Managing death: navigating divergent logics in end-of-life care.

Delivery of end-of-life care has gained prominence in the UK, driven by a focus upon the importance of patient choice. In practice choice is influenced by several factors, including the guidance and conduct of healthcare professionals, their different understandings of what constitutes 'a good death', and contested ideas of who is best placed to deliver this. We argue that the attempt to elicit and respond to patient choice is shaped in practice by a struggle between distinct 'institutional logics'. Drawing on qualitative data from a two-part study, we examine the tensions between different professional and organisational logics in the delivery of end-of-life care. Three broad clusters of logics are identified: finance, patient choice and professional authority. We find that the logic of finance shapes the meaning and practice of 'choice', intersecting with the logic of professional authority in order to shape choices that are in the 'best interest' of the patient. Different groups might be able to draw upon alternative forms of professionalism, and through these enact different versions of choice. However, this can resemble a struggle for ownership of patients at the end of life, and therefore, reinforce a conventional script of professional authority.

Exploring health work: a critical-action perspective.

Purpose The purpose of this paper is to describe a hybrid approach to the research developed during a multi-researcher, ethnographic study of NHS management in the UK. Design/methodology/approach This methodological paper elaborates a hybrid approach to the sociological analysis - the critical-action theory - and indicates how it can contribute to the critical health management studies. Findings After exploring the various theoretical, methodological and philosophical options available, the paper discusses the main research issues that influenced the development of this perspective and the process by which the critical-action perspective was applied to the studies of managerial work in four health service sectors - acute hospitals, ambulance services, community services and mental healthcare. Research limitations/implications This methodological perspective enabled a critical analysis of health service organisation that considered macro, meso and micro effects, in particular and in this case, how new public management drained power from clinicians through managerialist discourses and practices. Practical implications Healthcare organisations are often responding to the decisions that lie outside of their control and may have to enact changes that make little sense locally. In order to make sense of these effects, micro-, meso- and macro-level analyses are necessary. Originality/value The critical-action perspective is presented as an adjunct to traditional approaches that have been taken to the study of health service organisation and delivery.

Negotiating and valuing spaces: The discourse of space and 'home' in care homes.

This paper examines how space in care homes is experienced and negotiated by people who live and work in them. The analysis of qualitative data of five in-depth case studies of care homes in England revealed three key ways in which space is negotiated: a) the way in which values affect interactions inside versus outside the care home environment, b) the negotiation of boundaries and domains within the homes, and c) the sense of being at 'home'. The paper illuminates how the design of the buildings and organisational factors can reinforce or bridge dichotomies between inside and outside spaces. Residents' abilities to re-negotiate boundaries, domains and communal spaces within homes are shown to be affected by organisational factors such as priorities of staff members. Despite 'home' being a common discourse, the spaces within care homes were often organised, ordered and experienced as two distinct, co-present worlds: the dwelling place of residents and the workplace of staff.

A Wicked Problem? Whistleblowing in Healthcare Organisations Comment on "Cultures of Silence And Cultures of Voice: The Role Of Whistleblowing in Healthcare Organisations".

Mannion and Davies' article recognises whistleblowing as an important means of identifying quality and safety issues in healthcare organisations. While 'voice' is a useful lens through which to examine whistleblowing, it also obscures a shifting pattern of uncertain 'truths.' By contextualising cultures which support or impede whislteblowing at an organisational level, two issues are overlooked; the power of wider institutional interests to silence those who might raise the alarm and changing ideas about what constitutes adequate care. A broader contextualisation of whistleblowing might illuminate further facets of this multi-dimensional problem.

High performance HRM: NHS employee perspectives.

PURPOSE: The purpose of this paper is to examine National Health Service (NHS) employee perspectives of how high performance human resource (HR) practices contribute to their performance. DESIGN/METHODOLOGY/APPROACH: The paper draws on an extensive qualitative study of the NHS. A novel two-part method was used; the first part used focus group data from managers to identify high-performance HR practices specific to the NHS. Employees then conducted a card-sort exercise where they were asked how or whether the practices related to each other and how each practice affected their work. FINDINGS: In total, 11 high performance HR practices relevant to the NHS were identified. Also identified were four reactions to a range of HR practices, which the authors developed into a typology according to anticipated beneficiaries (personal gain, organisation gain, both gain and no-one gains). Employees were able to form their own patterns (mental models) of performance contribution for a range of HR practices (60 interviewees produced 91 groupings). These groupings indicated three bundles particular to the NHS (professional development, employee contribution and NHS deal). PRACTICAL IMPLICATIONS: These mental models indicate employee perceptions about how health services are organised and delivered in the NHS and illustrate the extant mental models of health care workers. As health services are rearranged and financial pressures begin to bite, these mental models will affect employee reactions to changes both positively and negatively. ORIGINALITY/VALUE: The novel method allows for identification of mental models that explain how NHS workers understand service delivery. It also delineates the complex and varied relationships between HR practices and individual performance.

Wicked problems or wicked people? Reconceptualising institutional abuse.

Institutional abuse is a global issue, sometimes ascribed to the behaviour of a few wicked people. It persists despite regulatory measures, interventions from enforcement and protection agencies, organisational policies and procedures. Therefore, the accurate recognition and early detection of abuse and taking corresponding steps to deal with perpetrators are critical elements in protecting vulnerable people who live in institutions. However, research is less clear about why and how abuse (re)occurs. Using the tame and wicked problem analysis of Rittell and Webber (1973) as a lens, we examine the ways institutional abuse is formulated in care settings. Drawing on case study data from eight care homes for older people, we show how solutions seeking to reduce institutional abuse and improve care quality can cause additional problems. The article reconceptualises institutional abuse through the lens of wicked problem analysis to illustrate the multifaceted and recurring, wicked problem characteristics of residential care provision.

How organizational factors interact to influence the quality of care of older people in the care home sector.

OBJECTIVES: To examine how organizational factors affect good care and mistreatment of older people in care homes. METHODS: Eight residential care homes for older people (including private sector, local authority and NHS providers) took part in a participatory observation-based study of organizational factors affecting care quality. RESULTS: Grouping organizational factors into infrastructure, management and procedures, staffing, resident population characteristics and culture, we show the context-sensitive nature of interactions between these factors. These interactions could enhance care quality where factors combined positively. Conversely, they could amplify difficulties where one factor came to undermine another, thereby limiting care quality. CONCLUSIONS: This analysis provides empirical insights into how and why similar sector-wide changes to care provision have differential effects at the care home level. It indicates the situated and unpredictable ways in which organizational factors interact, implying the need for locally contextualized quality assessment and improvement actions.

What have NHS managers ever done for us?

The image of the UK National Health Service manager has not always been positive. Like others in the public sector, NHS managers are sometimes associated in the media with waste and inefficiency, in contrast to those in 'front line roles'. Thus healthcare professionals and members of the public might ask, in the tradition of Monty Python's Life of Brian, what NHS managers have ever done for us. In this short article, we outline some of the evidence from the literature on attitudes to, and role of, healthcare managers, before drawing on our own interview and observation based fieldwork with managers themselves. We argue that the role of the healthcare manager is not always well understood, and that in a sector facing ever more intense and large scale organisational challenges, managers should be seen as important partners in a health service focused on clinical outcomes.

Human resource management and performance in healthcare organisations.

PURPOSE: The purpose of this paper is to compare the evidence from a range of reviews concerned with the links between human resource management (HRM) and performance. The aim of the paper is to review this diverse literature, and to derive human resource (HR) implications for healthcare researchers, policy makers and managers. DESIGN/METHODOLOGY/APPROACH: Recent reviews of the human resource management and performance literature are examined, in addition to the inclusion of a previously unpublished review. Their methods, HRM focus, findings and recommendations are contrasted in order to produce this review. FINDINGS: The paper finds that relationships have been found between a range of HRM practices, policies systems and performance. Despite being an important concern for HR professionals, there is little research exploring the link between HRM and performance in the health sector. RESEARCH LIMITATIONS/IMPLICATIONS: The paper sees that recent studies have found HRM practices to be associated with patient outcomes such as mortality, yet they yield little information regarding the processes through which HRM affects individual performance and its consequent impact on patient care. The use of approaches that seek to gain an understanding of workers' interpretations of their experience, i.e. the psychological process through which HRM can affect individual performance, may shed some light on how these processes work in practice. PRACTICAL IMPLICATIONS: The paper shows that increasing autonomy for healthcare organisations in the UK, i.e. Foundation Trusts, may offer increased opportunity for locally tailored HR systems and practices. ORIGINALITY/VALUE: The paper presents findings drawn from a review of previous research on a subject of increasing relevance to HR researchers and practitioners in healthcare organisations. The paper indicates alternative approaches to research and practice in light of extant research.