Sustaining Health Care Practice Change: The Experience of Best Practice Spotlight Organizations Implementing and Sustaining RNAO Best Practice Guidelines

Sustainability of change for improvement initiatives has been widely reported as a global challenge both within and outside health care settings. The purpose of this study was to examine the extent to which factors related to staff training and involvement, staff behaviour, and clinical leaders’ and senior leaders’ engagement and support impact the long term sustainability of practice changes for BPSO health care organizations who have implemented Registered Nursing Association of Ontario’s (RNAO) Best Practice Guidelines. Semi structured interviews with eleven organizational leaders’ from ten health care organizations were conducted to explore the unique experiences, views and perspectives on factors related to staff, clinical leaders and senior leaders and their involvement and impact on the long term sustainability of clinical practice changes within organizations who had implemented Registered Nursing Association of Ontario’s (RNAO) Best Practice Guidelines (BPGs). The interviews were coded and analyzed using thematic content analysis. Further analysis identified patterns and themes in relation to: 1. The National Health Service (NHS) Sustainability Model which was used as the theoretical framework for this research; and 2. Organizations found to have sustained practice changes longer term verses organizations that did not. Six organizations were found to have sustained practice changes while the remaining four were found to have been unsuccessful in their efforts to sustain the changes. Five major findings in relation to sustainability emerged from this study. First is the importance of early and sustained engagement and frontline staff, managers, and clinical leaders in planning, implementation and ongoing development of BPGs through use of working groups and champions models. Second is the importance of ongoing provision of formal training, tools and resources to all key stakeholders during and after the implementation phase and efforts made to embed changes in current processes whenever possible to ensure sustainability. Third is to ensure staff and management are receptive to the proposed change(s) and/or have been given the necessary background information and rationale so they understand and can support the need for the change. Fourth is the need for early and sustained fiscal and human resources dedicated to supporting BPG implementation and the ongoing use of the BPGs already in place. Fifth is ensuring clinical leaders are trusted, influential, respected and seen as clinical resources by frontline staff. The significance of this study lies in a greater understanding of the influence and impact of factors related to staff on the long term sustainability of implemented practice changes within health care organizations. This study has implications for clinical practice, policy, education and research in relation to sustainability in health care.

The neo-liberal state and the crisis of public service broadcasting in the Anglo-American democracies /

The NeO'liberal State and the Crisis ofPublic Service Broadcasting in the Anglo-American Democracies The purpose ofthis analysis ofthe present condition ofpublic service broadcasting in the Anglo- American democracies was to investigate whether such media can still be regarded as the primarypublic spherefor a dialogue between each nation 's civil society and the State. The motivationfor this thesis was based on a presumption that such fora for public discussion on the central issues of each society have become viewed as less relevant bypoliticians andpolicy-makers and thepublics they were intended to serve in the Anglo-American democracies over thepast two decades. It is speculated that this is the case because ofa beliefthat the post-war consensus between the respective States andpublics that led to the construction of the Keynesian Welfare State and the notion ofpublic service broadcasting has been displaced by an individualistic, neo-liberal, laissez-faire ideology. In other words, broadcasting as a consumer-oriented, commercial commodity has superseded concerns pertaining to the importance ofthe public interest. The methodology employed in this thesis is a comparative analysisfrom a criticalpolitical economy perspective. It was considered appropriate to focus on the United Kingdom, Australia, Canada and the\ United States because they comprise the four largest Anglo-American nations with democratic political systems andprimarily market economies. Justificationfor this particular sample is reinforced by thefact that case study countries also share a common socio-political and economic tradition. The evidence assembledfor this thesis consisted almost exclusively ofexisting literature on the subjects ofpublic service broadcasting, global economic andpolitical integration, and the ascendance ofthe 'free-market ' ethos in Western democracies since the late mid- to late-1970s. In essence, this thesis could be considered as a reinterpretation ofthe existing literature relevant to these issues. Several important common features werefound among the political, economic and broadcasting systems of the four case study nations. It is proposed that the prevalence of the neo-liberal world view throughout the political and policy environments of the four countries has undermined the stability and credibility of each nation 's national public service broadcasting organization, although with varying intensity and effect,. Deregulation ofeach nation 's broadcasting system and the supremacy ofthe notion of 'consumer sovereignty' have marginalized the view of broadcasting on any basis other than strictly economic criteria in thefour case study countries. This thesis concludes that,for a reconstruction ofa trulyparticipatory anddemocraticpublicsphere to be realized in the present as well as thefuture, a reassessment ofthe conventional concept ofthe 'public sphere ' is necessary. Therefore, it is recommended that thefocus ofpolicy-makers in each Anglo-American democracy be redirectedfrom that which conceived ofan all-encompassing, large, state-ownedand operated public broadcasting service toward a view which considers alternativeforms ofpublic communication, such as local community and ethnic broadcasting operations, that are likely to be more responsive to the needs of the increasingly diverse and heterogeneous populations that comprise the modem Anglo-American democracies. The traditional conception of public broadcasters must change in accordance with its contemporary environment if the fundamental principles of the public sphere and public service broadcasting are to be realized.