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.

Desire for fertility and associated factors among people living with HIV/AIDS (PLWHA) in selected antiretroviral therapy (ART) clinics of Horro Guduru Wollega Zone, North West Oromia, Ethiopia- A cross sectional study

Background: Most recently fertility issues in HIV positive men and women are becoming increasingly important. Because of ART access and its good life effect, it is expected that the need and desire to get married, to have children and to have sexual partners for PLWHA would change with the regard to reproductive health. In Ethiopia HIV positive individuals may or may not have desire to have children. And the extent of this desire and how it varies by individual, health and demographic characteristics is not well known.

Objective: the aim of the study was to assess desire for fertility and associated factors among PLWHA in selected ART clinics of Horro Guduru Wollega Zone, Oromia National Regional State, Ethiopia.

Methods: A cross-sectional, institutional-based study that employed quantitative and qualitative in-depth interviews was conducted. Three hundred twenty one study subjects were selected using systematic random sampling technique and the data was collected using interviewer administered structured questionnaire. Data entry and analysis were performed using EPI Info version 3.5.1 and SPSS version 16. P-value <0.05 was taken as statistically significant and logistic regression was used to control potential confounding factors.

Results: Seventy three (57.9%) of the males and seventy six (39%) of the females desired to have children, giving a total of 149(46.4%) of all study participants. PLWHA who desired children were younger (AOR:3.3, 95%CI: 1.3-8.9), married (AOR: 5.8, 95%CI: 2.7-12.8), had no children (AOR: 75, 95%CI: 20.1-273.3) and males (AOR; 1.9, 95%CI: 1.02-3.62) compared with their counter parts. The major reason for those people who did not desire children were having desired number of children 80 (46.5%) followed by fear of HIV transmission to child reported by 42 (24.4%) of them.

Conclusion: A considerable number of PLWHA wants to have a child currently or in the near future. Many variables like socio demography, partner related, number of alive children and HIV related disease condition were significantly associated with fertility desire.

A governance approach to integrated rural tourism: factors influencing organisational performance and tourism support of local development organisations

Ao longo das últimas três décadas, o envolvimento das comunidades na formulação de políticas locais tem vindo a ganhar cada vez mais atenção como uma abordagem sustentável para o desenvolvimento rural na União Europeia (UE) e no mundo. Emergendo da globalização, novas estruturas de governação têm desafiado a base territorial restricta da autoridade do Estado soberano através do envolvimento de uma rede complexa e de autoorganização de atores governamentais e não-governamentais na tomada de decisões coletivas. A reestruturação territorial e institucional das zonas rurais, associada à expansão da governança rural, ganhou atenção considerável na literatura. No entanto, o potencial de empregar princípios de governança como fatores que determinam as direções de desenvolvimento rural através de desempenho organizacional e apoio no turismo não tem sido amplamente explorado na literatura. Deste modo, o principal objetivo desta tese consiste no emprego de ‘integração’, ‘participação’ e ‘empowerment’ como fatores críticos que influenciam os rumos do desenvolvimento rural (1) através do desempenho organizacional das organizações de governança rural e (2) apoio no turismo de organizações de desenvolvimento rural tendo em vista a validação da abordagem de governança para o turismo integrado. Ao longo deste duplo objectivo geral, a tese é dividida numa componente qualitativa de ‘desempenho’ e numa componente quantitativa de ‘apoio’. Seguindo uma abordagem sistemática baseada num sistema conceptual, foram realizadas 38 entrevistas em profundidade com pessoas chave envolvendo gestores do programa LEADER da UE na Hungria (34% do número total de Grupos de Ação Local [GAL]), seguido por um levantamento de campo transversal realizado através de um sistema de recolha de dados na Internet, tendo resultado em 662 questionários válidos para uma taxa de resposta de 63.6%. Os resultados da componente “desempenho” revelaram padrões na implementação dos princípios de governança, que por sua vez permitiram a identificação de fatores que permitem e restringem o desempenho organizacional. Os resultados da componente “apoio” permitiram destacar que o ponto de vista de redes de desenvolvimento local nos princípios de governança não é homogéneo. Diferenças significativas foram encontradas entre organizações responsáveis pelo planeamento e os grupos de aconselhamento. Contudo, os resultados sugeriram que a dimensão sustentável de turismo rural integrado é um prognosticador da contribuição do turismo para o desenvolvimento global da comunicade e para o apoio do turismo ao longo das redes de desenvolvimento local. Este estudo responde a uma necessidade crescente de investigação, que resulta da proliferação à escala mundial de formações de governança em sistemas de administração pública, tanto no lado dos investigadores como no lado dos praticantes.

Small farmers and sustainability: institutional barriers to investment and innovation in the Malaysian palm oil industry in Sabah

The Malaysian palm oil industry is well known for the social, environmental and sustainability challenges associated with its rapid growth over the past ten years. Technologies exist to reduce the conflict between national development aims of economic uplift for the rural poor, on the one hand, and ecological conservation, on the other hand, by raising yields and incomes from areas already under cultivation. But the uptake of these technologies has been slow, particularly in the smallholder sector. In this paper we explore the societal and institutional challenges that influence the investment and innovation decisions of micro and small enterprise (MSE) palm oil smallholders in Sabah, Malaysia. Based on interviews with 38 smallholders, we identify a number of factors that reduce the smallholders' propensity to invest in more sustainable practices. We discuss why more effective practices and innovations are not being adopted using the concepts of, firstly, institutional logics to explore the internal dynamics of smallholder production systems, including attitudes to sustainability and innovation; and, secondly, institutional context to explore the pressures the smallholders face, including problems of access to land, labour, capital, knowledge and technical resources. These factors include limited access to global market information, corruption and uncertainties of legal title, weak economic status and social exclusion. In discussing these factors we seek to contribute to wider theoretical debates about the factors that block innovation and investment in business improvements in marginal regions and in marginalised groups.

Process virtualization theory (PVT) and institutional theory (INT) to explain SAAS adoption

Software as a service (SaaS) is a service model in which the applications are accessible from various client devices through internet. Several studies report possible factors driving the adoption of SaaS but none have considered the perception of the SaaS features and the pressures existing in the organization’s environment. We propose an integrated research model that combines the process virtualization theory (PVT) and the institutional theory (INT). PVT seeks to explain whether SaaS processes are suitable for migration into virtual environments via an information technology-based mechanism. INT seeks to explain the effects of the institutionalized environment on the structure and actions of the organization. The research makes three contributions. First, it addresses a gap in the SaaS adoption literature by studying the internal perception of the technical features of SaaS and external coercive, normative, and mimetic pressures faced by an organization. Second, it empirically tests many of the propositions of PVT and INT in the SaaS context, thereby helping to determine how the theory operates in practice. Third, the integration of PVT and INT contributes to the information system (IS) discipline, deepening the applicability and strengths of these theories.

The adoption of advanced feed-in tariffs in Ontario : a case of institutional layering

En mai 2009, l’Ontario a adopté la Loi sur l’énergie verte et devint ainsi la première juridiction en Amérique du Nord à promouvoir l’énergie renouvelable par le biais de tarifs de rachat garantis. En novembre 2010, dans son Plan énergétique à long terme, la province s’est engagée à déployer 10,700 MW en capacité de production d’énergie renouvelable non-hydroélectrique par 2018. Il s’agit de la cible de déploiement la plus élevée dans ce secteur au Canada. Les infrastructures de production et de distribution d’électricité comprennent des coûts d’installation élevés, une faible rotation des investissements et de longs cycles de vie, facteurs qui servent habituellement à ancrer les politiques énergétiques dans une dynamique de dépendance au sentier. Depuis le début des années 2000, cependant, l’Ontario a commencé à diverger de sa traditionnelle dépendance aux grandes centrales hydroélectriques, aux centrales à charbon et aux centrales nucléaires par une série de petits changements graduels qui feront grimper la part d’énergie renouvelable dans le mix énergétique provincial à 15% par 2018. Le but de ce mémoire est d’élucider le mécanisme de causalité qui a sous-tendu l’évolution graduelle de l’Ontario vers la promotion de l’énergie renouvelable par le biais de tarifs de rachat garantis et d’une cible de déploiement élevée. Ce mémoire applique la théorie du changement institutionnel graduel de Mahoney et Thelen au cas du développement de politiques d’énergie renouvelable en Ontario afin de mieux comprendre les causes, les modes et les effets du changement institutionnel. Nous découvrons que le contexte canadien de la politique énergétique favorise la sédimentation institutionnelle, c’est-à-dire un mode changement caractérisé par de petits gains favorisant l’énergie renouvelable. Ces gains s’accumulent pourtant en transformation politique importante. En Ontario, la mise sur pied d’une vaste coalition pour l’énergie renouvelable fut à l’origine du changement. Les premiers revendicateurs de politiques favorisant l’énergie renouvelable – les environnementalistes et les premières entreprises d’approvisionnement et de service en technologies d’énergie renouvelable – ont dû mettre sur pied un vaste réseau d’appui, représentant la quasi-totalité de la société ontarienne, pour faire avancer leur cause. Ce réseau a fait pression sur le gouvernement provincial et, en tant que front commun, a revendiqué l’énergie renouvelable non seulement comme solution aux changements climatiques, mais aussi comme solution à maints autres défis pressants de santé publique et de développement économique. La convergence favorable d’un nombre de facteurs contextuels a certes contribué à la réussite du réseau ontarien pour l’énergie renouvelable. Cependant, le fait que ce réseau ait trouvé des alliés au sein de l’exécutif du gouvernement provincial s’est révélé d’importance cruciale quant à l’obtention de politiques favorisant l’énergie renouvelable. Au Canada, les gouvernements provinciaux détiennent l’ultime droit de veto sur la politique énergétique. Ce n’est qu’en trouvant des alliés aux plus hauts échelons du gouvernement que le réseau ontarien pour l’énergie renouvelable a pu réussir.

Women's Labour Market Performance in Europe: Trends and Shaping Factors. CEPS Special Report, September 2012

We investigate the changes in women’s employment patterns across EU countries over the last 20 years both in terms of labour market participation and type of jobs using individual data from ECHP and EUSILC databases. Using a logistic multilevel model, we then pin down the role played by institutional and policy changes in explaining women’s employment. The key results indicate that women’s employment trends are related to the institutional and policy changes that have been introduced in almost all European countries since the end of the 1990s. Such changes had an important impact on the labour market opportunities’ of women by affecting the quality of potential jobs available, the chances to (re-)enter the labour market and the opportunity costs of employment (vs. non-employment).

Country, sector and regional factors in European property returns

For those portfolio managers who follow a top-down approach to fund management when they are trying to develop a pan-European investment strategy they need to know which are the most important factors affecting property returns, so as to concentrate their management and research efforts accordingly. In order to examine this issue this paper examines the relative importance of country, sector and regional effects in determining property returns across Europe using the largest database of individual property returns currently available. Using annual data over the period 1996 to 2002 for a sample of over 25,000 properties the results show that the country-specific effects dominate sector-specific factors, which in turn dominate the regional-specific factors. This is true even for different sub-sets of countries and sectors. In other words, real estate returns are mainly determined by local (country specific) conditions and are only mildly affected by general European factors. Thus, for those institutional investors contemplating investment into Europe the first level of analysis must be an examination of the individual countries, followed by the prospects of the property sectors within the country and then an assessment of the differences in expected performance between the main city and the rest of the country.

Building post crisis watchtowers: investment management Systems and new institutional logics for regulatory compliance

The financial crisis of 2007-2009 has precipitated large scale regulatory change. Tight deadlines for implementation require organizations to start working on remediation projects before final drafts of regulations are crystalized. Firms are faced with engaging in complex and costly change management programs at a time when profits are diminished. As a consequence of these factors, pre-crisis logics for organizing compliance practices are being questioned and new approaches introduced. Our study explores the use of Investment Management Systems (IMS) in facilitating compliance arrangements. Our motivation is to understand the new logics and the part played by IMS in supporting these approaches. The study adopts an institutional logics perspective to explore the use of such systems at eight financial organizations. The study found new logics for organizing compliance include consolidation, centralization, harmonization and consistency and that the IMS plays an important role in supporting and enabling related activities.

How remote are R&D labs? Distance factors and international innovative activities

This paper shows that value creation by multinational enterprises (MNEs) is the result of activities where geographic distance effects can be overcome. We submit that geographic distance has a relatively low impact on international research and development (R&D) investments, owing to the spiky nature of innovation, and to the unique ability of MNEs to absorb and transfer knowledge on a global scale. On the one hand, MNEs need to set up their labs as close as possible to specialized technology clusters where valuable knowledge is concentrated, largely regardless of distance from their home base. On the other, MNEs have historically developed technical and organizational competencies that enable them to transfer knowledge within their internal networks and across technology clusters at relatively low cost. Using data on R&D and manufacturing investments of 6320 firms in 59 countries, we find that geographic distance has a lower negative impact on the probability of setting up R&D than manufacturing plants. Furthermore, once measures of institutional proximity are accounted for, MNEs are equally likely to set up R&D labs in nearby or in more remote locations. This result is driven by MNEs based in Triad countries, whereas for non-Triad MNEs the effect of geographic distance on cross-border R&D is negative and significant.

The Nine Circles of Surveillance Hell: An Institutional View of Information Flows and Information Threats in Libraries

In the past few years, libraries have started to design public programs that educate patrons about different tools and techniques to protect personal privacy. But do end user solutions provide adequate safeguards against surveillance by corporate and government actors? What does a comprehensive plan for privacy entail in order that libraries live up to their privacy values? In this paper, the authors discuss the complexity of surveillance architecture that the library institution might confront when seeking to defend the privacy rights of patrons. This architecture consists of three main parts: physical or material aspects, logical characteristics, and social factors of information and communication flows in the library setting. For each category, the authors will present short case studies that are culled from practitioner experience, research, and public discourse. The case studies probe the challenges faced by the library—not only when making hardware and software choices, but also choices related to staffing and program design. The paper shows that privacy choices intersect not only with free speech and chilling effects, but also with questions that concern intellectual property, organizational development, civic engagement, technological innovation, public infrastructure, and more. The paper ends with discussion of what libraries will require in order to sustain and improve efforts to serve as stewards of privacy in the 21st century.

How does corruption hurt growth? Evidences about the effects of corruption on factors productivity and per capita income

Corruption is a phenomenon that plagues many countries and, mostly, walks hand in hand with inefficient institutional structures, which reduce the effectiveness of public and private investment. In countries with widespread corruption, for each monetary unit invested, a sizable share is wasted, implying less investment. Corruption can also be a burden on a nation’s wealth and economic growth, by driving away new investment and creating uncertainties regarding private and social rights. Thus, corruption can affect not only factors productivity, but also their accumulation, with detrimental consequences on a society’s social development. This article aims to analyze and measure the influence of corruption on a country’s wealth. It is implicitly admitted that the degree of institutional development has an adverse effect on the productivity of production factors, which implies in reduced per capita income. It is assumed that the level of wealth and economic growth depends on domestic savings, foster technological progress and a proper educational system. Corruption, within this framework, is not unlike an additional cost, which stifles the “effectiveness” of the investment. This article first discusses the key theories evaluating corruption’s economic consequences. Later, it analyzes the relation between institutional development, factor productivity and per capita income, based on the neoclassical approach to economic growth. Finally, it brings some empirical evidence regarding the effects of corruption on factor productivity, in a sample of 81 countries studied in 1998. The chief conclusion is that corruption negatively affects the wealth of a nation by reducing capital productivity, or its effectiveness.

The perception of brazilian researchers concerning the factors that influence the citation of their articles: A study in the field of sustainability

With growing institutional pressure from the Brazilian government to increase the impact of research that it funds, Brazilian researchers are increasingly interested in discovering factors that affect the citation of their articles. The aim of the present article was to assess the perceptions of Brazilian sustainability researchers to identify factors that influence the impacts of their research. A survey was conducted with researchers in the field of sustainability and 89 questionnaires were completed. All of those researchers have articles or research projects in the field of sustainability (mixing environmental, social and/or economical) recorded in the Scielo or Lattes Curriculum Brazilian databases. Results suggest four factors that may explain the impact of article citations: (1) prestige of the author and the research network; (2) prestige of the means of publication and indexing; (3) accessibility and quality characteristics of the article; and (4) international nature of communication and scope of the study. Surprisingly, such factors were not statistically significant in explaining the citations of the participating researchers. These results show the need to consider other factors that can explain the impact of research, discovering the missing links. © 2013 Elsevier Inc.

Potentially inappropriate medications used by the elderly: Prevalence and risk factors in Brazilian care homes

Abstract. Background: The use of potentially inappropriate medications (PIM) among the elderly is a serious public health problem because it is intrinsically linked to increased morbidity and mortality, causing high costs to public health systems. This study's objective was to verify the prevalence of and the factors associated with the use of PIMs by elderly Brazilians in institutional settings. Methods. We performed a transversal study, by consulting the case files of elderly people living in Long Term Care for the Elderly (LTC) in towns in the State of São Paulo, Brazil, as well as structured interviews with the nurses responsible for them.We identified PIMs using the list of recently updated Beers criteria developed by a group of specialists from the American Geriatrics Society (AGS), who reviewed the criteria based on studies with high scientific evidence levels. We defined the factors studied to evaluate the association with PIM use prior to the statistical analyses, which were the chi-square test and multiple logistic regression. Results: Among the elderly who used drugs daily, 82.6% were taking at least one PIM, with antipsychotics (26.5%) and analgesics (15.1%) being the most commonly used. Out of all the medications used, 32.4% were PIMs, with 29.7% of these being PIMs that the elderly should avoid independent of their condition, 1.1% being inappropriate medication for older adults with certain illnesses or syndromes, and 1.6% being medications that older adults should use with caution. In the multivariate analysis, the factors associated with PIM use were: polypharmacy (p = 0.0187), cerebrovascular disease (p = 0.0036), psychiatric disorders (p < 0.0001) and dependency (p = 0.0404). Conclusions: The results of this study showed a high prevalence of PIM use in institutionalized elderly Brazilian patients. and the associated factors were polypharmacy, psychiatric disorders, cerebrovascular diseases and dependency. © 2013 Lima et al.; licensee BioMed Central Ltd.

Implementing inflation targeting in Brazil: an institutional analysis

The paper shows the advantages and handicaps of implementing an inflation target (IT) regime, from a Post-Keynesian and, thus, an institutional stance. It is Post-Keynesian as long as it does not perceive any benefit in the mainstream split between monetary and fiscal policies. And it is institutional insofar as it assumes that there are several ways of implementing a policy, such that the chosen one is determined by historical factors, as it is illustrated by the Brazilian case. One could even support IT policies if their targets were seen just as “focusing devices” guiding economic policy, notwithstanding other targets, as, in the short run, output growth and employment and, in the long run, technology and human development. Nevertheless, an IT is not necessary, although it can be admitted, mainly if the target is hidden from the public, in order to increase the flexibility of the Central Bank.