Culture and behaviour in the English National Health Service:overview of lessons from a large multimethod study

Background - Problems of quality and safety persist in health systems worldwide. We conducted a large research programme to examine culture and behaviour in the English National Health Service (NHS). Methods - Mixed-methods study involving collection and triangulation of data from multiple sources, including interviews, surveys, ethnographic case studies, board minutes and publicly available datasets. We narratively synthesised data across the studies to produce a holistic picture and in this paper present a highlevel summary. Results - We found an almost universal desire to provide the best quality of care. We identified many 'bright spots' of excellent caring and practice and high-quality innovation across the NHS, but also considerable inconsistency. Consistent achievement of high-quality care was challenged by unclear goals, overlapping priorities that distracted attention, and compliance-oriented bureaucratised management. The institutional and regulatory environment was populated by multiple external bodies serving different but overlapping functions. Some organisations found it difficult to obtain valid insights into the quality of the care they provided. Poor organisational and information systems sometimes left staff struggling to deliver care effectively and disempowered them from initiating improvement. Good staff support and management were also highly variable, though they were fundamental to culture and were directly related to patient experience, safety and quality of care. Conclusions - Our results highlight the importance of clear, challenging goals for high-quality care. Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported.

Picture this:researching child workers

Visual methods such as photography are under-used in the active process of sociological research. As rare as visual methods are, it is even rarer for the resultant images to be made by rather than of research participants. Primarily, the paper explores the challenges and contradictions of using photography within a multi-method approach. We consider processes for analysing visual data, different ways of utilising visual methods in sociological research, and the use of primary and secondary data, or, simple illustration versus active visual exploration of the social. The question of triangulation of visual data against text and testimony versus a stand-alone approach is explored in depth.

Systematic financial resources allocation processes:a model for critical resources mobilization and deployment for nigerian universities

Purpose – The purpose of this research is to study the perceived impact of some factors on the resources allocation processes of the Nigerian universities and to suggest a framework that will help practitioners and academics to understand and improve such processes. Design/methodology/approach – The study adopted the interpretive qualitative approach aimed at an ‘in-depth’ understanding of the resource allocation experiences of key university personnel and their perceived impact of the contextual factors affecting such processes. The analysis of individual narratives from each university established the conditions and factors impacting the resources allocation processes within each institution. Findings – The resources allocation process issues in the Nigerian universities may be categorised into people (core and peripheral units’ challenge, and politics and power); process (resources allocation processes); and resources (critical financial shortage and resources dependence response). The study also provides insight that resourcing efficiency in Nigerian universities appears strongly constrained by the rivalry among the resource managers. The efficient resources allocation process (ERAP) model is proposed to resolve the identified resourcing deficiencies. Research limitations/implications – The research is not focused to provide generalizable observations but ‘in-depth’ perceived factors and their impact on the resources allocation processes in Nigerian universities. The study is limited to the internal resources allocation issues within the universities and excludes the external funding factors. The resource managers’ responses to the identified factors may affect their internal resourcing efficiency. Further research using more empirical samples is required to obtain more widespread results and the implications for all universities. Originality/value – This study contributes a fresh literature framework to resources allocation processes focusing at ‘people’, ‘process’ and ‘resources’. Also a middle range theory triangulation is developed in relation to better understanding of resourcing process management. The study will be of interest to university managers and policy makers.

Approximating the MaxMin and MinMax Area Triangulations using Angular Constraints

* A preliminary version of this paper was presented at XI Encuentros de Geometr´ia Computacional, Santander, Spain, June 2005.

Quadratic Time Computable Instances of MaxMin and MinMax Area Triangulations of Convex Polygons

We consider the problems of finding two optimal triangulations of a convex polygon: MaxMin area and MinMax area. These are the triangulations that maximize the area of the smallest area triangle in a triangulation, and respectively minimize the area of the largest area triangle in a triangulation, over all possible triangulations. The problem was originally solved by Klincsek by dynamic programming in cubic time [2]. Later, Keil and Vassilev devised an algorithm that runs in O(n^2 log n) time [1]. In this paper we describe new geometric findings on the structure of MaxMin and MinMax Area triangulations of convex polygons in two dimensions and their algorithmic implications. We improve the algorithm’s running time to quadratic for large classes of convex polygons. We also present experimental results on MaxMin area triangulation.

The experiences of con sultations on oral anticoagula-tion for AF:the importance of qualitative research incardiovascular sciences

Objectives: Multiple-perspective qualitative designs can aid researchersto develop a more multifaceted account of a phenomenon and as aform of triangulation of data. Two interlinking studies aimed toexplore patients’ and physicians’ experiences of atrial fibrillation (AF)and warfarin.Methods: Audio-recorded semistructured individual interviews wereused. Study 1: Three AF patient subgroups were interviewed (n = 11);accepted, refused, or discontinued warfarin. Study 2: Four physiciansubgroups (n = 16): consultant cardiologists, consultant general physi-cians, general practitioners, and cardiology registrars. Data was ana-lyzed using interpretative phenomenological analysis, a qualitativemethodology.Results: Study 1: Three overarching themes comprised patients’ experi-ences: the initial consultation, life after the consultation, and patients’reflections. Patients commented on the reassurance experienced duringthe consultation, but they perceived the decision-making processmostly led by the physician. Lack of education and take-home materi-als during the initial consultation were highlighted. Patients’ uptake ofinformation was influenced by past experiences and knowledge ofstroke and/or bleeding. Study 2: Two overarching themes covered phy-sicians’ experiences: communicating information and challenges withwarfarin prescription for AF. Physicians’ approach to the consultationstyle shifted through a continuum of compliance-adherence-concor-dance during the consultation. Time and the perceived patient trust inthem as the expert led to physicians to adopt a paternalistic approach.Guideline adherence and the need to adopt a multidisciplinaryapproach were pointed out as current challenges.Conclusion: There is a need to target patients’ and physicians’ abilityto communicate with each other in a comprehensible way. This projecthas illustrated the benefit of using a qualitative approach to under-stand the lived experience of the physician–patient consultation.Disclosure of Interest: None declare

The eye of the beholder: The impact of a district implementation plan of state mandates as perceived by the implementers

The purpose of this inquiry was to investigate the impact of a large, urban school district's experience in implementing a mandated school improvement plan and to examine how that plan was perceived, interpreted, and executed by those charged with the task. The research addressed the following questions: First, by whom was the district implementation plan designed, and what factors were considered in its construction? Second, what impact did the district implementation plan have on those charged with its implementation? Third, what impact did the district plan have on the teaching and learning practices of a particular school? Fourth, what aspects of the implemention plan were perceived as most and least helpful by school personnel in achieving stated goals? Last, what were the intended and unintended consequences of an externally mandated and directed plan for improving student achievement? The implementation process was measured against Fullan's model as expounded upon in The Meaning of Educational Change (1982) and The New Meaning of Educational Change (1990). The Banya implementation model (1993), because it added a dimension not adequately addressed by Fullan, was also considered.^ A case study was used as the methodological framework of this qualitative study. Sources of data used in this inquiry included document analysis, participant observations in situ, follow-up interviews, the "long" interview, and triangulation. The study was conducted over a twelve-month period. Findings were obtained from the content analysis of interview transcripts of multiple participants. Results were described and interpreted using the Fullan and Banya models as the descriptive framework. A cross-case comparison of the multiple perspectives of the same phenomena by various participants was constructed.^ The study concluded that the school district's implementation plan to improve student achievement was closely aligned to Fullan's model, although not intentionally. The research also showed that where there was common understanding at all levels of the organization as to the expectations for teachers, level of support to be provided, and availability of resources, successful implementation occured. The areas where successful implementation did not occur were those where the complexity of the changes were underestimated and processes for dealing with unintended consequences were not considered or adequately addressed. The unique perspectives of the various participants, from the superintendent to the classroom teacher, are described. Finally, recommendations for enhancement of implementation are offered and possible topics for further research studies are postulated. ^

A distance education case study: A comparison of instructional delivery methods practiced by higher education faculty and emerging standards

The purpose of this research was to compare the delivery methods as practiced by higher education faculty teaching distance courses with recommended or emerging standard instructional delivery methods for distance education. Previous research shows that traditional-type instructional strategies have been used in distance education and that there has been no training to distance teach. Secondary data, however, appear to suggest emerging practices which could be pooled toward the development of standards. This is a qualitative study based on the constant comparative analysis approach of grounded theory.^ Participants (N = 5) of this study were full-time faculty teaching distance education courses. The observation method used was unobtrusive content analysis of videotaped instruction. Triangulation of data was accomplished through one-on-one in-depth interviews and from literature review. Due to the addition of non-media content being analyzed, a special time-sampling technique was designed by the researcher--influenced by content analyst theories of media-related data--to sample portions of the videotape instruction that were observed and counted. A standardized interview guide was used to collect data from in-depth interviews. Coding was done based on categories drawn from review of literature, and from Cranton and Weston's (1989) typology of instructional strategies. The data were observed, counted, tabulated, analyzed, and interpreted solely by the researcher. It should be noted however, that systematic and rigorous data collection and analysis led to credible data.^ The findings of this study supported the proposition that there are no standard instructional practices for distance teaching. Further, the findings revealed that of the emerging practices suggested by proponents and by faculty who teach distance education courses, few were practiced even minimally. A noted example was the use of lecture and questioning. Questioning, as a teaching tool was used a great deal, with students at the originating site but not with distance students. Lectures were given, but were mostly conducted in traditional fashion--long in duration and with no interactive component.^ It can be concluded from the findings that while there are no standard practices for instructional delivery for distance education, there appears to be sufficient information from secondary and empirical data to initiate some standard instructional practices. Therefore, grounded in this research data is the theory that the way to arrive at some instructional delivery standards for televised distance education is a pooling of the tacitly agreed-upon emerging practices by proponents and practicing instructors. Implicit in this theory is a need for experimental research so that these emerging practices can be tested, tried, and proven, ultimately resulting in formal standards for instructional delivery in television education. ^

Transcultural experiences: A literature bridge to English for ESOL students from Cuba

This qualitative study is concerned with exploring the transcultural experiences of ESOL students and connecting their lived experiences to literature in the classroom. The purpose of this study was to describe and explain the transcultural perspectives of six high school and community college students: four Cuban born students and two American born/raised students of Cuban-American culture. The participants were from Barbara Goleman Senior High School and Miami-Dade Community College. The six phenomenological portraits were explored in the form of lived experience pieces, representing the students' transcultural experiences. The data was collected in the form of student interviews, researcher's journal, and document reviews. The following exploratory questions guided this study: (1) From the perspective of four Cuban-born, non-native English-speaking students (NNS), what are the essential structures of their transcultural identities? (2) What are the underlying themes that account for the Cuban NNS students' transcultural experiences? (3) What are the universal transcultural structures among the Cuban NNS students' transcultural experiences and the Cuban-American, native English/Spanish speaking (NESS) students' experiences? (4) What are the possible structural meanings of the Cuban NNS students' interests in relation to their transcultural experiences? (5) What are some connections between the structural themes inherent in the Cuban NNS students' transcultural experiences and teaching literature in ESOL? ^ A phenomenological approach was used to investigate the participants' transcultural experiences, focused on the students' lived experiences. The study consisted of three interview sessions for each of the six participants. The analysis of the data was conducted following the principles of qualitative research, which included participant interviews, thematic analysis, researcher's journal, document reviews, and triangulation. The researcher created portraits representing students' transcultural experiences. Subsequently, the participants' transcultural experiences were used to respond to the exploratory questions, including comparing and contrasting themes and drawing connections among teaching literature in the ESOL classroom. ^ The results of this study show some relevant specific statements and themes that emerged from the students' transcultural data. The results serve as a better understanding of these students' transcultural experiences and the potentiality of connecting their perspectives to literature in the classroom. In addition, this study shows the need for a better understanding of the connection between transcultural experiences and literature in ESOL. ^

Working adult students' perspectives on persisting in college

The purpose of this study was to describe and explain working adult undergraduate students' perspectives on persistence in college in order to address the applicability of retention theory to a specific group of college students. Retention of college students is a major concern in higher education where persistence rates have continued to decline for the last 16 years and changing student demographics have influenced enrollment patterns. ^ A qualitative research design was used. Data were collected through in-depth semi-structured interviews with nine working adult undergraduate students. The participants were selected to include diversity in age, race/ethnicity, family roles, career/work levels, college majors, and educational histories. ^ Triangulation was performed on data from the interviews, participant data forms, and a research journal. Open and axial coding were used to generate emerging themes. Member checking was used to verify the interpretation of the participants' perspectives. A peer reviewer corroborated the data analysis. Three major themes emerged from the data which explained how the students stayed motivated, engaged in learning, and managed the institutional aspects of college. ^ Five conclusions were drawn from the findings of this study. First, working adult students described their core experience of college as both positive and negative, creating tensions and often conflicts that influenced their persistence. Second, persistence factors associated with working adult students included personal aspects, such as having clear career/life goals, self management skills, and supportive relationships; learning aspects, such as interactive teaching methods, connections to prior learning, and relevance to career/life goals; and institutional aspects, such as customer service orientation of staff, flexibility of policies and procedures, and convenient access to information. Third, current retention theory was applicable to working adult students. However, working adult students described their experience of academic and social integration differently from that of traditional college students found in the literature. Fourth, findings from this study supported the developmental components of the Adult Persistence in Learning model (MacKinnon-Slaney, 1994). Finally, the study findings indicated a clearly active role required of the institution in the persistence of working adult students by providing flexibility and accessibility in procedures and services. ^

The impact of the Miami Cuban exile's political culture on the 1996 fiscal crisis of the city of Miami

The purpose of this study was to determine if the political culture of the Miami Cuban exile community was a significant factor in creating the environment that led to the 1996 fiscal crisis of the City of Miami. The study performed an ethnographic case study that utilized a triangulation strategy which included both qualitative and quantitative methods. Focus groups were conducted to ascertain qualitative and quantitative data as to differences among ethnic and generational groups regarding notions of governance, public administration practices, and overall political values and core beliefs. Quantitative data was obtained through a five year and seven month review of newspaper articles from two periodicals based in Miami-Dade County. A review was also conducted of secondary data in audit and management reports, blue ribbon commission studies, Certified Public Manager (CPM) enrollment, and legal case decisions to examine the administrative practices of the City of Miami leading up to and subsequent to its fiscal crisis. The study found that a political subculture of caudillismo was present in Cuban exile core areas of Miami that appears to have had an influence on the administrative practices and notions of governance that led to the fiscal crisis. The author concludes that an imported foreign political culture has imposed itself as a subculture in core areas of the exile community and that the operationalization of this subculture has manifested itself in non-mainstream notions of governance and public administration practices. ^

Teacher talk: A community of colleagues that values practical teacher knowledge through sharing experiences

The purpose of this study was to describe the experiences of five educators participating in a teacher-initiated learning community that valued practical teacher knowledge. Connelly and Clandinin (2000) argued that practical teacher knowledge grew out of experience through interaction in the professional knowledge landscape. Collaboration that promoted teacher learning was the foundation to effective school change (Wood, 1997). This teacher-initiated learning community consisted of members who had equal status and collaborated by participating in discourse on curriculum and instruction. The collegiality of the community fostered teacher professionalism that improved practice and benefited the school. This study focused on the following research questions: (1) What was the experience of these five educators in this learning community? (2) What did these five individuals understand about the nature of practical teacher knowledge? (3) According to the participants, what was the relationship between teacher empowerment and effective school change? ^ The participants were chosen because each voluntarily attended this teacher-initiated learning community. Each participant answered questions regarding the experience during three semi-structured tape-recorded interviews. The interviews were transcribed, and significant statements of meaning were extracted. Using a triangulation of ideas that were common to at least three of the participants ensured the trustworthiness of the analysis. These statements were combined to describe what was experienced and how the participants described their experience. The emerging themes were the characteristics of and the relationships, methods, conditions, and environment for the teachers. The teachers described how a knowledge base of practical teacher knowledge was gained as a spirit of camaraderie developed. The freedom that the teachers experienced to collaborate and learn fostered new classroom practice that affected school change as student interaction and productivity increased. ^ The qualitative analysis of this study provided a description of a learning community that valued practical teacher knowledge and fostered professional development. This description was important to educational stakeholders because it demonstrated how practical teacher knowledge was gained during the teachers' daily work. By sharing every day experiences, the teacher talk generated collaboration and accountability that the participants felt improved practice and fostered a safe, productive learning environment for students. ^

Fiscal and organizational determinants of transportation outcomes: A quantitative and qualitative analysis of sustainability factors

Federal transportation legislation in effect since 1991 was examined to determine outcomes in two areas: (1) The effect of organizational and fiscal structures on the implementation of multimodal transportation infrastructure, and (2) The effect of multimodal transportation infrastructure on sustainability. Triangulation of methods was employed through qualitative analysis (including key informant interviews, focus groups and case studies), as well as quantitative analysis (including one-sample t-tests, regression analysis and factor analysis). ^ Four hypotheses were directly tested: (1) Regions with consolidated government structures will build more multimodal transportation miles: The results of the qualitative analysis do not lend support while the results of the quantitative findings support this hypothesis, possibly due to differences in the definitions of agencies/jurisdictions between the two methods. (2) Regions in which more locally dedicated or flexed funding is applied to the transportation system will build a greater number of multimodal transportation miles: Both quantitative and qualitative research clearly support this hypothesis. (3) Cooperation and coordination, or, conversely, competition will determine the number of multimodal transportation miles: Participants tended to agree that cooperation, coordination and leadership are imperative to achieving transportation goals and objectives, including targeted multimodal miles, but also stressed the importance of political and financial elements in determining what ultimately will be funded and implemented. (4) The modal outcomes of transportation systems will affect the overall health of a region in terms of sustainability/quality of life indicators: Both the qualitative and the quantitative analyses provide evidence that they do. ^ This study finds that federal legislation has had an effect on the modal outcomes of transportation infrastructure and that there are links between these modal outcomes and the sustainability of a region. It is recommended that agencies further consider consolidation and strengthen cooperation efforts and that fiscal regulations are modified to reflect the problems cited in qualitative analysis. Limitations of this legislation especially include the inability to measure sustainability; several measures are recommended. ^

Constructing literacy: Disadvantaged Irish mothers' attempts at developing literacy with their preschool children during storybook reading and jigsaw puzzle building

Early childhood research beginning in the 1960s has focused on the literacy experiences of preschool children in the home and the contribution of those experiences to later school success. Decades of research since then have investigated learning experiences of preschool children as they interacted with caregivers, siblings or peers prior to formal schooling (Durkin, 1966; Heath, 1983). ^ In this qualitative investigation into early literacy events that occur between disadvantaged Irish mothers and their children, four research questions were investigated. (1) How do disadvantaged Irish mothers engage their preschool children in literacy events such as storybook reading and jigsaw puzzle building? (2) How does the mother's previous school experience affect her role as the child's first teacher? (3) How does the culture of the neighborhood affect the child's developing literacy? (4) What risk factors inhibit literacy development in these Irish children? ^ This study examined the conversational exchanges between three disadvantaged Irish mothers and their preschool children living near Dublin, Ireland, as the mothers read a storybook to their children and assisted them in jigsaw puzzle building. Conversations were recorded, transcribed and analyzed into reading skill and teaching strategy categories for the purpose of determining the mothers' literacy intent during her turn. Journal notes, field notes and interviews with the mothers recorded other information and allowed for triangulation of data. ^ The results of this investigation indicated four findings. The first finding was that these disadvantaged mothers employed many of the same techniques that classroom teachers use during the reading lesson. They attempted high-level and low-level questions, teaching strategies, and other interactions that are so familiar in the classroom. The second finding was that jigsaw puzzle building produced a richer literacy interaction than storybook reading. The third finding was that the environment of the disadvantaged neighborhood posed many risks to children's literacy development. A final finding was that the mothers used thinking out loud behavior to vocalize their inner thoughts during literacy interactions. ^ Future research suggests studying mother/child dyads in other socio-economic environments and cultures to determine if other mothers practice the same skills and strategies as these mothers. ^

An analysis of teachers' perceptions of informal science professional development

Science professional development, which is fundamental to science education improvement, has been described as being weak and fragmentary. The purpose of this study was to investigate teachers' perceptions of informal science professional development to gain an in-depth understanding of the essence of the phenomenon and related science-teaching dispositions. Based on the frameworks of phenomenology, constructivism, and adult learning theory, the focus was on understanding how the phenomenon was experienced within the context of teachers' everyday world. ^ Data were collected from eight middle-school teachers purposefully selected because they had participated in informal programs during Project TRIPS (Teaching Revitalized Through Informal Programs in Science), a collaboration between the Miami-Dade school district, government agencies (including NASA), and non-profit organizations (including Audubon of Florida). In addition, the teachers experienced hands-on labs offered through universities (including the University of Arizona), field sites, and other agencies. ^ The study employed Seidman's (1991) three-interview series to collect the data. Several methods were used to enhance the credibility of the research, including using triangulation of the data. The interviews were transcribed, color-coded and organized into six themes that emerged from the data. The themes included: (a) internalized content knowledge, (b) correlated hands-on activities, (c) enhanced science-teaching disposition, (d) networking/camaraderie, (e) change of context, and (f) acknowledgment as professionals. The teachers identified supportive elements and constraints related to each theme. ^ The results indicated that informal programs offering experiential learning opportunities strengthened understanding of content knowledge. Teachers implemented hands-on activities that were explicitly correlated to their curriculum. Programs that were conducted in a relaxed context enhanced teachers' science-teaching dispositions. However, a lack of financial and administrative support, perceived safety risks, insufficient reflection time, and unclear itineraries impeded program implementation. The results illustrated how informal educators can use this cohesive model as they develop programs that address the supports and constraints to teachers' science instruction needs. This, in turn, can aid teachers as they strive to provide effective science instruction to students; notions embedded in reforms. Ultimately, this can affect how learners develop the ability to make informed science decisions that impact the quality of life on a global scale. ^