Reframing clinical governance: policy and practice in aged persons mental health
AffiliationSchool of Health Sciences
Document TypePhD thesis
CitationsCharleston, R. (2011). Reframing clinical governance: policy and practice in aged persons mental health. PhD thesis, School of Health Sciences, The University of Melbourne.
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© 2011 Dr. Rosemary Charleston
This study examines the translation of Clinical Governance (CG) policy into risk practices into Aged Persons Mental Health (APMH). CG is the system in which clinicians and governing bodies share responsibility and are held accountable for the delivery of safe quality health care. Policy indicates that it is the health care organisation's responsibility to embed CG as 'everyday business', ensuring that this is not just an optional 'add-on' for care provision. However, since its inception, CG has received mixed reviews both in Australia, and internationally. It is emphasised that CG must be driven through all levels of an organisation, not just emerge as a whole new bureaucracy of its own. The relationship between effective CG and positive consumer outcomes make this especially pertinent in Aged Persons Mental Health. In Australia, Aged care services collectively assist over one million older adults. Although there have been improvements in the range and quality of aged care services over time, several key weaknesses remain. For example, workforce shortages (including the higher than average age of the workforce), uncompetitive wages and over-regulation, and the variable quality in terms of service provision, all hinder improvement initiatives in some way. Additionally, APMH (as in other areas of health) also experience the need for a larger workforce in the context of an ever shrinking pool of recruits. The retirement of the 'Baby Boomers', with their higher expectations of health care, will also place additional pressure on aged care services in the future. More importantly for CG however, is that the system will be challenged by a substantial population increase overall; one that is expected to bring with it increasing diagnostic complexity for the older adult. Consequently, the broad aim of this research is to understand if, and how, clinical governance policies influence risk management practices in APMH. More specifically, this thesis explores the: degree of understanding of CG between the various participant groups; range of facilitators and inhibitors to CG implementation; and possible improvement strategies for embedding CG into practice. A qualitative design was considered appropriate in order to fulfil these aims, which resulted in the development of a three-staged approach. This ensured that data was triangulated from multiple perspectives, with the study strengthened further by using a variety of data collection techniques (including individual and group interviews, and document analysis). Information from three distinct participant groups was obtained across the three stages. Specifically, interviews were carried out with Policy-makers and Organisational Implementers. In addition, the views of clinicians in APMH residential care facilities were sought via case studies. A comprehensive document review of Australian CG policy was also conducted. Collectively, the qualitative approaches of Miles and Huberman, Scott, and Kurland, then provide a framework from which to understand and present the findings. As a result, perceived deficits in knowledge, communication and leadership were identified as barriers to the effective translation of CG policy into practice. Furthermore, the heavy managerial reliance on the risk component of the model (including documentation and reporting) to the perceived detriment of other aspects, was also considered to be problematic. In summary, these findings suggest that the true value of CG may be lost if restricted to mandated ‘tick-box’ reporting, rather than being strengthened by an approach that conceptualises and promotes CG in a way that clinicians understand. Ultimately, if change fails to occur, attention may be diverted away from the quality of care that CG was originally intended to support. Finally, this research provides a new perspective from which to consider the facilitators, limitations, and strategies for improving the translation of CG into risk practices in APMH. A new model for reframing the existing CG approach, and addressing these issues in APMH, is put forward.
Keywordsolder people; mental disabilities; care; Australia; government policy; quality control; psychiatric nurses; psychiatric nursing; clinical competence
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