public health strategy.

Purpose The purpose of this paper is to introduce translational mobilization theory (TMT) and explore its application for healthcare quality improvement purposes. Design/methodology/approach TMT is a generic sociological theory that explains how projects of collective action are progressed in complex organizational contexts. This paper introduces TMT, outlines its ontological assumptions and core components, and explores its potential value for quality improvement using rescue trajectories as an illustrative case. Findings TMT has value for understanding coordination and collaboration in healthcare. Inviting a radical reconceptualization of healthcare organization, its potential applications include: mapping healthcare processes, understanding the role of artifacts in healthcare work, analyzing the relationship between content, context and implementation, program theory development and providing a comparative framework for supporting cross-sector learning. Originality/value Poor coordination and collaboration are well-recognized weaknesses in modern healthcare systems and represent important risks to quality and safety. While the organization and delivery of healthcare has been widely studied, and there is an extensive literature on team and inter-professional working, we lack readily accessible theoretical frameworks for analyzing collaborative work practices. TMT addresses this gap in understanding.

Purpose The purpose of this paper is to discuss the human rights issues pertinent to adolescents of diverse sexual orientation and gender identities and the health consequences resulting for the transgression of these rights. In 1948, the United Nations General Assembly passed a resolution endorsing the Universal Declaration of Human Rights. Yet, 73 member states criminalize the activities of these individuals. The other member states do not impose legal penalties on these activities, yet sexual and gender minority youth within these states continue to experience acts of physical and psychological aggression. Design/methodology/approach A commissioned position paper grounded in a convenient scholarly literature review on this topic. Findings Human rights transgressions by states or individuals lead to minority stress affecting the mental health and physical health of these youth. Originality/value The author makes a number of recommendations to address some of the impact resulting from the transgression of human rights in the world.

Purpose Healthcare regulation is one means to address quality challenges in healthcare systems and is carried out using compliance, deterrence and/or improvement approaches. The four countries of the UK provide an opportunity to explore and compare different regulatory architecture and models. The purpose of this paper is to understand emerging regulatory models and associated tensions. Design/methodology/approach This paper uses qualitative methods to compare the regulatory architecture and models. Data were collected from documents, including board papers, inspection guidelines and from 48 interviewees representing a cross-section of roles from six organisational regulatory agencies. The data were analysed thematically using an a priori coding framework developed from the literature. Findings The findings show that regulatory agencies in the four countries of the UK have different approaches and methods of delivering their missions. This study finds that new hybrid regulatory models are developing which use improvement support interventions in parallel with deterrence and compliance approaches. The analysis highlights that effective regulatory oversight of quality is contingent on the ability of regulatory agencies to balance their requirements to assure and improve care. Nevertheless, they face common tensions in sustaining the balance in their requirements connected to their roles, relationships and resources. Originality/value The paper shows through its comparison of UK regulatory agencies that the development and implementation of hybrid models is complex. The paper contributes to research by identifying three tensions related to hybrid regulatory models; roles, resources and relationships which need to be managed to sustain hybrid regulatory models.

Purpose The Voice of the Clinician project commenced during an era when practitioner burnout, dissatisfaction, and turnover became an increasingly global health workforce concern. One key problem is clinical staff not being empowered to voice their concerns to decision-makers, as was found in this case study of an Australian public health organization. The following research question informed the present study: What is a better committee system for clinician engagement in decision-making processes? The paper aims to discuss this issue. Design/methodology/approach The Mid North Coast Local Health District in New South Wales aspired to improve engagement between frontline clinicians and decision-makers. Social network analysis methods and mathematical modeling were used in the discovery of how committees are connected to each other and subsequently to other committee members. Findings This effort uncovered a hidden organizational architecture of 323 committees of 926 members which overall cost 84,729 person hours and AUD$2.923 million per annum. Furthermore, frontline clinicians were located far from centers of influence, just 37 percent of committees had terms of reference, and clinicians reported that meeting agendas were not being met. Practical implications In response to the findings, a technological platform was created so that the board of directors could visually see all the committees and the connections between them, thus creating ways to further improve communication, transparency of process, and – ultimately – clinician engagement. Originality/value The breakthrough idea is that all organizational meetings can be seen as a system of engagement and should be analyzed to determine and describe the points and pathways where clinician voice is blocked.

Purpose Policy makers are applying market-inspired competition and financial incentives to drive efficiency in healthcare. However, a lack of knowledge exists about the process whereby incentives are filtered through organizations to influence staff motivation, and the key role of managers is often overlooked. The purpose of this paper is to explore the strategies managers use as intermediaries between financial incentives and the individual motivation of staff. The authors use empirical data from a local case in Swedish specialized care. Design/methodology/approach The authors conducted an exploratory qualitative case study of a patient-choice reform, including financial incentives, in specialized orthopedics in Sweden. In total, 17 interviews were conducted with professionals in managerial positions, representing six healthcare providers. A hypo-deductive, thematic approach was used to analyze the data. Findings The results show that managers applied alignment strategies to make the incentive model motivating for staff. The managers’ strategies are characterized by attempts to align external rewards with professional values based on their contextual and practical knowledge. Managers occasionally overruled the financial logic of the model to safeguard patient needs and expressed an interest in having a closer dialogue with policy makers about improvements. Originality/value Externally imposed incentives do not automatically motivate healthcare staff. Managers in healthcare play key roles as intermediaries by aligning external rewards with professional values. Managers’ multiple perspectives on healthcare practices and professional culture can also be utilized to improve policy and as a source of knowledge in partnership with policy makers.

PurposeThe purpose of this paper is to describe a quality improvement (QI) intervention in primary health facilities providing childbirth care in rural Southern Tanzania.Design/methodology/approachA QI collaborative model involving district managers and health facility staff was piloted for 6 months in 4 health facilities in Mtwara Rural district and implemented for 18 months in 23 primary health facilities in Ruangwa district. The model brings together healthcare providers from different health facilities in interactive workshops by: applying QI methods to generate and test change ideas in their own facilities; using local data to monitor improvement and decision making; and health facility supervision visits by project and district mentors. The topics for improving childbirth were deliveries and partographs.FindingsMedian monthly deliveries increased in 4 months from 38 (IQR 37-40) to 65 (IQR 53-71) in Mtwara Rural district, and in 17 months in Ruangwa district from 110 (IQR 103-125) to 161 (IQR 148-174). In Ruangwa health facilities, the women for whom partographs were used to monitor labour progress increased from 10 to 57 per cent in 17 months.Research limitations/implicationsThe time for QI innovation, testing and implementation phases was limited, and the study only looked at trends. The outcomes were limited to process rather than health outcome measures.Originality/valueHealthcare providers became confident in the QI method through engagement, generating and testing their own change ideas, and observing improvements. The findings suggest that implementing a QI initiative is feasible in rural, low-income settings.

PurposeDespite evidence that exposure to traumatic events can be an important antecedent to a range of serious and chronic mental health problems – it appears that within the British National Health Service at least, this is still not fully understood nor acted upon. This paper aims to examine this evidence and asks why these findings have not been fully implemented in terms of updating practice.Design/methodology/approachA literature search was undertaken alongside relevant British DH policy. This resulted in a subsequent policy analysis.FindingsAlthough there have recently been changes in recommendation in clinical practice (e.g. CPA guidance) and policy (No Health without Mental Health) it appears that although some knowledge in this area has been changed into policy, its implementation remains “patchy”.Practical implicationsThis short paper outlines some of the evidence, examines current issues and highlights a possible pathway which might be of value in addressing this.Originality/valueThis short paper highlights traumatic exposure as an important antecedent to a range of mental health issues and highlights ways in which this may be assessed and, where relevant, addressed.

PurposeThe purpose of this paper is to examine the implications for drug and alcohol treatment of radical policy changes being implemented by the government, particularly the proposed transition of responsibility for treatment from the National Treatment Agency to a new public health service from 2013.Design/methodology/approachIt is argued that this is a critical moment in the development of substance misuse services in England, particularly given the impact of health service reform. Concerns are raised about the lack of reference to drug and alcohol treatment in key policy documents, such as the Department of Health's White Paper Healthy Lives, Healthy People. The removal of the “ring fence” from the pooled treatment budget may result in national disinvestment at a time when public spending cuts are likely to reduce local authority spending on drug and alcohol treatment. It will be challenging to deliver on the vision of recovery in the “Drug strategy 2010”.FindingsThe new public health structures and the commitment to recovery create new opportunities to improve services too – for example, the potential for joint working through Health and Wellbeing Boards. It is also positive that Healthy Lives, Healthy People stated that the NHS Constitution will apply to the public health service.Originality/valueWhile these changes could provide a platform for improving outcomes, there is a genuine risk that substantial disinvestment in drug and alcohol services will be witnessed.

This position paper focuses on the current tensions and challenges of aligning inpatient care with innovations in mental health services. It argues that a cultural shift is required within inpatient services. Obstacles to change including traditional perceptions of the role and responsibilities of the psychiatrist are discussed. The paper urges all staff working in acute care to reflect on the service that they provide, and to consider how the adoption of new ways of working might revolutionise the organisational culture. This cultural shift offers inpatient staff the opportunity to fully utilise their expertise. New ways of working may be perceived as a threat to existing roles and responsibilities or as an exciting opportunity for professional development with increased job satisfaction. Above all, the move to new ways of working, which is gathering pace throughout the UK, could offer service users1 a quality of care that meets their needs and expectations.

Purpose – In light of the recent report on regulation by the CMO of England and Wales and the subsequent Department of Health White Paper, this paper aims to consider the nexus between revalidation, appraisal and clinical governance. It provides a summary of the history of revalidation in the UK and explores how revalidation is linked to annual appraisal. It further considers the implications of this relationship and its potential impact on clinical governance and practise. Design/methodology/approach – This is a policy review related to revalidation and appraisal including primary sources from the Department of Health, the GMC, Fifth report of the Shipman Inquiry and published journal articles. Findings – Local clinical governance will be a significant part of the route to re‐licensing for the vast majority of doctors working in the NHS and many of the larger private sector hospitals. Although it will be used for two different purposes, it is generally accepted that the information collected by doctors for their annual appraisal will also form the basis of evidence for revalidation. If appraisal is to be effective, robust and consistent, it is important that the clinical governance framework within which it operates is appropriately designed for its increased role within the regulatory system. Originality/value – This paper is a valuable summary and introduction to the concept of revalidation in the UK, its history and its impact on clinical governance and regulation. It provides a timely review and analysis of the proposed changes to clinical governance at the local, SHA level and the strengthened connection between consultant appraisal and revalidation, contained in both the Department of Health White Paper – Trust, Assurance and Safety and the report – Good Doctors, Safer Patients, by the Chief Medical Officer for England and Wales.

The incoming Labour Government's vision for reforming the NHS in Scotland was outlined in the White Paper Designed to Care. While bearing similarities to the proposals outlined for the rest of the UK, it also had distinctive differences. Organisational structures, roles, and relationships between the different parts of the NHS were to be fundamentally altered, particularly in primary and community care. This paper reports upon a series of interviews undertaken across several Health Board areas, with key stakeholders involved in the primary and community sectors. These interviews were intended to examine the development and evolution of the new organisational arrangements, and to identify potential barriers to the successful implementation of Designed to Care. Several barriers and sources of institutional resistance to the new roles and relationships were found during this study, and are discussed. Suggestions upon how these may be overcome and implementation improved are then made.

Clinical practice guidelines are increasingly being recognised as integral to the clinical effectiveness agenda. According to the recent Scottish White Paper, Scotland “leads the way in clinical effectiveness”. The Scottish Intercollegiate Guidelines Network (SIGN), established in 1993, has produced over 20 clinical practice guidelines, and plans to produce at least as many more, while reviewing existing guidelines at a minimum of every two years. This represents a substantial investment of NHS resources. This paper investigates whether this investment is being recouped in Scottish NHS acute trusts via the implementation of SIGN guidelines, and whether their implementation is being audited properly. It is argued that without clinical audit, guideline implementation is unlikely to succeed. This has important ramifications for the implementation of clinical governance.

THIS ARTICLE APPRAISES the Government's White Paper, The New NHS: Modern, Dependable, from the perspective of a health authority chief executive, outlining the context for developing health care, the joint challenges of the White Paper and the Green Paper, Our Healthier Nation, the role and potential of primary care groups (in detail), the developing role of the health authority, and the agenda for shaping and improving the delivery of health and health services. It ends with an appraisal of particular implications for community care.

The white paperWorking for Patientsintroduced fundholding to general practitioners (GPs), quickly followed by “The New Contract” and the “Patient’s Charter”. All have radically changed the way GP practices are run and managed. In response to increasing demands mechanisms are needed which will harness the motivation and commitment of practice staff. This paper reports the findings of an empirical study into GP practices conducted during 1998. The research aims were to establish the impact of the investors in people (IiP) programme on the attitudes and motivation of staff and examine any links with total quality management (TQM). The findings highlight significant differences between IiP and non‐IiP and raise some interesting issues for practice managers. There is strong evidence to suggest that using IiP as a tool to promote a TQM culture can work, but this is influenced and limited by the management style adopted.

The UK Government′s White Paper on the National Health Service, 1989, defined a programme of action aimed at achieving two objectives: give patients, wherever they live, better health care and greater choice of the services available; and produce greater satisfaction and rewards for NHS staff who successfully respond to local needs and preferences. The Paper defines seven key measures, each designed to make its own vital contribution to those objectives. One of these was the introduction of self‐governing hospital trusts, and one of the primary concerns of the Boards of Directors set up to run each of the new Trusts will be the development of a clear customer service strategy; one which combines clinical excellence with the highest standards of customer care. The customer care element of that strategy must combine the best of tried and tested management and organisation theory, with common sense, realism and pragmatism.

Explains the background to the Green Paper, The Health of the Nation, which was published in the middle of 1991 and has stimulated much debate and discussion about future strategy towards government policy on health. Discusses what it is hoped to achieve when the new approach is implemented.

The Government White Paper “Working for Patients” asks new District Health Authorities to identify core services which must be provided locally for the benefit of the District′s resident population. South Tees Purchasing Steering Group has developed a list of criteria which could be employed in this task and has proposed a methodology using these criteria to identify which medical conditions must be provided for locally and which could be catered for elsewhere on a best value for money basis. Using this methodology it then becomes possible to establish what proportion of conditions in any specialty require core service provision. The additional problem of sub‐regional specialties is also addressed and a solution offered.

PurposeThis paper aims to explore the voices of women describing the perceived barriers for advancing to leadership positions in healthcare.Design/methodology/approachA systematic search was conducted through Elton B Stephans Company (EBSCO) host research platform using the databases Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, Medical Literature Analysis and Retrieval System Online (MEDLINE) Complete and American Psychological Association (APA) PsycInfo. Nine papers were selected for this review. Thomas and Harden's (2008) method of thematic synthesis was used drawing from eight qualitative papers and one mixed methods paper describing women's lived experiences in, or advancing to, leadership positions in the healthcare sector. Analysis was conducted using three steps of thematic synthesis: the inductive coding of the text, the development of descriptive themes and the generation of analytical themes.FindingsThrough the method of thematic synthesis, six descriptive themes (barriers) emerged: internalised feelings, work–life balance, lack of support, stereotypes, discriminatory behaviours and organisational culture. From these, three analytical themes were identified: personal, interpersonal and organisational.Research limitations/implicationsThis review looked at nine papers and documented women's voices. However, the women were in disparate geographical areas across the world and did not consider the specific cultural context in which the women were located. The healthcare sector is very large, and therefore, whilst there are shared commonalities, the disparateness could be a limitation.Practical implicationsBarriers were categorised as either structural barriers or attitudinal barriers to determine the policy and practice.Originality/valueThis research is crucial to better understanding what remedies need to be implemented to address gender disparity in the sector.

PurposeThe aim of this paper is to review research conducted on managing the ageing healthcare workforce and identify gaps for further research.Design/methodology/approachA systematic literature search of studies in the English language was carried out in Scopus and Web of Science databases.FindingsThe study consists of an analysis of 75 published articles. The majority of the papers were published in recent years, indicating a growing interest in the field. The authors specified the following inclusion criteria: all years, articles/reviews, English language and full text in the Web of Science and Scopus databases. The authors of the paper illustrated seven major categories with different topics that were suggested for future research. It included: challenges of labor market in the healthcare field, age-related changes and their influence on work ability, training opportunities and lifelong learning among ageing health workforce, motives of early retirement, ageing and its relationship to Occupational Health and Safety. Longitudinal studies and case study strategy with mixed-methods approaches were suggested for future research by the authors.Originality/valueThe paper summarizes knowledge related to the management of ageing health workforce, describes topics researched and as a result, presents findings on and conclusions about the most important future implications of the ageing workforce for management in the healthcare field providing lines for further research. To the authors' knowledge, no holistic systematic literature reviews have been published in academic journals targeted specifically to ageing healthcare workers.

Purpose The purpose of this paper are threefold paper are threefold; firstly, to validate and measure significant dimensions of customer experience in the health care sector; secondly, to evaluate the antecedents and dimensions of customer experience and its impact on customer outcomes in health care; and thirdly, to examine the role of customer involvement as a moderator between antecedents and dimensions of customer experience. Design/methodology/approach This study is based upon primary data collection sources, particularly in-depth interviews, focus group interviews and survey methods. Both qualitative and quantitative studies were carried out. This qualitative study was conducted to conceptualize customer experience in the health-care sector. Whereas the quantitative study was undertaken to collect data from randomly selected, experienced 181 respondents for testing the proposed model. Findings Affective, relational and physical have emerged as significant customer experience dimensions in the health-care sector. All three dimensions have a positive and significant impact on the important customer outcomes, that is, satisfaction, attitudinal loyalty and brand equity. Service quality, supportive services and contextual services significantly affect customer experience. Customer involvement moderates the relationship between all the three antecedents and dimensions of customer experience. Research limitations/implications This study is primarily focused on customers' perceptions of the health-care sector. This study’s model could be implemented in different sectors such as lodging, food service, restaurant or other industries as well. Further, the role of moderators, namely, consumer attitudes, service quality, perceived risk, price and past experience, are also suggested to be explored for theorising the customer experience. Originality/value This study makes a maiden attempt to establish affective, relational and physical as three significant dimensions of customer experience in the health-care sector. Sensory and cognitive dimensions are found to be insignificant.

PurposeThis paper explores the role of hospital cleaners and their contribution to healthcare safety. Few studies have examined the activities and input of hospital cleaners, rendering them largely invisible in healthcare research. Yet, as coronavirus disease 2019 (COVID-19) has demonstrated, this sizeable workforce carries out tasks critical to healthcare facilities and wider health system functioning.Design/methodology/approachDrawing on the work of Habermas, the authors examine the literature surrounding cleaners and quality and safety in healthcare. The authors theorise cleaners' work as both instrumental and communicative and examine the perceptions of healthcare professionals and managers, as well as cleaners themselves, of healthcare professionals and managers' role and contribution to quality and safety.FindingsCleaners are generally perceived by the literature as performing repetitive – albeit important – tasks in isolation from patients. Cleaners are not considered part of the “healthcare team” and are excluded from decision-making and interprofessional communication. Yet, cleaners can contribute to patient care; ubiquity and proximity of cleaners to patients offer insights and untapped potential for involvement in hospital safety.Originality/valueThis paper brings an overdue focus to this labour force by examining the nature and potential of their work. This paper offers a new application of Habermas' work to this domain, rendering visible how the framing of cleaners' role works to exclude this important workforce from participation in the patient safety agenda.

Purpose There has been growing awareness underpinned with legislative recognition of the need to reduce the stigma attached to mental health. Education is seen as an integral factor for this endeavour. The purpose of this paper is to review existing literature to determine both positive and negative attitudinal changes of health-care-related undergraduate students towards mental illness after a training intervention within higher education. Design/methodology/approach A search of papers written in the English Language was conducted between 2004 and 2021, using CINAHL, Eric, Educational Research Complete, Medline, psychINFO and SocIndex. Search terms used were undergraduate, attitudes or perceptions, mental illness/mental ill health, education, stigma and students. Findings In total, 24 studies were critically reviewed, which included experimental, descriptive and exploratory designs. The appraisal of papers used recognised evaluation tools to review the methodological quality. Findings suggest that overall, anti-stigma education has a significant positive effect for student attitudinal change. Research limitations/implications Mental health anti-stigma education is beneficial for changing attitudes, however, more bio-medically framed training is less powerful for initiating change. Learning from those with the lived experience appears to have a more sustainable impact as indicated in some of the studies. There is a need for more exploratory research to gain further knowledge on the critical educational mechanisms that may foster more long-term reframing of positive attitudes towards mental health. Practical implications Training providers need to consider the compelling evidence base surrounding anti-stigma pedagogy that supports the use of individuals with experience of mental ill health within the educational processes. Social implications Mental health stigma has potential for profound negative impact on individuals and at a wider societal level. Education is central to enable learners to consider their attitudes to mental illness to reduce stigmatising attitudes. Students on health-care-related courses are influential in becoming catalysts for change. Originality/value This paper has critically reviewed the literature examining the attitudes of health-care-related undergraduate students following anti-stigma education, offering insights into some of positive and negative attitudinal changes and opinions of the event. In particular contributing to an understanding on the important components for eradicating the stigma surrounding mental health.

PurposeGiven the efficacy of a robust public healthcare system in handling public health emergencies, the rapid rate of COVID-19 pandemic infection in early-hit (advanced) countries with competent healthcare system is intriguing. The popular public health argument supports the strengthening of the healthcare system as a significant response strategy to minimize infection. Hence, this paper examines the catalysts that exacerbated the pandemic’s rapid spread in these countries despite the sound state of their healthcare system. Also, it assesses the condition of Nigerian public healthcare system in the lights of the novel COVID-19 pandemic and suggests the need for improvement and effective functioning.Design/methodology/approachThis paper uses a documentary approach to establish the authors’ opinion on the subject matter under investigation.FindingsFactors such as climate, temperature, and humidity levels played a key role in infection in the winter of 2020. These factors facilitated for the pandemic’s rapid spread in advanced countries. In peripheral countries like Nigeria, the public healthcare system is burdened by a lack of funding, an insufficiency in welfare and training for healthcare staff and facilities and other operational challenges. Hence, the effective management of COVID-19 outbreak in Nigeria relative to advanced countries was hindered by the inadequacies mentioned above.Originality/valueThis paper provides an understanding on the condition of public healthcare system in peripheral nations in relation to the healthcare system advisories from the World Health Organization (WHO) in the context of handling the pandemic outbreak. Also, it explains the catalysts that heightened the pandemic’s rapid spread in advanced countries despite the higher capacity of their healthcare system to manage health emergencies.