“Paths for Action”: Leadership Theory and Practice in Complex Public Sector Systems

The nature and challenges of public sector leadership and management are examined in four case studies of project management in complex metropolitan environments. The cases selected by the authors as representative of contextual factors affecting decision-making processes and project outcomes. Drawing on recent theoretical work on complex leadership approaches (Uhl-Bein et al 2007, Hazy 2008, Lichtenstein & Plowman 2009), the authors assess leadership practices enacted and the circumstances that influence these practices. Leadership types theorized by Uhl-Bein et al (2007) are identified operating at different levels and across networks, with contextual factors outlined. The article concludes with a framework for leadership practice and management identifying network facilitation and complexity friendly tools as a practice within complex public sector systems.

Realistic evaluation of EWS and ALERT: factors enabling and constraining implementation.

Realistic Evaluation of EWS and ALERT: factors enabling and constraining implementation Background The implementation of EWS and ALERT in practice is essential to the success of Rapid Response Systems but is dependent upon nurses utilising EWS protocols and applying ALERT best practice guidelines. To date there is limited evidence on the effectiveness of EWS or ALERT as research has primarily focused on measuring patient outcomes (cardiac arrests, ICU admissions) following the implementation of a Rapid Response Team. Complex interventions in healthcare aimed at changing service delivery and related behaviour of health professionals require a different research approach to evaluate the evidence. To understand how and why EWS and ALERT work, or might not work, research needs to consider the social, cultural and organisational influences that will impact on successful implementation in practice. This requires a research approach that considers both the processes and outcomes of complex interventions, such as EWS and ALERT, implemented in practice. Realistic Evaluation is such an approach and was used to explain the factors that enable and constrain the implementation of EWS and ALERT in practice [1]. Aim The aim of this study was to evaluate factors that enabled and constrained the implementation and service delivery of early warnings systems (EWS) and ALERT in practice in order to provide direction for enabling their success and sustainability. Methods The research design was a multiple case study approach of four wards in two hospitals in Northern Ireland. It followed the principles of realist evaluation research which allowed empirical data to be gathered to test and refine RRS programme theory. This approach used a variety of mixed methods to test the programme theories including individual and focus group interviews, observation and documentary analysis in a two stage process. A purposive sample of 75 key informants participated in individual and focus group interviews. Observation and documentary analysis of EWS compliance data and ALERT training records provided further evidence to support or refute the interview findings. Data was analysed using NVIVO8 to categorise interview findings and SPSS for ALERT documentary data. These findings were further synthesised by undertaking a within and cross case comparison to explain the factors enabling and constraining EWS and ALERT. Results A cross case analysis highlighted similarities, differences and factors enabling or constraining successful implementation across the case study sites. Findings showed that personal (confidence; clinical judgement; personality), social (ward leadership; communication), organisational (workload and staffing issues; pressure from managers to complete EWS audit and targets), educational (constraints on training; no clinical educator on ward) and cultural (routine task delegated) influences impact on EWS and acute care training outcomes. There were also differences noted between medical and surgical wards across both case sites. Conclusions Realist Evaluation allows refinement and development of the RRS programme theory to explain the realities of practice. These refined RRS programme theories are capable of informing the planning of future service provision and provide direction for enabling their success and sustainability. References: 1. McGaughey J, Blackwood B, O’Halloran P, Trinder T. J. & Porter S. (2010) A realistic evaluation of Track and Trigger systems and acute care training for early recognition and management of deteriorating ward–based patients. Journal of Advanced Nursing 66 (4), 923-932. Type of submission: Concurrent session Source of funding: Sandra Ryan Fellowship funded by the School of Nursing & Midwifery, Queen’s University of Belfast

Learning to manage complexity through simulation: students' challenges and possible strategies

Many have called for medical students to learn how to manage complexity in healthcare. This study examines the nuances of students' challenges in coping with a complex simulation learning activity, using concepts from complexity theory, and suggests strategies to help them better understand and manage complexity.Wearing video glasses, participants took part in a simulation ward-based exercise that incorporated characteristics of complexity. Video footage was used to elicit interviews, which were transcribed. Using complexity theory as a theoretical lens, an iterative approach was taken to identify the challenges that participants faced and possible coping strategies using both interview transcripts and video footage.Students' challenges in coping with clinical complexity included being: a) unprepared for 'diving in', b) caught in an escalating system, c) captured by the patient, and d) unable to assert boundaries of acceptable practice.Many characteristics of complexity can be recreated in a ward-based simulation learning activity, affording learners an embodied and immersive experience of these complexity challenges. Possible strategies for managing complexity themes include: a) taking time to size up the system, b) attuning to what emerges, c) reducing complexity, d) boundary practices, and e) working with uncertainty. This study signals pedagogical opportunities for recognizing and dealing with complexity.

The design and performance of a 2.5-GHz telecommand link for wireless biomedical monitoring

This paper details the implementation and operational performance of a minimum-power 2.45-GHz pulse receiver and a companion on-off keyed transmitter for use in a semi-active duplex RF biomedical transponder. A 50-Ohm microstrip stub-matched zero-bias diode detector forms the heart of a body-worn receiver that has a CMOS baseband amplifier consuming 20 microamps from +3 V and achieves a tangential sensitivity of -53 dBm. The base transmitter generates 0.5 W of peak RF output power into 50 Ohms. Both linear and right-hand circularly polarized Tx-Rx antenna sets were employed in system reliability trials carried out in a hospital Coronary Care Unit, For transmitting antenna heights between 0.3 and 2.2 m above floor level, transponder interrogations were 95% reliable within the 67-m-sq area of the ward, falling to an average of 46 % in the surrounding rooms and corridors. Overall, the circular antenna set gave the higher reliability and lower propagation power decay index.

A comprehensive comparison between generalized incidence calculus and Dempster-Shafer theory of evidence.

Dealing with uncertainty problems in intelligent systems has attracted a lot of attention in the AI community. Quite a few techniques have been proposed. Among them, the Dempster-Shafer theory of evidence (DS theory) has been widely appreciated. In DS theory, Dempster's combination rule plays a major role. However, it has been pointed out that the application domains of the rule are rather limited and the application of the theory sometimes gives unexpected results. We have previously explored the problem with Dempster's combination rule and proposed an alternative combination mechanism in generalized incidence calculus. In this paper we give a comprehensive comparison between generalized incidence calculus and the Dempster-Shafer theory of evidence. We first prove that these two theories have the same ability in representing evidence and combining DS-independent evidence. We then show that the new approach can deal with some dependent situations while Dempster's combination rule cannot. Various examples in the paper show the ways of using generalized incidence calculus in expert systems.

THEORY AND DESIGN OF A TUNABLE QUASI-LUMPED QUADRATURE COUPLER

In this article, we present the theory and a design methodology for a unable Quasi-Lumped Quadrature Coupler (QLQC). Because of its topology, the coupler is simply reconfigured by switching the bias of two varactor diodes via a very simple DC bias circuitry. No additional capacitors or inductors are required. A prototype at 3.5 GHz is etched on a 0.130-mm-thick layer substrate with a dielectric material of relative permittivity of 2.22. The simulated and measured scattering parameters are, presented. (c) 2009 Wiley Periodicals, Inc. Microwave Opt Technol Lett 51: 2219-2222 2009: Published online in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/mop.24526

Low power field programmable gate array implementation of fast digital signal processing algorithms: characterisation and manipulation of data locality

Dynamic power consumption is very dependent on interconnect, so clever mapping of digital signal processing algorithms to parallelised realisations with data locality is vital. This is a particular problem for fast algorithm implementations where typically, designers will have sacrificed circuit structure for efficiency in software implementation. This study outlines an approach for reducing the dynamic power consumption of a class of fast algorithms by minimising the index space separation; this allows the generation of field programmable gate array (FPGA) implementations with reduced power consumption. It is shown how a 50% reduction in relative index space separation results in a measured power gain of 36 and 37% over a Cooley-Tukey Fast Fourier Transform (FFT)-based solution for both actual power measurements for a Xilinx Virtex-II FPGA implementation and circuit measurements for a Xilinx Virtex-5 implementation. The authors show the generality of the approach by applying it to a number of other fast algorithms namely the discrete cosine, the discrete Hartley and the Walsh-Hadamard transforms.

“La littérature est la seule patrie”: Nabile Farès and the Poetry of Postcolonial Displacment

Nabile Farès is a key author within postcolonial studies, due in particular to his uniquely expressive writing style. This article discusses writing style in his 1982 text, L’état perdu: précédé du discours pratique de l’immigré. Throughout the mainly French text, different alphabets are woven, alluding to the complexity of Algerian linguistic history and the importance of language in the construction and expression of identity. Meanwhile, the grammar and structure of the French language seems confused and at times illogical, raising further questions about use of a colonial language in a postcolonial context. Farès’s writing style is avant-garde in nature, and deliberate intertextuality with the Surrealists situates the text within an avant-garde tradition in the French language, developing new ideas surrounding the effect of this written genre in the aftermath of colonialism.

Environmental Inequalities and Democratic Citizenship: Linking Normative Theory with Empirical Research

The aim of this paper is to link empirical findings concerning environmental inequalities with different normative yard-sticks for assessing whether these inequalities should be deemed unjust, or not. We argue that such an inquiry must necessarily take into account some caveats regarding both empirical research and normative theory. We suggest that empirical results must be contextualised by establishing geographies of risk. As a normative yard-stick we propose a moderately demanding social-egalitarian account of justice and democratic citizenship, which we take to be best suited to identify unjust as well as legitimate instances of socio-environmental inequality.

The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK).

Background
The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention.

Methods
Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff.

Results
Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision.

Conclusions
We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes.

DEX: self-healing expanders

A realistic evaluation of Early Warning Systems and acute care training in Northern Ireland: findings and recommendations

Statement of purpose The purpose of this concurrent session is to present the main findings and recommendations from a five year study evaluating the implementation of Early Warning Systems (EWS) and the Acute Life-threatening Events: Recognition and Treatment (ALERT) course in Northern Ireland. The presentation will provide delegates with an understanding of those factors that enable and constrain successful implementation of EWS and ALERT in practice in order to provide an impetus for change. Methods The research design was a multiple case study approach of four wards in two hospitals in Northern Ireland. It followed the principles of realist evaluation research which allowed empirical data to be gathered to test and refine RRS programme theory [1]. The stages included identifying the programme theories underpinning EWS and ALERT, generating hypotheses, gathering empirical evidence and refining the programme theories. This approach used a variety of mixed methods including individual and focus group interviews, observation and documentary analysis of EWS compliance data and ALERT training records. A within and across case comparison facilitated the development of mid-range theories from the research evidence. Results The official RRS theories developed from the realist synthesis were critically evaluated and compared with the study findings to develop a mid-range theory to explain what works, for whom in what circumstances. The findings of what works suggests that clinical experience, established working relationships, flexible implementation of protocols, ongoing experiential learning, empowerment and pre-emptive management are key to the success of EWS and ALERT implementation. Each concept is presented as ‘context, mechanism and outcome configurations’ to provide an understanding of how the context impacts on individual reasoning or behaviour to produce certain outcomes. Conclusion These findings highlight the combination of factors that can improve the implementation and sustainability of EWS and ALERT and in light of this evidence several recommendations are made to provide policymakers with guidance and direction for future policy development. References: 1. Pawson R and Tilley N. (1997) Realistic Evaluation. Sage Publications; London Type of submission: Concurrent session Source of funding: Sandra Ryan Fellowship funded by the School of Nursing & Midwifery, Queen’s University of Belfast

Realist Evaluation: a theory driven approach.

Realistic Evaluation assumes that all programmes implemented in practice have an underlying theory to explain how a particular intervention is meant to work. The purpose of realist evaluation is to test the theoretical propositions underpinning the implementation of a programme in order to understand how and why it works, or might not work, in certain circumstances. The first stage of the realist evaluation is to track and articulate the programme theories to determine the evidence on the ‘official conjecture’ (Pawson et al 2004 pg 16) of how the programme is suppose to work in practice. These official conjectures are then tested and refined by gathering empirical evidence to establish causal relationships between a programme and its outcome. Evaluation of the factors and interactions between factors, supporting or hindering the implementation of a programme in practice facilitate theory refinement. Theory refinement is viewed as an iterative and cyclical process undertaken to synthesise the empirical evidence and develop mid-range theories which can be generalised and applied to other programmes to improve implementation and sustainability. In this symposium an example of realist evaluation used to test and refine the theory underpinning the implementation of Early Warning Systems (EWS) is provided to clarify how this theory driven approach can be applied in practice.

Triangular Objects and Systematic K-Theory

We investigate modules over “systematic” rings. Such rings are “almost graded” and have appeared under various names in the literature; they are special cases of the G-systems of Grzeszczuk. We analyse their K-theory in the presence of conditions on the support, and explain how this generalises and unifies calculations of graded and filtered K-theory scattered in the literature. Our treatment makes systematic use of the formalism of idempotent completion and a theory of triangular objects in additive categories, leading to elementary and transparent proofs throughout.