Factors affecting the successful implementation and sustainability of the Liverpool Care Pathway for dying patients – a realist evaluation

Objectives: The Liverpool Care Pathway for the dying patient (LCP) was designed to improve end-of-life care in generalist health care settings. Controversy has led to its withdrawal in some jurisdictions. The main objective of this research was to identify the influences that facilitated or hindered successful LCP implementation.

Method: An organisational case study using realist evaluation in one health and social care trust in Northern Ireland. Two rounds of semi-structured interviews were conducted with two policy makers and twenty two participants with experience and/or involvement in management of the LCP during 2011 and 2012.

Results: Key resource inputs included facilitation with a view to maintaining LCP ‘visibility’, reducing anxiety among nurses and increasing their confidence regarding the delivery of end-of-life care; and nurse and medical education designed to increase professional self-efficacy and reduce misuse and misunderstanding of the LCP. Key enabling contexts were consistent senior management support; ongoing education and training tailored to the needs of each professional group; and an organisational cultural change in the hospital setting that encompassed end-of-life care.

Conclusion: There is a need to appreciate the organizationally complex nature of intervening to improve end-of-life care. Successful implementation of evidence-based interventions for end-of-life care requires commitment to planning, training and ongoing review that takes account of different perspectives, institutional hierarchies and relationships and the educational needs of professional disciplines. There is a need also to recognise that medical consultants require particular support in their role as gatekeepers and as a lead communication channel with patients and their relatives.

Interface Implementation for GPRS/PCU Software Testing with Emulators

Jatkuvasti lisääntyvä matkapuhelinten käyttäjien määrä, internetin kehittyminen yleiseksi tiedon ja viihteen lähteeksi on luonut tarpeen palvelulle liikkuvan työaseman liittämiseksi tietokoneverkkoihin. GPRS on uusi teknologia, joka tarjoaa olemassa olevia matka- puhelinverkkoja (esim. NMT ja GSM) nopeamman, tehokkaamman ja taloudellisemman liitynnän pakettidataverkkoihin, kuten internettiin ja intranetteihin. Tämän työn tavoitteena oli toteuttaa GPRS:n paketinohjausyksikön (Packet Control Unit, PCU) testauksessa tarvittavat viestintäajurit työasemaympristöön. Aidot matkapuhelinverkot ovat liian kalliita, eikä niistä saa tarvittavasti lokitulostuksia, jotta niitä voisi käyttää GPRS:n testauksessa ohjelmiston kehityksen alkuvaihessa. Tämän takia PCU-ohjelmiston testaus suoritetaan joustavammassa ja helpommin hallittavassa ympäristössä, joka ei aseta kovia reaaliaikavaatimuksia. Uusi toimintaympäristö ja yhteysmedia vaativat PCU:n ja muiden GPRS-verkon yksiköiden välisistä yhteyksistä huolehtivien ohjelman osien, viestintäajurien uuden toteutuksen. Tämän työn tuloksena syntyivät tarvittavien viestintäajurien työasemaversiot. Työssä tarkastellaan eri tiedonsiirtotapoja ja -protokollia testattavan ohjelmiston vaateiden, toteutetun ajurin ja testauksen kannalta. Työssä esitellään kunkin ajurin toteuttama rajapinta ja toteutuksen aste, eli mitkä toiminnot on toteutettu ja mitä on jätetty pois. Ajureiden rakenne ja toiminta selvitetään siltä osin, kuin se on oleellista ohjelman toiminnan kannalta.

Implementation of hospital-wide computer information system :a case study of this change process

This case study examines the impact of a computer information system as it was being implemented in one Ontario hospital. The attitudes of a cross section of the hospital staff acted as a barometer to measure their perceptions of the implementation process. With The Mississauga Hospital in the early stages of an extensive computer implementation project, the opportunity existed to identify staff attitudes about the computer system, overall knowledge and compare the findings with the literature. The goal of the study was to develop a greater base about the affective domain in the relationship between people and the computer system. Eight exploratory questions shaped the focus of the investigation. Data were collected from three sources: a survey questionnaire, focused interviews, and internal hospital documents. Both quantitative and qualitative data were analyzed. Instrumentation in the study consisted of a survey distributed at two points in time to randomly selected hospital employees who represented all staff levels.Other sources of data included hospital documents, and twenty-five focused interviews with staff who replied to both surveys. Leavitt's socio-technical system, with its four subsystems: task, structure, technology, and people was used to classify staff responses to the research questions. The study findings revealed that the majority of respondents felt positive about using the computer as part of their jobs. No apparent correlations were found between sex, age, or staff group and feelings about using the computer. Differences in attitudes, and attitude changes were found in potential relationship to the element of time. Another difference was found in staff group and perception of being involved in the decision making process. These findings and other evidence about the role of change agents in this change process help to emphasize that planning change is one thing, managing the transition is another.

Clinician-Perceived Bridges and Barriers to Parental Implementation of Picture Exchange Communication System (PECS): An evaluation.

Picture Exchange Communication System (PECS) is an augmentative and alternative communicative system that improves communication and decreases problem behaviors in children with Developmental Disabilities and Autism. The mediator model is a validated approach that clinicians use to train parents to perform evidence-based interventions. Parental non-adherence to treatment recommendations is a documented problem. This qualitative study investigated clinician-perceived factors that influence parental adherence to PECS recommendations. Three focus groups (n=8) were conducted with Speech Language Pathologists and Behavior Therapists experienced in providing parents with PECS recommendations. Constant comparison analysis was used. In general, clinicians believed that PECS was complex to implement. Thirty-one bridges were identified to overcome complexity. Twenty-two barriers and 6 other factors also impacted parental adherence. Strategies to address these factors were proposed based on a review of the literature. Future research will be performed to validate these findings using parents and a larger sample size.

Investigation of Changes in Prescribed and Voluntary Job Roles in Community Service Delivery for People who have Intellectual Disabilities after the Implementation of the 3 Rs; Rights, Respect and Responsibility Project

The purpose of this thesis was to explore whether there is change in organizational citizenship behaviours in community agency staff following agency adoption of a rights - based service philosophy. Four community agency support staff were interviewed to investigate how residential care providers in services for persons who have intellectual disabilities describe their voluntary job related behaviours following training about human rights. The major finding was that the participants were actively engaged in displaying civic virtue, courtesy, and altruism discretionary behaviours. There was evidence of a post rights training shift in communication patterns with support staff reporting that they used language that prom,oted and advocated for human rights, and reported increased communication exchanges among persons supported by the agency, support staff and managers. Participants also suggested that the individuals they support asserted their rights more frequently and they were more active in their own life choices following rights training.

Complexité de la communication sur un canal avec délai

Nous introduisons un nouveau modèle de la communication à deux parties dans lequel nous nous intéressons au temps que prennent deux participants à effectuer une tâche à travers un canal avec délai d. Nous établissons quelques bornes supérieures et inférieures et comparons ce nouveau modèle aux modèles de communication classiques et quantiques étudiés dans la littérature. Nous montrons que la complexité de la communication d’une fonction sur un canal avec délai est bornée supérieurement par sa complexité de la communication modulo un facteur multiplicatif d/ lg d. Nous présentons ensuite quelques exemples de fonctions pour lesquelles une stratégie astucieuse se servant du temps mort confère un avantage sur une implémentation naïve d’un protocole de communication optimal en terme de complexité de la communication. Finalement, nous montrons qu’un canal avec délai permet de réaliser un échange de bit cryptographique, mais que, par lui-même, est insuffisant pour réaliser la primitive cryptographique de transfert équivoque.