Work stressors, strains and hospital unit performance

Hospital employees who work in an environment with zero tolerance to error, face several stressors that may result in psychological, physiological, and behavioural strains, and subsequently, in suboptimal performance. This thesis includes two studies which investigate the stressor-to-strain-to-performance relationships in hospitals. The first study is a cross-sectional, multi-group investigation based on secondary data from 65,142 respondents in 172 acute/specialist UK NHS trusts. This model proposes that senior management leadership predicts social support and job design which, in turn, moderate stressors-to-strains across team structure. The results confirm the model's robustness. Regression analysis provides support for main effects and minimal support for moderation hypotheses. Therefore, based on its conclusions and inherent limitations, study one lays the framework for study two. The second study is a cross-sectional, multilevel investigation of the strain-reducing effects of social environment on externally-rated unit-level performance based on primary data from 1,137 employees in 136 units, in a hospital in Malta. The term "social environment" refers to the prediction of the moderator variables, which is to say, social support and decision latitude/control, by transformational leadership and team climate across hospital units. This study demonstrates that transformational leadership is positively associated with social support, whereas team climate is positively associated with both moderators. At the same time, it identifies a number of moderating effects which social support and decision latitude/control, both separately and together, had on specific stressor-to-strain relationships. The results show significant mediated stressor-to-strain-to-performance relationships. Furthermore, at the higher level, unit-level performance is positively associated with shared unit-level team climate and with unit-level vision, the latter being one of the five sub-dimension of transformational leadership. At the same time, performance is also positively related to both transformational leadership and team climate when the two constructs are tested together. Few studies have linked the buffering effects of the social environment in occupational stress with performance. Therefore, this research strives to make a significant contribution to the occupational stress and performance literature with a focus on hospital practice. Indeed, the study highlights the wide-ranging and far-reaching implications that these findings provide for theory, management, and practice.

Differences between theoretical predictions and operational performance in a stock control application

Over the past decade, several experienced Operational Researchers have advanced the view that the theoretical aspects of model building have raced ahead of the ability of people to use them. Consequently, the impact of Operational Research on commercial organisations and the public sector is limited, and many systems fail to achieve their anticipated benefits in full. The primary objective of this study is to examine a complex interactive Stock Control system, and identify the reasons for the differences between the theoretical expectations and the operational performance. The methodology used is to hypothesise all the possible factors which could cause a divergence between theory and practice, and to evaluate numerically the effect each of these factors has on two main control indices - Service Level and Average Stock Value. Both analytical and empirical methods are used, and simulation is employed extensively. The factors are divided into two main categories for analysis - theoretical imperfections in the model, and the usage of the system by Buyers. No evidence could be found in the literature of any previous attempts to place the differences between theory and practice in a system in quantitative perspective nor, more specifically, to study the effects of Buyer/computer interaction in a Stock Control system. The study reveals that, in general, the human factors influencing performance are of a much higher order of magnitude than the theoretical factors, thus providing objective evidence to support the original premise. The most important finding is that, by judicious intervention into an automatic stock control algorithm, it is possible for Buyers to produce results which not only attain but surpass the algorithmic predictions. However, the complexity and behavioural recalcitrance of these systems are such that an innately numerate, enquiring type of Buyer needs to be inducted to realise the performance potential of the overall man/computer system.

Accessibility, deprivation and rural planning policies.

Since the Second World War a range of policies have been implemented by central and local government agencies, with a view to improving accessibility to facilities, housing and employment opportunities within rural areas. It has been suggested that a lack of reasonable access to a range of such facilities and opportunities constitutes a key aspect of deprivation or disadvantage for rural residents. Despite considerable interest, very few attempts have been made to assess the nature and incidence of this disadvantage or the reaction of different sections of the population of rural areas to it. Moreover, almost all previous assessments have relied on so-called 'objective' measures of accessibility and disadvantage and failed to consider the relationship between such measures and 'subjective' measures such as individual perceptions. It is this gap in knowledge that the research described in this thesis has addressed. Following a critical review of relevant literature the thesis describes the way in which data on 'objective' and 'subjective' indicators of accessibility and behavioural responses to accessibility problems was collected, in six case study areas in Shropshire. Analysis of this data indicates that planning and other government policies have failed to significantly improve rural resident's accessibility to their basic requirements, and may in some cases have exacerbated it, and that as a result certain sections of the rural population are relatively disadvantaged. Moreover, analysis shows that .certain aspects of individual subjective' assessments of such accessibility disadvantage are significantly associated with more easily-obtained 'objective' measures. By using discriminant analysis the research demonstrates that it is possible to predict the likely levels of satisfaction with access to facilities from a range of 'objective' measures. The research concludes by highlighting the potential practical applications of such indicators in policy formulation, policy appraisal and policy evaluation.

Tetrahydrobiopterin metabolism, neurotransmitters and behaviour in the rat

Various neurotoxins were investigated to assess their suitability for developing an animal model to study partial brain BH4 deficiency, neurotransmitters and behavioural alterations. Acute dosing with lead, diethylstilboestrol (DES), amphetamine and scopolamine produced no significant changes in rat brain BH4 metabolism though total biopterins in the liver were significantly reduced by lead and DES. Acute starvation of adult rats decreased brain biopterins. This loss of biopterins may be due to enhanced oxidative catabolism of the active cofactor caused by glutathione depletion. Dietary administration of a BH4 biosynthesis inhibitor, DAHP, consistently decreased brain total biopterins in weaner rats but did not alter the levels of DA, NA, 5-HT or metabolites. However the DAHP diet also induced a marked reduction in food intake. Rats subjected to an equivalent degree of food restriction without inhibitor showed significant but less severe reductions in brain biopterins and again no effect on transmitter levels. DAHP produced a significant decrease in locomotor activity and rearing. This could not be ascribed to reduction in food intake as animals subjected to just dietary restriction showed an increase in these activities. As gross brain levels of DA, NA and 5-HT were unaltered by DAHP the behavioural changes associated with the induced deficiency in brain total biopterins might not have been mediated through the action of these compounds. Although localised changes in neurotransmitter levels may have been obscured by gross analysis it is also possible that the behaviour changes were mediated by a role of BH4 not yet elucidated. Long-term administration of a high aluminium low calcium diet to mice produced no effect on gross brain total biopterins, catecholamines, serotonin or choline acetyltransferase activity though significant behavioural changes were observed.

Measurement of productivity and cost of the direct labour organisation within highways maintenance departments

The objective of this thesis is to investigate, through an empirical study, the different functions of the highways maintenance departments and to suggest methods by means of which road maintenance work could be carried out in a more efficient way by utilising its resources of men, material and plant to the utmost advantage. This is particularly important under the present circumstances of national financial difficulties which have resulted in continuous cuts in public expenditure. In order to achieve this objective, the researcher carried out a survey among several Highways Authorities by means of questionnaire and interview. The information so collected was analysed in order to understand the actual, practical situation within highways manintenance departments, and highlight any existing problems, and try to answer the question of how they could become more efficient. According to the results obtained by the questionnaire and the interview, and the analysis of these results, the researcher concludes that it is the management system where least has been done, and where problems exist and are most complex. The management of highways maintenance departments argue that the reasons for their problems include both financial and organisational difficulties, apart from the political aspect and nature of the activities undertaken. The researcher believes that this ought to necessitate improving the management's analytical tools and techniques in order to achieve the most effective way of performing each activity. To this end the researcher recommends several related procedures to be adopted by the management of the highways maintenance departments. These recommendations, arising from the study, involve the technical, practical and human aspects. These are essential factors of which management should be aware - and certainly should not neglect - in order to achieve its objectives of improved productivity in the highways maintenance departments.

The complexity of leadership and organisations

The thesis contributes to the evolving process of moving the study of Complexity from the arena of metaphor to something real and operational. Acknowledging this phenomenon ultimately changes the underlying assumptions made about working environments and leadership; organisations are dynamic and so should their leaders be. Dynamic leaders are behaviourally complex. Behavioural Complexity is a product of behavioural repertoire - range of behaviours; and behavioural differentiation - where effective leaders apply appropriate behaviour to the demands of the situation. Behavioural Complexity was operationalised using the Competing Values Framework (CVF). The CVF is a measure that captures the extent to which leaders demonstrate four behaviours on four quadrants: Control, Compete, Collaborate and Create, which are argued to be critical to all types of organisational leadership. The results provide evidence to suggest Behavioural Complexity is an enabler of leadership effectiveness; Organisational Complexity (captured using a new measure developed in the thesis) moderates Behavioural Complexity and leadership effectiveness; and leadership training supports Behavioural Complexity in contributing to leadership effectiveness. Most definitions of leadership come down to changing people’s behaviour. Such definitions have contributed to a popularity of focus in leadership research intent on exploring how to elicit change in others when maybe some of the popularity of attention should have been on eliciting change in the leader them self. It is hoped that this research will provoke interest into the factors that cause behavioural change in leaders that in turn enable leadership effectiveness and in doing so contribute to a better understanding of leadership in organisations.

Having a word with yourself:neural correlates of self-criticism and self-reassurance

Self-criticism is strongly correlated with a range of psychopathologies, such as depression, eating disorders and anxiety. In contrast, self-reassurance is inversely associated with such psychopathologies. Despite the importance of self-judgements and evaluations, little is known about the neurophysiology of these internal processes. The current study therefore used a novel fMRI task to investigate the neuronal correlates of self-criticism and self-reassurance. Participants were presented statements describing two types of scenario, with the instruction to either imagine being self-critical or self-reassuring in that situation. One scenario type focused on a personal setback, mistake or failure, which would elicit negative emotions, whilst the second was of a matched neutral event. Self-criticism was associated with activity in lateral prefrontal cortex (PFC) regions and dorsal anterior cingulate (dAC), therefore linking self-critical thinking to error processing and resolution, and also behavioural inhibition. Self-reassurance was associated with left temporal pole and insula activation, suggesting that efforts to be self-reassuring engage similar regions to expressing compassion and empathy towards others. Additionally, we found a dorsal/ventral PFC divide between an individual's tendency to be self-critical or self-reassuring. Using multiple regression analyses, dorsolateral PFC activity was positively correlated with high levels of self-criticism (assessed via self-report measure), suggesting greater error processing and behavioural inhibition in such individuals. Ventrolateral PFC activity was positively correlated with high self-reassurance. Our findings may have implications for the neural basis of a range of mood disorders that are characterised by a preoccupation with personal mistakes and failures, and a self-critical response to such events.

Elevated amygdala activity to sad facial expressions:a state marker of bipolar but not unipolar depression

Background - Difficulties in emotion processing and poor social function are common to bipolar disorder (BD) and major depressive disorder (MDD) depression, resulting in many BD depressed individuals being misdiagnosed with MDD. The amygdala is a key region implicated in processing emotionally salient stimuli, including emotional facial expressions. It is unclear, however, whether abnormal amygdala activity during positive and negative emotion processing represents a persistent marker of BD regardless of illness phase or a state marker of depression common or specific to BD and MDD depression. Methods - Sixty adults were recruited: 15 depressed with BD type 1 (BDd), 15 depressed with recurrent MDD, 15 with BD in remission (BDr), diagnosed with DSM-IV and Structured Clinical Interview for DSM-IV Research Version criteria; and 15 healthy control subjects (HC). Groups were age- and gender ratio-matched; patient groups were matched for age of illness onset and illness duration; depressed groups were matched for depression severity. The BDd were taking more psychotropic medication than other patient groups. All individuals participated in three separate 3T neuroimaging event-related experiments, where they viewed mild and intense emotional and neutral faces of fear, happiness, or sadness from a standardized series. Results - The BDd—relative to HC, BDr, and MDD—showed elevated left amygdala activity to mild and neutral facial expressions in the sad (p < .009) but not other emotion experiments that was not associated with medication. There were no other significant between-group differences in amygdala activity. Conclusions - Abnormally elevated left amygdala activity to mild sad and neutral faces might be a depression-specific marker in BD but not MDD, suggesting different pathophysiologic processes for BD versus MDD depression.

Interval timing in children:effects of auditory and visual pacing stimuli and relationships with reading and attention variables

Motor timing tasks have been employed in studies of neurodevelopmental disorders such as developmental dyslexia and ADHD, where they provide an index of temporal processing ability. Investigations of these disorders have used different stimulus parameters within the motor timing tasks which are likely to affect performance measures. Here we assessed the effect of auditory and visual pacing stimuli on synchronised motor timing performance and its relationship with cognitive and behavioural predictors that are commonly used in the diagnosis of these highly prevalent developmental disorders. Twenty- one children (mean age 9.6 years) completed a finger tapping task in two stimulus conditions, together with additional psychometric measures. As anticipated, synchronisation to the beat (ISI 329 ms) was less accurate in the visually paced condition. Decomposition of timing variance indicated that this effect resulted from differences in the way that visual and auditory paced tasks are processed by central timekeeping and associated peripheral implementation systems. The ability to utilise an efficient processing strategy on the visual task correlated with both reading and sustained attention skills. Dissociations between these patterns of relationship across task modality suggest that not all timing tasks are equivalent.

Organisational justice:new insights from behavioural ethics

Both organizational justice and behavioural ethics are concerned with questions of 'right and wrong' in the context of work organizations. Until recently they have developed largely independently of each other, choosing to focus on subtly different concerns, constructs and research questions. The last few years have, however, witnessed a significant growth in theoretical and empirical research integrating these closely related academic specialities. We review the organizational justice literature, illustrating the impact of behavioural ethics research on important fairness questions. We argue that organizational justice research is focused on four reoccurring issues: (i) why justice at work matters to individuals; (ii) how justice judgements are formed; (iii) the consequences of injustice; and (iv) the factors antecedent to justice perceptions. Current and future justice research has begun and will continue borrowing from the behavioural ethics literature in answering these questions. © The Author(s) 2013.

Small business development and the “learning organisation”

The paper proffers a tentative conceptualisation of the “small business strategic learning process”, demonstrating the complexity of the small firm learning and management task. The framework, built upon personal construct theory and learning theories, is elaborated through the grounding of relevant areas of the strategic management literature in an understanding of the distinctive managerial and behavioural features of the small business. The framework is then utilised to underpin consideration of the concepts of “organisational learning” and the “learning organisation” within a small firm developmental context. It is suggested that whilst organisational learning may be a key and effective small business management approach to underpin sustainable development, the learning organisation, as currently conceived in the mainstream literature, fails to recognise and address the idiosyncrasies, problems and constraints relating to sustainable small business development. There does appear, however, to be great potential for extending understanding of the learning organisation concept into the small business context. An indicative research agenda is suggested.

Levonorgestrel intrauterine system versus medical therapy for menorrhagia

ABSTRACT: Menorrhagia is a common problem that interferes with a woman’s physical, emotional, and social life. Evidence to guide physicians for decision about therapy for heavy menstrual bleeding is lacking. One treatment option, the levonorgestrel-releasing intrauterine system (levonorgestrel-IUS), has been available in the United States since 2009. Updated meta-analyses comparing the levonorgestrel-IUS with nonhormonal and hormonal treatments showed that the levonorgestrel-IUS produced a greater reduction in menstrual blood loss at 3 to 12 months of follow-up. It is not clear whether these short-term benefits persist. Moreover, the rates of discontinuation of the levonorgestrel-IUS at 2 years are as high as 28%, and effects on bleeding-related quality of life are not known. This pragmatic, multicenter, randomized trial compared the effectiveness of the levonorgestrel-IUS with that of usual medical treatment among women with menorrhagia in a primary care setting. A total of 571 women with menorrhagia were randomized to treatment with levonorgestrel-IUS (n = 285) or usual medical treatment (n = 286). Usual treatment was tranexamic acid, mefenamic acid, combined estrogen-progestogen, or progesterone alone. The primary study outcome measure was the patient-reported score on the condition-specific Menorrhagia Multi-Attribute Scale (MMAS) assessed over a 2-year period. The MMAS scores range from 0 to 100, with lower scores indicating greater severity. Summary MMAS scores were assessed at 6, 12, and 24 months. Secondary outcome measures included general health-related quality of life, sexual-activity scores, and surgical intervention. There was a significant improvement in total MMAS scores from baseline to 6 months in both the levonorgestrel-IUS group and the usual-treatment group; the mean increase was 32.7 and 21.4 points, respectively; P < 0.001 for both comparisons. Over the 2-year follow-up, improvements were maintained in both groups but were significantly greater in the levonorgestrel-IUS group (mean between-group difference, 13.4 points; 95% confidence interval, 9.9–16.9; P < 0.001). Significantly greater improvements in all MMAS domains (practical difficulties, social life, psychological health, physical health, work and daily routine, and family life and relationships) occurred with the levonorgestrel-IUS than with the usual treatment (P < 0.001 with the use of a test for trend). This was also found for 7 of the 8 quality-of-life domains. At the 2-year end point, almost twice as many women were still using the levonorgestrel-IUS than were those receiving the usual medical treatment (64% vs 38%, P < 0.001). No significant between-group differences were noted in the rates of surgical intervention or sexual-activity scores as well as in the frequency of serious adverse events. These data show that levonorgestrel-IUS is more effective than usual medical treatment in improving the quality of life of women with menorrhagia in a primary care setting.

An empirical examination of the strategic decision-making process:the relationship between context, process, and outcomes

Despite concerted academic interest in the strategic decision-making process (SDMP) since the 1980s, a coherent body of theory capable of guiding practice has not materialised. This is because many prior studies focus only on a single process characteristic, often rationality or comprehensiveness, and have paid insufficient attention to context. To further develop theory, research is required which examines: (i) the influence of context from multiple theoretical perspectives (e.g. upper echelons, environmental determinism); (ii) different process characteristics from both synoptic formal (e.g. rationality) and political incremental (e.g. politics) perspectives, and; (iii) the effects of context and process characteristics on a range of SDMP outcomes. Using data from 30 interviews and 357 questionnaires, this thesis addresses several opportunities for theory development by testing an integrative model which incorporates: (i) five SDMP characteristics representing both synoptic formal (procedural rationality, comprehensiveness, and behavioural integration) and political incremental (intuition, and political behaviour) perspectives; (ii) four SDMP outcome variables—strategic decision (SD) quality, implementation success, commitment, and SD speed, and; (iii) contextual variables from the four theoretical perspectives—upper echelons, SD-specific characteristics, environmental determinism, and firm characteristics. The present study makes several substantial and original contributions to knowledge. First, it provides empirical evidence of the contextual boundary conditions under which intuition and political behaviour positively influence SDMP outcomes. Second, it establishes the predominance of the upper echelons perspective; with TMT variables explaining significantly more variance in SDMP characteristics than SD specific characteristics, the external environment, and firm characteristics. A newly developed measure of top management team expertise also demonstrates highly significant direct and indirect effects on the SDMP. Finally, it is evident that SDMP characteristics and contextual variables influence a number of SDMP outcomes, not just overall SD quality, but also implementation success, commitment, and SD speed.

Metabolic induction and early responses of mouse blastocyst developmental programming following maternal low protein diet affecting life-long health

Previously, we have shown that a maternal low protein diet, fed exclusively during the preimplantation period of mouse development (Emb-LPD), is sufficient to induce by the blastocyst stage a compensatory growth phenotype in late gestation and postnatally, correlating with increased risk of adult onset cardiovascular disease and behavioural dysfunction. Here, we examine mechanisms of induction of maternal Emb-LPD programming and early compensatory responses by the embryo. Emb-LPD induced changes in maternal serum metabolites at the time of blastocyst formation (E3.5), notably reduced insulin and increased glucose, together with reduced levels of free amino acids (AAs) including branched chain AAs leucine, isoleucine and valine. Emb-LPD also caused reduction in the branched chain AAs within uterine fluid at the blastocyst stage. These maternal changes coincided with an altered content of blastocyst AAs and reduced mTORC1 signalling within blastocysts evident in reduced phosphorylation of effector S6 ribosomal protein and its ratio to total S6 protein but no change in effector 4E-BP1 phosphorylated and total pools. These changes were accompanied by increased proliferation of blastocyst trophectoderm and total cells and subsequent increased spreading of trophoblast cells in blastocyst outgrowths. We propose that induction of metabolic programming following Emb-LPD is achieved through mTORC1signalling which acts as a sensor for preimplantation embryos to detect maternal nutrient levels via branched chain AAs and/or insulin availability. Moreover, this induction step associates with changes in extra-embryonic trophectoderm behaviour occurring as early compensatory responses leading to later nutrient recovery. © 2012 Fleming et al.

Predictors of maternal control of feeding at 1 and 2 years of age

Objective: To establish the best predictors of maternal use of controlling feeding practices at 1 and 2 years of age. Design: A longitudinal study from birth to 2 years. Participants: Sixty-two mothers of 2-year-old children. Measures: Infant weight at birth, 6, 12 and 24 months, breastfeeding history, infant temperament and feeding difficulties at 6 and 12 months, maternal demographics at 12 and 24 months, maternal mental health at 6 and 12 months, maternal controlling feeding practices at 12 and 24 months. Results: Controlling feeding practices at 1 year were predicted by perceptions of infant temperament at 6 months, birth weight, length of breastfeeding, mental health at 6 months, and mealtime negativity at 6 months. Parental control over feeding when their child reached 2 years was predicted by the mother's tendency to use that particular strategy at 1 year in combination with the perceptions of infant temperament and feeding problems at 1 year, weight at 1 year, length of breastfeeding in infancy, and/or maternal mental health at 1 year. Conclusions: Breastfeeding appears to promote subsequent monitoring, and is associated with reduced use of pressurising and restrictive feeding practices. Infant characteristics are important predictors of control at both 1 and 2 years of age. The use of controlling feeding practices is relatively stable from 1 to 2 years. © 2007 Nature Publishing Group All rights reserved.