School of Health Sciences
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Item Understanding the power relations in health policy implementation in Pakistan(Queen Margaret University, Edinburgh, 2016) Bajwa, FatimaPolicy implementation is a complex, technical and political process. It is shaped by the capacity of the government, political patronage, influence of diverse actors, power relationships, role of the state, nature of the political systems and their mechanisms for participation in the policy subsystem. Tackling the implementation gap is a health policy concern in Low and Middle Income Countries (LMICs). In these countries, governments frequently fail to achieve effective policy implementation. The government of Pakistan has over six decades introduced many health initiatives and plans to improve the health status of its population. Still, the implementation process remains arduous. To identify the implementation gaps and their drivers, forty-two semi-structured interviews were conducted with the key policy actors from general political sphere and health policy subsystem in Pakistan, to explore their knowledge, perspectives and experience. The key informants were mainly politicians, bureaucrats, health ministry officials, and technocrats from Islamabad, Punjab, Khyber Pakhtunkhwa and Sind provinces in Pakistan. The data was analysed using thematic analysis. This qualitative exploratory study using an inductive approach draws on the concepts of power, policy networks and path dependency. Findings suggest that the factors influencing the policy-action relationship in the health sector in Pakistan operate at two levels: actors and institutional or structural. Political history as a part of the structure plays an important role as well. The power relations within the health sector are a complex interplay of ideas, interests and incentives resulting in policy networks or iron triangles at different levels. The underlying power relations remain the same and policy implementation process is path dependent. Due to this, most health policies remain in long periods of stasis or equilibrium. The stalemate over these policies was seen because of the elitist system of interest groups' hold over policy choices. Frequently, policies are caught in a web of interests.Item Working in a storied way.The development and evaluation of a narrative based approach to practice development in an older adult residential care setting.(Queen Margaret University, Edinburgh, 2015) Buckley, CatherineThis thesis presents the development, implementation and evaluation of a methodological framework for a narrative based approach to practice development and person-centred care in residential aged care settings. The study is underpinned by practice development, person-centred care and narrative methodologies. Narrative focuses on a way of being, paying attention to past present and future, and also as a way of doing, as the means through which action is understood and made meaningful. Carried out between 2010 and 2014 and underpinned by theories of narrative inquiry, person-centred care, practice development and action research, this study is guided by the philosophical perspectives of Heidegger (1962). Forty six interviews, collected as part of a national research programme, (Person-Centred Care Practice Development Programme 2007-2010), were analysed for key themes by myself, four focus groups of 12 clinical nurse managers and two independent experts. Themes were also derived from a focus group of eight residents who explored person-centredness and narrative. Combined, this analyses led to a single set of themes that were used to develop a Framework of Narrative Practice. This framework consists of four pillars, prerequisites, care processes, care environment and narrative aspects of care. The framework further includes three narrative operational elements, narrative knowing, narrative being and narrative doing. Working with the four foundational pillars and the three narrative elements enabled staff to 'work in a storied way' and provide person-centred outcomes and a narrative informed philosophy of care for older adults. Using an action research approach with work-based learning groups, the framework was implemented in two residential care settings that were comprised of 37 residents and 38 staff. Three action cycles (1) narrative practice and culture identification, (2) developing narrative practice and (3) working in a storied way emerged during the implementation. Using these action cycles, staff developed action plans to address areas where changes could improve practice and quality of life for the residents. These plans included communication/intercommunication, homely environment, having more going on with and for the residents and meals and mealtimes. By taking account of their biography, the framework confirmed the identity of older people. Three key areas emerged, however, that warranted further conceptualisation. These were, how staff and residents responded to change (narrative being), development of shared understandings (narrative knowing) and intentional action (narrative doing).Item How do the characteristics of context influence the work of facilitators when implementing a standardised educational intervention targeting nursing home staff to reduce restraint in dementia care?(Queen Margaret University, Edinburgh, 2015) Mekki, ToneThis research is part of a larger study - a sequential mixed method education intervention targeting staff in 24 Nursing Homes (NHs) in Norway to reduce use of restraint and psychotropic drugs. Building on a previous successful intervention, we used the Promoting Action on Research Implementation in Health Services (PARIHS) prospectively to combine cluster randomized controlled trial, participatory action research (PAR) and ethnography to design and evaluate the effectiveness of 2 day staff education and 1 hour monthly coaching during 6 months in two rounds (12 x 2 NHs). In my research that is the primary focus of this thesis, four teams of eight facilitators facilitated the intervention and simultaneously participated in PAR to co-construct knowledge of hindering and promoting implementation factors. A 'Creative Hermeneutic Knowledge Co- Production' (CrHeKCoP) model blending paradigmatic and epistemological assumptions from critical and participatory worldviews was created and used in spirals of 10 mini-cycles of actions to co-construct knowledge of the implementation process.