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Objective: To examine the perception of patient safety culture amongst health care workers in Libyan Hospitals. Study Design: The study adopted a mixed methods approach with 2 phases. Phase 1 was conducted prior to the Libyan revolution. This was a quantitative research study, which used the Survey of Hospital Patient Safety Culture (HSOPSC) that was developed by the US Agency for Health Care Research and Quality (AHRQ, 2004). Phase 2 was conducted post revolution and it was a qualitative research study, which used semi-structured interviews. Setting: The three largest hospitals which were located in the Northeast of Libya were involved in the study. Participants and sampling: Phase 1 of the study included a stratified sample of 346 health care workers who were working as Doctors, Nurses, Technicians, Pharmacists and Managers. Phase 2 of the study used a purposeful sample which involved 27 health care workers from those took part in the survey study. Main Outcome Measures: The survey measured twelve Patient Safety Culture dimensions. It indicated that ten of the twelve dimensions were weak and need to be improved. The interview findings also showed that the 12 patient safety culture dimensions were very weak and shed light on some of the reasons for this sub-optimal practice. Findings: The respondents who took part in the study were from different departments in the three hospitals. The survey showed the dimensions with acceptable positive ratings were teamwork within hospitals and organizational learning and continuous improvement, while those with lowest ratings included frequency of reporting errors, non-punitive response to error and communication and openness. Approximately 60% of health care workers perceived patient safety culture practice in Libya negatively. Twenty respondents (5.8%) who gave an excellent grade for patient safety in their hospitals. Furthermore, the interviews results revealed that patient safety culture dimensions were very weak. The interview explored further factors and issues of poor safety culture in the 3 hospitals; which had not been identified in the survey. These were related to results of the political changes, administrative factors, environmental issues, organisational system issues, and health care workers matters. Conclusions: The study identified that the current state of patient safety culture in Libyan hospitals is very weak and there is a need for improvement to safety practice and for promotion of this important issue amongst those health care workers and health managers working at the frontline of health care delivery. Furthermore, the study found that the level of patient safety in the 3 hospitals was below an unacceptable level according to the perceptions of the health care staff. It was noted that there was no effective patient safety system in any of the 3 hospitals to deal with patient safety issues and there were no proactive patient safety measures in place to reduce the level of risk to patients. Furthermore, the study revealed other significant aspects that represent a serious threat to patient safety in the 3 hospitals, which were mainly due to poor hospital management, ineffective emergency services and a lack of training programmes. Moreover, poor organisation of monitoring systems for the licensing of medical practice of health care workers was shown to have a significant impact on patient safety culture. Lastly, the study showed the political change in Libya had affected patients’ safety sharply as result of the military conflict and the lack of hospitals’ preparedness to cope with such emergency events.

This thesis describes a series of studies that examine how nurses who work with people with intellectual disability make clinical decisions in practice. Current research offers evidence and guidance to support clinical decision making for nurses working within mainstream healthcare services. However, the available reviews of intellectual disability nursing research have identified that evidence to support intellectual disability nursing practice is sparse. Consequently, little is known about how and what decisions intellectual disability nurses make in practice; and the types and sources of evidence they use to support their practice. In the context of intellectual disability nursing and in light of a review of the literature (Chapter 1 and 2), three studies were conducted. The aim of this thesis was to use mixed methods (Chapter 3) to explore the process of clinical decision making in intellectual disability nursing. In Study 1 (Chapter 4), Interpretative Phenomenological Analysis was used to explore how twelve intellectual disability nurses made decisions in practice and how their decisions were influenced by evidence. Four key themes emerged : 1) getting to know the person, 2) working as a team, 3) evidence to support decision making, and 4) understanding of evidence based practice. An all Wales survey (Study 2) of nurses employed by the National Health Service intellectual disability nursing service in Wales was conducted. The survey determined the types and sources of evidence nurses used to make decisions in practice; further identifying the demographic and cognitive characteristics that influenced the use of evidence (see Chapter 5). Study 3 explored how individuals with intellectual disability perceive the role of intellectual disability nurses (Chapter 6). Seven participants engaged in semi structured interviews and the analysis of the data was guided by Foucault's concepts of dividing practice, scientific classification and subjectification. Two discursive themes emerged from the analysis: (1) Inclusion: empowering and supportive healthcare practice; and (2) Exclusion : challenges and practices that resist healthcare involvement.