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Terrestrial fusion power is a low carbon alternative to conventional power sources with reduced waste and proliferation concerns relative to fission power. The complexity of fusion research devices means that many high performance diagnostics are necessary to investigate the underlying physics of the environment. Field Programmable Gate Array technology provides a powerful and flexible option when designing bespoke instrumentation.

This thesis examines the effect American human rights conduct during the war on terror had on three international human rights norms: torture, habeas corpus, and rendition for the purposes of torture. It does so by analysing a large-n sample of public legitimation strategies of both the United States and other members of international society during the administration of President George W. Bush. The thesis asks three questions: First, has the defection of the United States from these human rights norms led to a ―norm cascade‖ that delegitimized the norms? Second, did the United States run an exemptionalist argument for each, and was this successful? Third, did the material preponderance of the United States help it to legitimate its preferences in international society? The thesis argues that the United States was unsuccessful at overtly legitimating its preferences in the habeas corpus case study. In the torture case study the United States had some early success using a strategy of norm justification, but most international legitimation strategies were subsequently abandoned. It was relatively successful in the rendition case study where it pursued very few legitimation strategies, relying instead on secrecy and denial. Furthermore, there is no overt evidence that the United States either attempted or was successful in an exemptionalist strategy, though some of the conduct by the United States and other members of international society might imply that a covert strategy was in effect. Lastly, though the material preponderance of the United States allowed it to absorb the costs associated with its illegitimate behaviour, there was no evidence that it was useful in transforming international human rights norms.

Complex medical care is now performed by families at home, and is no longer solely the domain of healthcare professionals working in hospitals. Parents caring for children with serious or chronic conditions perform a range of medical procedures for their children, including caring for children with feeding tubes and children who need support with breathing (children dependent on long-term ventilation). This thesis examines the challenges and risks of complex medical care for children at home, and explores how best to train and prepare parents to provide this care, drawing upon relevant psychological theory and the lived experience of families. The first section of the thesis explores the clinical issues: Chapters 3 and 4 examine the safety concerns of clinicians who support families at home through analyses of incident reporting data, and Chapters 5 and 6 explore the experiences of parents caring for children with complex medical needs through interviews and surveys. This first section reveals a clear need to improve training and support for families. The second section (Chapters 7-9) consists of a series of experiments on how findings from psychology could inform the development of training interventions for parents caring for children with gastrostomies (a type of feeding tube). There was a significant benefit of supplementary videos and images on parents' learning, but limited benefit of retrieval practice. Schema-enhanced training had a detrimental impact on performance in a test of knowledge. In the final section (Chapters 10 and 11) I develop and evaluate a package of training and support for parents caring for children with feeding tubes which has now been implemented across Oxfordshire and the Thames Valley. The training package consists of a library of videos to support families from referral for a gastrostomy through to the first few years caring for their child at home. Survey data from families and clinicians confirm the value of the library of videos for educating and empowering families.

Burnout constitutes a significant challenge for healthcare organisations not only in respect to individual wellbeing but also in terms of the catastrophic downstream implications to patient safety, patient satisfaction, and quality of care. This DPhil, divided into three parts, aims to explore burnout in healthcare professionals, an accelerating phenomenon that is hotly discussed but minimally understood, with a focus on the impact uncertainty has and an exploration into the novel use of neurohormones as potential biomarkers of wellbeing. Part I: Exploration of concepts: burnout and uncertainty. Chapter 1 presents a selective overview of the broad context of burnout in healthcare, reporting existing literature on the impact of burnout—to physicians, to patients, and to healthcare organisations—and considering the challenges that pertain to burnout research, particularly relating to challenges in measurement. Chapter 2 explores the presence of uncertainty in the healthcare environment looking at what impacts an individual’s tolerance of uncertainty and how the reaction affects provider- and patient-centred outcomes. Chapters 3 and 4 present two observational studies exploring drivers of satisfaction at work for faculty in an academic medical centre, with an analysis of the interplay between burnout and uncertainty in the clinical environment. Chapter 5 presents a study that looks at how language used in clinical hand-over affects sense of uncertainty in the receiving clinician, demonstrating how language variation can influence emotional perception of uncertainty. Part II: Exploration of biology: exploration into use of biomarkers to measure burnout. Chapters 6 and 7 explore the novel use of cortisol and oxytocin levels as potential biomarkers of stress and burnout in clinical faculty at a large teaching hospital. Part III: Exploration of interventions to reduce burnout and strategies to embrace uncertainty. Chapter 8 presents an interprofessional intervention study looking to reduce burnout through self-facilitated groups meeting monthly for three months. This study re-affirms the importance of the findings presented in this thesis and points to the need for more interventions aimed at enhancing trainee and faculty wellbeing. Chapter 9 synthesises current literature on tolerance of uncertainty alongside findings of the thesis, self-experience, and experience of colleagues and students in a narrative review to identify strategies to help clinicians thrive in the face of clinical uncertainty. Finally, Chapter 10 presents an overview of the key findings from each study, their methodological strengths and limitations, directions for future research, and implications for clinical training, the measurement of wellbeing initiatives, and patient care.

Due to the myriad of geometric topologies that modern computational fluid dynamicists desire to mesh and run solutions on, the need for a robust Cartesian Mesh Generation algorithm is paramount. Not only do Cartesian meshes require less elements and often help resolve flow features but they also allow the grid generator to have a great deal of control in so far as element aspect ratio, size, and gradation. Fully Anisotropic Split-Tree Adaptive Refinement (FASTAR) is a code that allows the user to exert a great deal of control and ultimately generate a valid, geometry conforming mesh. Due to the split-tree nature and the use of volumetric pixels (voxels), non-unit aspect ratio meshing is easily achieved. Nodes are not generated until the end which mitigates tolerance issues. The tree is retained coherently, and viscous layers may be inserted in the space between the geometry and the Cartesian mesh before it is tetrahedralized. FASTAR uses tree traversal to determine neighbors robustly, and with the tetrahedralization of only a small amount of space around the geometry, sliver cells and inverted elements are avoided. The code uses Riemannian Metric Tensors to generate geometry-appropriate spacing and is capable of adaptive meshing from a spacing field generated either by the user or from solution data. FASTAR is a robust, general mesh generator that allows maximum flexibility with minimal post-processing.

Among the most consistent findings in the warnings literature is the so-called 'familiarity effect.' Research has shown that the more familiar an individual is with a product or situation the less likely he or she is to notice, read, recall, or comply with hazard communications. The effect has been found across numerous product types and situations using various operational definitions of familiarity and measures of warning effectiveness. However, research has also shown that subjective familiarity ratings are not highly correlated with actual product experience. Thus, individuals must be capable of developing a false or exaggerated sense of familiarity. One possible source of this exaggerated familiarity is exposure to product advertising. Three experiments were conducted to investigate whether the familiarity effect can be produced from exposure to product advertising. The relationships between advertising exposure and perceived familiarity and between perceived familiarity, perceived safety and warning effectiveness were examined. Experiment 1 explored participants' attitudes and beliefs about well-known and obscure brands of household, consumer products and sought to determine how past, direct product experience influences those attitudes and beliefs. Experiments 2 and 3 examined how the number of advertising exposures and the safety-related content of advertisements influence attitudes and beliefs about the advertised products and the effectiveness of on product warnings. Results of Experiment 1 revealed that past experience can not fully explain consumers' attitudes and beliefs about household, consumer products. Experiments 2 and 3 showed that advertising influences perceived product familiarity and knowledge. While there was a trend of greater perceived safety with increased ad exposures, the effect was not significant. No effects of advertising on warning recall were found. Implications for the design of product advertisements and product packaging as well as directions for future research are discussed.

In the face of the oft-quoted dictum 'primum non nocere', it is now widely recognised that a significant number of patients come to harm whilst in hospital. A large body of evidence demonstrates that half of all harm events are preventable and the operating theatre appears to be the most common site for adverse events to occur. For patients undergoing arterial intervention, technical expertise and risk-factor management are clearly important in achieving excellent outcomes. Recent research in vascular surgery has focussed on volume-outcome relationships and the impact of advancements in endovascular intervention. By contrast, there is a relative lack of research examining the extraordinarily complex system within which patients with arterial disease are treated. This thesis aims to develop a broad understanding of system failures and their relationship with patient safety and outcomes in arterial surgery in the British NHS. In section I (chapter 1 and 2) the systems approach is outlined and discussed and the rationale for adopting this approach in arterial surgery is provided. Section II consists of three exploratory studies: chapter 3 presents a systematic review of the literature examining the impact of system factors on safety in arterial surgery; chapter 4 reports a mixed-methods study exploring surgeons' perceptions of the causes of adverse events in arterial surgery; and chapter 5 presents a multi-centre study of safety culture in vascular operating departments in England. Section III provides an account of the LEAP study: a multi-centre study of system failures occurring during aortic intervention. The methods and main findings of the LEAP study are presented in chapters 6 and 7. Chapter 8 reports on the determinants of intraoperative system failures and the relationship between intraoperative failure and patient outcome. Chapter 9 summarises the main findings and limitations of this thesis, and discusses recommendations for practice and future research.

Situation awareness (SA) is a cognitive skill which has been studied extensively in military and industrial settings. Recent studies have shown that errors in SA commonly underpin adverse incidents in healthcare but there is little data to improve our understanding of how to measure or improve SA in clinical settings. The aim of this thesis was to draw attention to the importance of SA in healthcare and to provide insights into how we might better train multidisciplinary teams in acute care settings. Error in healthcare and research into SA were reviewed and a novel, holistic method for the analysis of the role of SA in the evolution of error in an acute care setting was devised. A systematic review of tools for the measurement of non-technical skills (NTS) was undertaken and this informed a study to assess the reliability and usability of such tools in the measurement of SA. The final study involved the analysis of a variety of different techniques for the measurement of SA in teams from adult intensive care (AICU). The results revealed that SA errors were present in 96% of serious incidents in a large teaching hospital in the NHS. Challenges were highlighted in the measurement of NTS in healthcare including: 76 measurement tools, revealed by the systematic review, with great variability in quality of design and psychometric testing; low levels of reliability amongst expert raters using these tools and limited evidence of validity for direct and indirect measures of SA in simulated scenarios for teams from AICU. This work has revealed that SA errors are common in acute care settings and that there are significant challenges in the reliable measurement of SA. Future work should focus on improving measurement of SA and intelligent targeting of teamwork training which highlights the importance of SA and forms part of a system wide safety strategy in the NHS.

A theory of starch viscosity

Surgical patient outcomes are related to technical and non-technical skills of the surgeon. Trauma patient operative and management experience has declined since trainee duty-hour restrictions were mandated in 2003 resulting in less experience in technical surgical skills. The Advanced Surgical Skills for Exposure in Trauma (ASSET) cadaver-based course, teaching vascular exposure and haemorrhage control, was developed to fill this training gap. The aim of this Thesis is to develop surgeon performance metrics and to test surgeons before and after taking the ASSET course to determine whether such training improves performance of peripheral vascular control. The importance of training in surgical vascular control in both civilian and military practice, and a description of current surgical training for trauma are described in Chapter 1. Reviews of existing trauma training courses and surgical performance metrics are provided in Chapters 2 and 3, and show limited testing of training courses and lack of trauma surgical performance metrics. Data collection methods, evaluator training and analysis are described in Chapter 4. Chapter 5 evaluates self-confidence of surgeons performing the vascular control procedures in cadavers compared to the performance evaluated by trained evaluators. Preliminary validation of vascular-control performance metrics and testing of a standardized script with item analysis and inter-rater reliability are discussed in Chapter 6. Testing 40 surgeons performing 3 extremity vascular control procedures before and after training is reported in Chapter 7. ASSET training improves performance, but large performance variability, repeated errors and no improvements were found in some surgeons. Chapter 8 reports how blind video analysis checklist, global rating metrics, error occurrence and recovery show convergent validity with co-located evaluators. Chapter 9 identifies the key findings and implications, innovation of the work described in the Thesis and concludes with the potential impact on military readiness and my personal reflection on what I learnt.

Vaccination coverage in adults remains suboptimal. Health organisations have only recently begun to recognise the role of socio-psychological factors in vaccination decisions. These factors are particularly important, given that they are inherently amenable to policy and behaviour change. This thesis employs a mixed-methods approach to investigate the determinants of adult seasonal influenza and tetanus vaccination in the UK general adult population. It focuses on socio-psychological factors and draws upon health behaviour models, heuristics and biases and customer journey mapping theoretical approaches to guide research and elucidate findings. A narrative and a systematic review and meta-analysis reveal there are a number of socio-psychological factors frequently associated with vaccination, particularly influenza and influenza vaccine risk perception, perceived vaccine effectiveness and reported physician recommendation, and show that most of the evidence in this area is produced in the US. They also highlight the importance of some vaccine risk perceptions, such as influenza-like symptoms and unspecific side-effects, and demonstrate that the existing evidence is highly heterogeneous and often lacking in quality, further supporting a case for robust empirical research on this topic. Two qualitative studies show that vaccine uptake is largely driven by people’s risk perception of influenza and tetanus, and that the tetanus vaccine is perceived as safe, unlike the influenza vaccine. They also reveal how specific healthcare ‘touchpoints’ across the immunisation journey can facilitate or hinder uptake. A novel finding is that certain childhood experiences can influence adult vaccination decisions. Two cross-sectional survey studies show that a compact set of variables can predict 91% of influenza and 75% of tetanus vaccination behaviour. They also demonstrate that socio-psychological factors are the most important determinants of vaccination behaviour. This thesis shows that incorporating socio-psychological dimensions in all aspect of immunisation policy, from surveillance systems to policy evaluation, is critical to improve vaccination rates.

A large body of international outcomes research has documented significant variation in the results of health care, beyond differences attributable to patient age, comorbidity or chance. Naturally, quality of care, however measured, may vary by provider within a health care system. Yet detailed understanding of the relationship between quality of care and health care outcomes continues to elude researchers. Much research has focused on the patient level, determining which patient-focused clinical processes deliver the best outcomes. By contrast, there is a relative lack of research examining intermediate and higher levels, to understand team performance and how teams work to provide high quality care, though research in this area is growing. This thesis aims to develop a greater understanding of how the best colorectal surgical units may be identified, and how they achieve their results. Chapter 1 provides background to the present approach to the assessment of performance in health care. Chapter 2 summarises salient surgical outcomes research, and chapter 3 presents a literature review of evidence associating specific organisational structures and processes with clinical outcomes. Chapter 4 presents a patient questionnaire study, undertaken to assess the involvement of patients with gastrointestinal cancer in choosing a provider, and what provider-level information patients consider important. Chapters 5 to 8 describe the methods and results of a series of studies using routine administrative data to explore changes within colorectal surgery over time, as well as the relationship between different outcome measures at the unit level. Chapters 9 to 12 present research designed to understand how units achieve their results. This work included developing a semi-structured interview to better understand the key organisational factors determining length of stay after elective colonic surgery. Chapter 13 summarises the main findings and limitations of this thesis, and discusses its implications for practice and future research.

The national identification of high performing providers in surgery is of prime importance to patients, surgeons and commissioners of healthcare. This thesis explores how high performance is identified, defined and measured nationally and attempts to identify the factors that underlie high performance in colorectal cancer surgery during the peri-operative period. An introduction into the determinants of high performance in surgery as well as defining quality as it pertains to surgery is then undertaken. Identification of available national data sources and metrics for national performance are then identified. Comparison is made between voluntary and compulsory reporting systems highlighting greater capture of peri-operative mortality in compulsory reporting datasets. A novel marker that reflects outcome following complication management is developed. This marker is based on re-operations and is derived from compulsory reporting datasets. The use of non-operative re-interventions is then assessed in oesophago-gastric cancer resections as proof of concept. An appraisal of all colorectal cancer units in England is then undertaken using a panel of metrics demonstrating that analysis on a single marker alone may be too simplistic. Identifying factors that pertain to high performance beyond those available from routinely available datasets using a novel methodological approach called HiPer (High Performance) is performed. The interview based methodology identified rich qualitative factors in a group of colorectal cancer units worldwide that may be causal in their performance status. Finally, results from the interview study were related to hard outcome data from each unit which demonstrated some correlation between the HiPer methodology and the outcome data in the final section of the feasibility study. The implications of this may be that a dual approach of analysing routinely collected data with a more qualitative HiPer style methodology may help us better understand how high performing units achieve their results.

Background One in ten hospital patients are unintentionally harmed by their healthcare management. Healthcare professionals are often blamed for making mistakes that could be prevented if all the factors influencing human performance were addressed by designing the system to be safer. Hypothesis This thesis is part of the Designing Out Medical Error (DOME) project, which tested the hypothesis that a multidisciplinary team of designers, clinicians, psychologists and business analysts working collaboratively could design interventions to improve patient safety in surgical wards. Methods & Results We used a combination of observational techniques including Healthcare Failure Mode and Effects Analysis to proactively assess risk in surgical wards. We focused on five high-risk processes: hand hygiene, isolation of healthcare-associated infection, vital signs monitoring, handover communication and medication delivery. Patients and healthcare professionals were involved at every stage and helped co-design a suite of concepts to address risk in these processes. We progressed two prototypes: the Respiratory Rate Recorder and the CareCentre® (a bedside work table containing equipment including alcohol hand-rub) to simulated and clinical trials. The trials demonstrated that the accuracy of manual respiratory rate measurement and the adherence of healthcare workers to hand hygiene guidelines was significantly improved respectively, thus supporting the hypothesis. Conclusion Multidisciplinary collaborations that engage with the teams, processes and equipment of the healthcare system can co-design safer interventions. Better design can influence behaviour and improve the performance of healthcare professionals. The DOME project demonstrates a successful method for others to follow.

There is a growing concern that adverse events occur frequently in operating theatres. Adverse events such as wrong site surgery and surgical site infections have a severe detrimental impact on not only the patient but also the healthcare staff and the services. Institute of Medicine's report, 'To err is human', highlighted that teamwork failures are a leading cause of death and suffering. Yet, in surgery, measuring teamwork and designing interventions to improve teamwork and patient safety in operating theatres remains an area of research that is largely unexplored. This thesis aims to measure and improve teamwork in operating theatres to ensure safer surgery. In this project, the WHO surgical safety checklist was evaluated for its impact on patient safety. The WHO checklist improved patient safety processes in operating theatres but its impact on teamwork, intra-operative problems and theatre efficiency was not clearly understood. Therefore, a framework was developed to measure teamwork failures, equipment problems and technical failures as surrogate markers of teamwork, patient safety and efficiency in operating theatres. Equipment failures emerged as a sensitive measure of teamwork in operating theatres. Teamwork failures were also associated with technical failures, delay in case progress and patient harm. It emerged that the WHO checklist can improve teamwork and theatre efficiency and reduce equipment problems in operating theatres when it is used in its true spirit rather than a tick-box exercise.

There are more than 600,000 emergency general surgery admissions per year in England. These patients comprise about 50 percent of general surgical workload but make up 80-90 percent of all general surgical deaths. In recent years surgical colleges and societies in the UK have warned of significant variability in the quality of care between hospitals but, to date, little formal evaluation of the quality of care in emergency general surgery exists. This thesis uses the Structure/Process/Outcome quality assessment framework, devised by Avedis Donabedian, to examine quality of care in emergency general surgery across all three of these domains. A study of high risk emergency general surgical admissions using the administrative Hospital Episode Statistics dataset demonstrated significant variability in 30-day in-hospital mortality between NHS Trusts. Investigation of NHS Trust structure was performed using data from the Department of Health. There were significant differences in the provision of intensive care beds and in the utilization of computed tomography and ultrasound scanning between low mortality and high mortality NHS Trusts. The process of care was assessed using an explicit checklist for the admission phase of care and using ethnographic field notes for patients’ subsequent hospital stay. Across 5 London hospitals, process reliability during admissions to hospital was poor, with nearly 20% of recommended processes omitted. Failures in the process of care were also common in subsequent ward based care. Failures were considered to be highly preventable and frequently caused harm to patients or delayed their discharge. Overall, this thesis has identified significant variability in the quality of care for emergency general surgical patients in structure, process and outcomes. While the thesis does not evaluate every single aspect of patient care it demonstrates the degree of improvement required in emergency surgical care and provides some recommendations for future quality improvement.

Adverse events constitute a significant challenge for healthcare organisations not only in terms of their prevention but also in terms of their after-effects on the injured patients and the staff involved. This PhD aims to investigate the psychological impact of surgical complications on patients and surgeons on the basis that the operating room is one of the highest risk areas for serious adverse events. Chapter 1 presents background literature on the aftermath of patient safety incidents both from the patients’ and the healthcare professionals’ perspectives and outlines the gaps of knowledge in this area. Chapter 2 sets the scene for surgical complications and presents the limited existing data on patients’ and surgeons’ experiences of surgical adverse events. Chapter 3 provides an overview of relevant theoretical frameworks for the investigation and discussion of the psychological impact of surgical complications on patients and surgeons. A systematic review of the literature on the psychosocial impact of surgical complications on patients follows in Chapter 4. Chapters 5 and 6 present two empirical studies on surgeons’ experiences of surgical complications. Chapter 5 reports an interview study with 27 surgeons which yielded a range of themes relevant to the personal and professional impact of complications on surgeons, the factors that affect their reactions, their coping, their perceptions of support as well as their perceptions of the institutional cultures in the aftermath of serious complications. Chapter 6 presents a cross-sectional survey study, which aims to quantify the psychological effects of serious surgical complications on surgeons and to identify their psychosocial correlates. Chapters 7 and 8 focus on patients’ experiences of surgical complications. A two time-points interview study with 17 surgical patients who experienced complications of various levels of severity is reported in Chapter 7. This study presents findings relevant to the psychosocial effects of surgical complications on patients, the factors that affect their reactions as well as issues of patient-surgeon communication around complications. Informed by the findings of the systematic review, the patient interview study and relevant literature, a longitudinal cohort study on the psychological impact of surgical complications on patients and the psychosocial predictors of this impact is presented in Chapter 8. Chapter 9 presents an online survey study with patient safety managers on the management of the aftermath of serious patient safety incidents in the NHS. This study investigates how the aftermath of patient safety incidents is managed by NHS organisations and describes the support that is typically available to patients and healthcare staff. Chapter 10 ends with an overview of the key findings from each study, their methodological limitations, directions for future research and implications for supporting surgeons and patients in the aftermath of surgical complications.

Organisational resilience in healthcare is important if hospitals are to recover effectively from unexpected events, such as infection outbreaks and manage successfully the continuous pressure from hospital associated infections. Yet studies of resilience in hospital organisations are rare and organisational resilience theory is insufficiently developed. The aim of this thesis is to examine organisational resilience in UK acute hospitals, through a case study and empirical analysis. The objectives are to investigate what is known about the concept, associated factors and application of organisational resilience to hospitals, to explore theoretically and empirically the two contexts for organisational resilience (expected conditions and unexpected events) and finally to design and test a tool to measure organisational resilience in the context of an unexpected event. A multi-methods approach was adopted to examine organisational resilience. A literature and systematic review were carried out to establish the evidence-base for organisational resilience. These reviews informed two health care studies of organisational resilience; a micro and meso-level case study exploring an unexpected infection outbreak and a macro-level study assessing the system response to infections as continuous stressors on routine practice. The case study informed the design and testing of an organisational resilience questionnaire. The key contributions to the literature were: firstly a novel multidisciplinary resilience questionnaire from which a framework of organisational resilience constructs was developed; secondly, a modest theoretical contribution of an intermediate resilience category within a framework that identifies levels of resilient practice and associated sensemaking characteristics; and thirdly, a positive example of ICT-enabled national surveillance programmes that increased hospitals' resilience to infection through the enrolment of clinical leaders in self-surveillance. In conclusion, this research has generated novel, empirically-derived theoretical developments to this field of study that facilitate the measurement, application and improved conceptualisation of organisational resilience.

Resuscitation is the process medical teams use in an attempt to save a patient’s life when they have suffered a cardiopulmonary arrest. It is a stressful, time-pressured procedure, and unfortunately is often futile. Care of a patient in the emergency setting is particularly prone to errors and adverse events for a variety of reasons. These include the time-pressured decision making, increased rate of patient interventions, and the fact that teams are “assembled” by the emergency call that may have never worked together, or even met each other, before. Recent analysis of incident reports specifically from resuscitation attempts suggests that the majority of incidents relate to issues with the resuscitation team, problems related to human performance, and incidents relating to malfunctioning or absent equipment. One of the aims of this thesis is to look at ways to address these issues, and reduce rates of adverse events and critical incidents at resuscitation attempts. I will specifically look at the areas of non-technical teamworking skills, team training with environmental risk assessment, and the design of ergonomic equipment. In Chapter 4 I will describe the process of development and evaluation of a tool to assess non-technical teamworking skills in resuscitation teams. When this tool was initially developed, no other tools had been published. However, another tool has subsequently been made available, therefore in Chapter 5 I will compare our tool, OSCAR, with this other tool, called TEAM. In Chapter 6 I describe the process of in situ simulation for resuscitation training. I organised resuscitation team simulations as part of a training programme, and gathered participant feedback on the training. I also describe some of the unanticipated benefits of this training, such as risk assessment of the ward environment. In Chapters 7 and 8 I describe two studies that were undertaken to evaluate the newly designed Resus:Station. Specifically I assessed its use during simulated cardiac arrest scenarios, and when nursing staff performed a stock check of the trolley.

As frontline clinicians, junior doctors (trainees) are being increasingly recognised as powerful agents for change in improving patient safety. However, routine postgraduate medical education (PGME) offers little opportunity for trainees to develop the requisite knowledge and skills to advance safety improvement efforts. This thesis aims to build on the evidence base for patient safety education by developing and evaluating educational interventions informed by users, the existing literature, and educational theory. Section One (Chapters 1 to 3) sets the context for the thesis, providing an introduction to patient safety, relevant educational theory, and the role of education and engagement in improving patient safety. Subsequently, Section Two reports exploratory research to inform the development of a patient safety course for Foundation trainees – junior doctors at the very start of their careers. A systematic review reveals how the UK lags behind international efforts to deliver patient safety education for trainees, and highlights the need to address barriers to its sustainable integration into medical curricula (Chapter 4). An analysis of Foundation trainees’ portfolio entries demonstrates the feasibility of using patient safety incidents (PSIs) experienced by trainees as the basis for learning about patient safety (Chapter 5). Drawing on these findings, Section Three reports the development and evaluation of ‘Lessons Learnt: Building a Safer Foundation’. This is a novel patient safety programme designed to formalise the opportunity for all 1000+ trainees across a Foundation School to learn from PSIs in a structured, facilitated forum. The development and delivery of the programme is first described (Chapter 6), followed by empirical studies to develop senior faculty (Chapter 7), and to evaluate the impact of the programme on trainees’ learning both qualitatively (Chapter 8) and quantitatively (Chapter 9). In Section Four, a different approach is taken to explore non-technical skills (NTS) training for more senior trainees. A tri-continental interview study of 33 surgical team members underlines the need to improve debriefing as a core NTS in Surgery and explores the user perspective on effective debriefing in surgical training (Chapter 10). These findings are used to inform the development of the ‘SHARP 5-Step Feedback Tool for Surgery’ and to evaluate its impact through observation of 100 surgical cases (Chapter 11). A number of conclusions are drawn from the research. Patient safety education is well accepted by trainees and trainers alike, and results in improved safety competencies across knowledge, skill and behavioural domains. It is feasible to embed a large-scale patient safety programme into PGME and to engage senior doctors to support its delivery. Overall, these findings suggest that patient safety education not only improves ‘safety skills’ at an individual level, but may also promote the safety of the wider healthcare system through enhancing medical engagement in patient safety and fostering cultural change. The concluding Section (Chapter 12) summarises the findings in detail. Strengths and limitations of the research are discussed, and recommendations are drawn for accelerating the integration of patient safety education into PGME.

Hospitalised patients are most likely to suffer harm in the operating theatre. Non-technical and team skills have been identified, and are increasingly recognised, as critical to safety and efficiency in the operating theatre. Despite increasing awareness of the importance of these skills to patient safety, education, training and assessment is lacking. The overarching aim of this Thesis is to facilitate and accelerate the integration of these skills into the education, training, and assessment of operating theatre teams by addressing a number of challenges related to this endeavour. An introduction to patient safety and the core non-technical and team skills that underpin expertise and safety in the operating theatre is presented, providing the theoretical basis for this work (Chapters 1 & 2). A systematic review on the impact of non-technical skills on technical performance in surgery is presented (Chapter 3), underlining the need to integrate these skills into the education, training and assessment of operating theatre teams. The empirical work of this Thesis is then reported. An observational study exploring stress and teamwork in the operating theatre is presented (Chapter 4), increasing our understanding of the factors that facilitate and impede teamwork in the operating theatre. To ensure the robust assessment of teamwork in the operating theatre, the formal content validation and refinement of the Observational Teamwork Assessment for Surgery (OTAS) tool is reported (Chapter 5). This is followed by an observational study exploring team performance at specific operative stages, as well as in multiport versus single incision laparoscopic surgery (Chapter 6). Chapters 7-8 report the development of guidelines, based on expert consensus, to train faculty in the assessment of non-technical and teamwork skills, an essential feat if non-technical and team skills are to be successfully integrated into the training and assessment of operating theatre teams. Chapter 9 reports the development, piloting and evaluation of a programme, based on the findings of Chapters 7-8, to train faculty to assess teamwork in the operating theatre. Finally, Chapter 10 provides a general discussion of the work presented in this Thesis, reflecting on the findings and the wider evidence base. Implications for clinical practice, patient safety and future research are explored.

Healthcare managers have a responsibility for the standard of their services and patient care delivered. Their work is thought to be essential in achieving and improving high quality care and patient safety. However, little is empirically known about their role in this. This thesis investigates acute care managerial work and impact in the context of quality of care and patient safety. It draws upon power and work-activity group theories and literature from other industries to guide investigation and elucidate findings. The introductory Chapters (Chapters 1-3) provide the background context of quality of care and patient safety, relevant management theory, and literature on the role of acute care managers in quality and safety. A systematic literature review in Chapter 4 illustrates a case for empirical research on this topic and suggests areas for further investigation. Chapters 5 and 6 report a case study investigation of the senior manager’s dimensions of involvement in a quality and safety improvement collaborative. These Chapters present self-reports of 17 Chief Executive Officers and 18 Medical Directors across 20 NHS hospitals on their actions and contributions to the UK Safer Patients Initiative (SPI). From this, a model of five principle dimensions of involvement emerged. Corroborating this model, Chapter 7 reports the staff perspective of their senior managements’ role in SPI, comprising interviews with 36 staff also involved in the SPI programme across the 20 hospitals. To explore the work of the acute care middle manager in quality and patient safety, 36 interviews with general managers, service and divisional managers across two NHS Trusts and two specialities reveal their relevant training/learning, demands, choices and constraints (Chapter 8). This informed two follow up surveys that further quantified the interview findings and explored theoretical power and role constructs. The first survey presents the views of 100 middle managers from 10 NHS Trusts on their quality and safety-related time, learning, activities, power and impact (Chapter 9). The second survey reports 60 clinical staff views on the same items, illustrating some divergence on critical constructs (Chapter 10). The thesis closes with a final Chapter (Chapter 11) comprising a summary of the key findings per Chapter and the overarching themes from the thesis. Methodological limitations/strengths, wider implications for managers and policy makers, and future research are considered. The Chapter ends with concluding remarks on the critical work performed by acute care managers across organisational levels for the daily preservation of quality and patient safety and its improvement.

Cancer care in many countries is delivered by healthcare professionals working together as multidisciplinary teams (MDTs). In the UK the delivery of care by MDTs is mandatory. The aims of the research reported here were to investigate the factors that affect the quality of clinical decision-making in MDT meetings, to develop and evaluate tools to measure this process, and to use these tools to evaluate interventions designed to improve the quality of such decisions. The introduction presents an overview of the evidence for clinical decision-making in MDT meetings, before Chapter 2 provides a critical appraisal of existing evidence, focussing on specific factors that affect decision-making by MDTs. My first empirical Chapters have explored the attitudes and experiences of MDT members and patients. Chapters 3 and 4 present analyses of national survey data that explore the views of MDT members from different professional groups across a range of tumour types. Chapters 5 and 6 present data from in-depth exploration of the views of urology MDT members and cancer patients respectively. Chapters 8 and 9 present data from studies that develop and cross-validate an observational tool for the assessment of decision-making in MDT meetings (MDT-MODe). I have used this tool in Chapter 10 to assess the relationship between organisational factors, information use, teamworking and decision-making in urology MDT meetings. Having built up a picture of the factors that are important for good decision-making, Chapter 11 reports a study that uses MDT-MODe to evaluate a multistage intervention to improve the quality of decision-making in urological MDT meetings. Finally, my general discussion reflects on the findings and the wider evidence base, explores the limitations and presents implications of my work for clinical practice, patient care, future research and policy.

In recent years safety in medicine has been high on the agenda, both for government and for healthcare providers. This thesis starts by describing the evolution of patient safety and then goes on to explore error specifically in the Emergency Department (ED). Focus is drawn to the role of non-technical skills for improving safety. The initial broad aim of this research was to learn how the ED team could function better to improve patient care. An interview study is developed to investigate how ED staff change their behaviour during periods of high demand and to determine the direction of future research. This study highlights that staff would benefit from increased awareness of the nontechnical skills that contribute to effective teamwork and enhanced patient safety. The interviews also reveal the leadership role of the registrar is of particular importance. Therefore, a series of studies are developed to identify and describe the non-technical skills required by Emergency Medicine trainees, with a specific focus on leadership. The process of developing a provisional assessment tool for assessing non-technical skills in the ED is described. This draws on published literature and curricula as well as considering existing methods of assessment. The assessment tool is revised using re-analysis of staff interviews and a series of preliminary observations in the ED. Content validity of the tool is measured using a survey of expert opinion and this helps to further refine the tool components. An experimental study reveals that whilst adequate levels of inter-rater reliability are achievable, rater accuracy appears to be more problematic. Various sources or rater error are also explored and this leads onto a larger, multicentre observational study investigating use of the tool in the workplace. Further data for reliability is collected and field notes are analysed to provide a detailed description of the non-technical skills displayed by ED registrars. Findings of the studies are summarised and limitations, applications and further research are discussed.

Effective Information transfer and Communication is one of the key aspects of good medical practice and essential for surgical safety. High reliability organisations such as aviation have highlighted the importance of communication for safety and regularly provide communication skills training to their team members via Crew resource management (CRM) module. This report discusses important aspects of communication research in high-risk environments and confers its application in surgery. It analyses the nature and scope of communication failures in surgical field. The thesis has taken bottom-up approach unlike other research in this field, which has taken a top-down approach. First we have mapped and analysed the communication failures across the entire surgical pathway. Analysis of full pathway is critical as communication failures are not discrete events; information loss in one phase of care can potentially compromise safety in a subsequent phase. After the analysis, user-centred interventions were developed and implemented to enhance the information transfer and communication in the postoperative handover phase. Results show that information transfer and communication failures are ubiquitous and distributed across the continuum of surgical care. These findings indicate that there is a room for improvement for enhancing ITC in surgical care. There is an imminent need for standardizing and structuring communication through use of checklists, proformas, care pathways and information technology. Subsequently we have demonstrated that standardization of ITC process through the implementation of postoperative handover proforma has improved the information transfer and decreased the ITC errors. It is hoped that this thesis provides a first step towards understanding, assessing and improving information transfer and communication through entire surgical care pathway, which in a long run will improve surgical safety.

Childhood immunisation effectively protects personal and public health, but a sizeable minority of parents actively reject vaccines for their children. This Thesis explores how parents decide whether to have their children immunised, in order to inform efforts to improve immunisation uptake. A consistent profile of beliefs relating to vaccine rejection emerged across a systematic review of existing evidence, a semi-structured interview study (n=24), and two evidence-based questionnaire studies (n=900), which all focused on the measles, mumps and rubella (MMR) vaccine. Vaccine-rejecting parents doubted vaccine safety and efficacy, mistrusted health professionals and immunisation policy, perceived ‘pro-vaccine’ bias in most available information, believed most vaccine-preventable diseases are mild and uncommon, and were not motivated by the potential social benefits of MMR uptake. The review also indicated several pervasive methodological flaws in the evidence – including retrospective designs, parent-reported outcomes, and lack of multifactorial models – which were remedied in the new empirical work. Three behavioural experiments (n=703) were then used to explore the influence of this belief profile on immunisation decision-making under controlled conditions. These experiments indicated that the belief profile was less influential when decision-makers mistrusted vaccine providers and policy, were generally anxious, or sought to assimilate multiple belief profile factors on the basis of limited information. They also showed that information processing limitations and biases may influence decisions independently of information content, and accordingly written risk communication method was found in the final study (n=42) to impact on outcomes even after adjusting for information content. These findings indicate that parents’ immunisation decisions are typically not borne of simple vaccine versus disease risk-benefit analyses. Interventions to increase trust in the immunisation system and to communicate the social desirability (and normality) of vaccine acceptance may improve immunisation uptake and support informed, satisfying decision-making.

Older people, often frail with multiple co-morbidities, constitute the largest proportion of hospital inpatient populations. Yet existing ways of measuring the quality and safety of care that they receive are not usually designed with the unique problems encountered by this vulnerable population in mind. The aims of the work presented in this thesis were to investigate what is known about the types, incidence and causes of safety and quality issues in older medical inpatients, to develop and test novel tools to measure the safety and quality of care that they receive and finally to design and test interventions to improve care. In Section 1 of the thesis (Chapters 1 and 2), an introduction of patient safety and quality in older people is presented, with an overview of current strategies for measurement and improvement, and the rationale for undertaking this research. Section 2 (Chapters 3 - 5) contains three exploratory studies in which different approaches (a systematic review of the literature and re-analysis of the major adverse event studies, a qualitative study involving staff who are involved in the care of older people, and an exploratory retrospective case record review) were used to produce an overall picture of safety and quality issues in older medical inpatients. This information was used to develop two novel case record review tools (the “Long tool” and “COMPACT”) to measure the quality and safety of care in older medical inpatients, using a combination of outcome and process measures. Section 3 (Chapters 6 and 7) describes the development and testing of these tools. Next, Section 4 (Chapters 8 and 9) of the thesis consists of two studies which were designed to provide the basis for further safety and quality improvement work in older medical inpatients. In Chapter 8, an investigation of the importance and trainability of safety skills (attributes of the safe practitioner) that may form the basis of a template for future patient safety curricula is described. In Chapter 9, a different improvement approach is described - the development and use of a multidisciplinary goal sheet on a medicine for the elderly ward, its effect on quality of care as measured by COMPACT, on staff perceptions of the incidence of adverse events, teamwork and communication, and on goal understanding. Finally, the discussion (Section 5, Chapter 10) reflects on the overall findings, strengths and weaknesses of the studies, and implications for clinical practice and future research.

Over the years the NHS has made great strides towards engaging patients in their healthcare management. In more recent years, the way in which patients could help to improve patient safety by reducing/preventing rates of medical errors has been highlighted. However, despite growing recognition of the valuable role of the patient in improving patient safety, very little is known about patients’ preferences for taking on an active role. This thesis aims to address the current gap in the evidence base with specific reference to a hospital inpatient cohort. Review work and a series of empirical investigations were undertaken which examined patients’ willingness and ability to participate in a range of safety-related behaviours. In total, empirical data was collected from 580 medical and surgical inpatients, using quantitative and mixed-method approach methodologies. A number of conclusions can be drawn from the research. Patients were more willing to engage in long standing safety recommendations than those practices which are newer or unfamiliar to the patient. Patients were particularly reticent to engage in those behaviours that they perceive as challenging the clinical abilities of healthcare staff. Several strategies appeared to be effective for encouraging patients to participate in safety-related behaviours: namely, patient-focussed leaflets or videos, or by patients being given encouragement from the doctors or nurses involved in the patient’s care. Overall the work in this thesis strongly suggests that while there is much to gain from involving patients in safety-related aspects of their healthcare management, patients need to be educated about how to be involved and where they can access safety-related information resources. In addition, doctors and nurses can have a pivotal role in encouraging patient involvement. Thus, it is paramount that both patients and healthcare professionals support patient participation in this area and healthcare professionals actively encourage the involvement of the patient.

This PhD thesis addresses the question of how we define, measure and improve surgical judgment and decision making, and how junior surgeons may be trained in these skills. The introduction to the thesis outlines the importance of surgical decision making, and the rationale for undertaking this research. An overview of relevant cognitive psychology research is presented, and the methodologies used in the experimental chapters of the thesis are described in detail. The introduction concludes with a systematic review of published empirical work on surgical decision making. The first two empirical studies are qualitative in nature, using interviews and simulation. They address how we define surgical decisions and their relationship to the process of care, including how surgeons subjectively view their own decision making, and whether we can draw inferences from observation of the process in action. Subsequent experimental chapters focus on the measurement of the quality of judgments of risk - a pre-decisional process in which likely outcomes of surgery are evaluated and estimated. Judgment analysis methodology is used to measure surgeons' performance at estimating surgical risks, with evaluation of whether the method shows construct validity, and whether feedback derived from judgment analysis tasks can be used as a teaching tool. The final empirical section of the thesis develops the theme of training junior surgeons in understanding risk and becoming better decision-makers. The process of developing, piloting, implementing and evaluating of a course module aiming to improve surgical trainees' approaches to decision making is presented. Finally the discussion reflects on the strengths and weaknesses of the studies, and outlines the implications of the work for clinical practice, training of junior surgeons, and future research.