Adaptive capacities for safe clinical practice for patients hospitalised during a suicidal crisis: A qualitative study

Background. Safe clinical practice for patients during a suicidal crisis is situated within a complex, non-linear and uncertain context. It involves a complex set of practices in which adaptation is perceived as a source of safety. This study aims to develop a deeper understanding of safe clinical practice and the capacity to adapt to challenges and changes in clinical care for patients hospitalised in mental health wards during a suicidal crisis. Methods. This study applied a qualitative design based on focus group and individual interviews. Twenty-five health care professionals (HCPs) participated in the focus groups, and 18 HCPs were individually interviewed. The study was conducted at open and locked wards in a university hospital in Norway that provides specialised mental health services for adults.Findings. Adaptive capacities for clinical practice were described in relation to three themes. 1) HCPs described using expertise to make sense of suicidal behaviour to support complex decision-making. Their strategies relied on setting the checklist aside to prioritise trust and making judgements beyond spoken words. They improved their understanding by seeking others’ perspectives through a collaborative sense-making process involving the health care team and the patient. 2) HCPs reported individualising the therapeutic milieu to address the diversity of patients with suicidal behaviour. Safe clinical practice was provided by creating individual clinical pathways, making trade-offs between under- and over-protection and adjusting observations 3) It was necessary for HCPs manage uncertainty to provide safe clinical practice. They did so as a team by developing mutual collegial trust, support and shared understanding. Conclusion. HCPs’ adaptive capacities are vital to the complex set of practices involved in safe clinical practice for patients hospitalised during a suicidal crisis. By using expertise, individualising the therapeutic milieu, and managing uncertainty, HCPs individually and collectively develop their capacity to adapt to challenges and changes in clinical care. Safe clinical practice cannot easily be ensured by following standards; it depends on HCP adaptations. Ward systems ensuring collegial trust and support are needed, as are arenas supporting shared understanding and collaborative sense-making. Keywords: Adaptation, sense-making, situational awareness, shared understanding, trade-offs, mental health, suicide, uncertainty

Enabling School Structures, Trust, and Collective Efficacy in Private International Schools

We explored the role of enabling school structures, collegial trust, and collective efficacy in 15 pre-Kindergarten to 12th grade international, private schools in South and Central America and Mexico. While most of these schools shared an “American” curriculum the local culture and school norms affected the climate of the school and the likelihood of the development of a professional learning community (PLC) in each school and country accordingly. As enabling school structures, trust in the principal, collegial trust, and collective efficacy were more established, the PLC was more likely to be developed based upon teacher perceptions in this quantitative study.

The intricate implementation of performance measurement systems: exploring developments in professional-service organizations in the Dutch non-profit sector

Institutional and organizational theory supports the argument that current features of performance measurement systems (PMS) in public organizations are generally unsuitable for the actual nature of these professional organizations. Longitudinal and cross-sectional studies in the health care and higher education sectors in the Netherlands have shown that, despite external pressures, the implementation of such systems is slower than intended and seems to occur outside the primary process of the organization. Two rounds of interviews with quality coordinators in 2003 and 2006 showed that the gap between performance measurement systems and the operational process continued to exist, although its nature had changed. In general, quality coordinators responded pragmatically to the changes imposed upon them, as peer review and collegial trust played a vital part. The empirical findings illustrate that institutional and professional theories supplement each other in a fruitful way. Points for practitioners Policy-makers in the public sector involved with quality care and assurance should be aware that a well-structured performance measurement system (PMS) is no guarantee of smooth implementation. On the contrary, the implementation deserves attention in its own right. The more sophisticated and demanding the design of PMS, the more likely it is that employees find ways to work round such a system and only use it in a superficial or compliant manner. If implementation is not taken seriously into account, this will only lead to a greater gap between reality and rhetoric.