Knowledge based strategy: appraising knowledge creation capability in organisations.

This thesis sets out a journey which culminates in the development of an analytical framework, the "Organisational Creativity Appraisal" which is intended to assist organisations in evaluating their ability to support and develop creativity. This framework is derived from the common thread of the thesis, which is drawn from a range of research and consultancy projects, and the resulting published work, spanning an eight year period, centring on the role of knowledge and creativity in the strategy and performance of organisations. The literature of strategy, learning and creativity increasingly recognises that organisational context is critical to the formation of strategy, to the content of the strategy and to its successful implementation. The thesis explores the ways in which learning and creativity, the basis of knowledge-based strategy, are influenced by organisational context or social architecture. The research explores the ways in which managers can gain greater understanding of the social architectures of their organisations so as to assist in supporting their strategic development. The central core of the thesis is the nine published papers upon which it is based but it also derives from the broader perspective of my published work in the form of both articles and books. The thesis further draws upon my own experience as a leader and manager in the context of university business schools and as a consultant, researcher and developer in the context of a range of international private and public sector organisations. The work is based upon a premise that theory should inform practice and that practice should inform theory. The "Organisational Creativity Appraisal" framework is informed by both theory and practice and is intended to assist in management practice. There is no assumption that management research can arrive at prescriptions for managerial and organisational behaviour. On the other hand management research can usefully inform management and organisational behaviour, as long as it is employed in a critically reflective manner. The "Organisational Creativity Appraisal" presented in this work should be regarded as the framework in its present form which is likely to develop further as my research progresses in the future.

Design thinking - a critical analysis.

The latest buzz phrase to enter the world of design research is “Design Thinking”. But is this anything new and does it really have any practical or theoretical relevance to the design world? Many sceptics believe the term has more to do with business strategy and little to do with the complex process of designing products, services and systems. Moreover, many view the term as misleading and a cheap attempt to piggyback the world of business management onto design. This paper seeks to ask is design thinking anything new? Several authors have explicitly or implicitly articulated the term “Design Thinking” before, such as Peter Rowe’s seminal book “Design Thinking” [1] first published in 1987 and Herbert Simon’s “The Sciences of the Artificial” [2] first published in 1969. In Tim Brown’s “Change by Design” [3], design thinking is thought of as a system of three overlapping spaces rather than a sequence of orderly steps namely inspiration – the problem or opportunity that motivates the search for solutions; ideation – the process of generating, developing and testing ideas; and implementation – the path that leads from the design studio, lab and factory to the market. This paper seeks to examine and critically analyse the tenets of this new design thinking manifesto set against three case studies of modern design practice. As such, the paper will compare design thinking theory with the reality of design in practice.

Development of process control methodology for tracking the quality and safety of pain, agitation and sedation management in critical care units

Objective: To develop sedation, pain, and agitation quality measures using process control methodology and evaluate their properties in clinical practice. Design: A Sedation Quality Assessment Tool was developed and validated to capture data for 12-hour periods of nursing care. Domains included pain/discomfort and sedation-agitation behaviors; sedative, analgesic, and neuromuscular blocking drug administration; ventilation status; and conditions potentially justifying deep sedation. Predefined sedation-related adverse events were recorded daily. Using an iterative process, algorithms were developed to describe the proportion of care periods with poor limb relaxation, poor ventilator synchronization, unnecessary deep sedation, agitation, and an overall optimum sedation metric. Proportion charts described processes over time (2 monthly intervals) for each ICU. The numbers of patients treated between sedation-related adverse events were described with G charts. Automated algorithms generated charts for 12 months of sequential data. Mean values for each process were calculated, and variation within and between ICUs explored qualitatively. Setting: Eight Scottish ICUs over a 12-month period. Patients: Mechanically ventilated patients. Interventions: None. Measurements and Main Results: The Sedation Quality Assessment Tool agitation-sedation domains correlated with the Richmond Sedation Agitation Scale score (Spearman [rho] = 0.75) and were reliable in clinician-clinician (weighted kappa; [kappa] = 0.66) and clinician-researcher ([kappa] = 0.82) comparisons. The limb movement domain had fair correlation with Behavioral Pain Scale ([rho] = 0.24) and was reliable in clinician-clinician ([kappa] = 0.58) and clinician-researcher ([kappa] = 0.45) comparisons. Ventilator synchronization correlated with Behavioral Pain Scale ([rho] = 0.54), and reliability in clinician-clinician ([kappa] = 0.29) and clinician-researcher ([kappa] = 0.42) comparisons was fair-moderate. Eight hundred twenty-five patients were enrolled (range, 59-235 across ICUs), providing 12,385 care periods for evaluation (range 655-3,481 across ICUs). The mean proportion of care periods with each quality metric varied between ICUs: excessive sedation 12-38%; agitation 4-17%; poor relaxation 13-21%; poor ventilator synchronization 8-17%; and overall optimum sedation 45-70%. Mean adverse event intervals ranged from 1.5 to 10.3 patients treated. The quality measures appeared relatively stable during the observation period. Conclusions: Process control methodology can be used to simultaneously monitor multiple aspects of pain-sedation-agitation management within ICUs. Variation within and between ICUs could be used as triggers to explore practice variation, improve quality, and monitor this over time

Understanding nurses’ decision-making when managing weaning from mechanical ventilation: a study of novice and experienced critical care nurses in Scotland and Greece.

Aim and objectives To examine how nurses collect and use cues from respiratory assessment to inform their decisions as they wean patients from ventilatory support. Background Prompt and accurate identification of the patient's ability to sustain reduction of ventilatory support has the potential to increase the likelihood of successful weaning. Nurses' information processing during the weaning from mechanical ventilation has not been well-described. Design A descriptive ethnographic study exploring critical care nurses' decision-making processes when weaning mechanically ventilated patients from ventilatory support in the real setting. Methods Novice and expert Scottish and Greek nurses from two tertiary intensive care units were observed in real practice of weaning mechanical ventilation and were invited to participate in reflective interviews near the end of their shift. Data were analysed thematically using concept maps based on information processing theory. Ethics approval and informed consent were obtained. Results Scottish and Greek critical care nurses acquired patient-centred objective physiological and subjective information from respiratory assessment and previous knowledge of the patient, which they clustered around seven concepts descriptive of the patient's ability to wean. Less experienced nurses required more encounters of cues to attain the concepts with certainty. Subjective criteria were intuitively derived from previous knowledge of patients' responses to changes of ventilatory support. All nurses used focusing decision-making strategies to select and group cues in order to categorise information with certainty and reduce the mental strain of the decision task. Conclusions Nurses used patient-centred information to make a judgment about the patients' ability to wean. Decision-making strategies that involve categorisation of patient-centred information can be taught in bespoke educational programmes for mechanical ventilation and weaning. Relevance to clinical practice Advanced clinical reasoning skills and accurate detection of cues in respiratory assessment by critical care nurses will ensure optimum patient management in weaning mechanical ventilation