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To describe the genomic analysis and epidemiologic response related to a slow and prolonged methicillin-resistant Staphylococcus aureus (MRSA) outbreak.
Prospective observational study.
Neonatal intensive care unit (NICU).
We conducted an epidemiologic investigation of a NICU MRSA outbreak involving serial baby and staff screening to identify opportunities for decolonization. Whole-genome sequencing was performed on MRSA isolates.
A NICU with excellent hand hygiene compliance and longstanding minimal healthcare-associated infections experienced an MRSA outbreak involving 15 babies and 6 healthcare personnel (HCP). In total, 12 cases occurred slowly over a 1-year period (mean, 30.7 days apart) followed by 3 additional cases 7 months later. Multiple progressive infection prevention interventions were implemented, including contact precautions and cohorting of MRSA-positive babies, hand hygiene observers, enhanced environmental cleaning, screening of babies and staff, and decolonization of carriers. Only decolonization of HCP found to be persistent carriers of MRSA was successful in stopping transmission and ending the outbreak. Genomic analyses identified bidirectional transmission between babies and HCP during the outbreak.
In comparison to fast outbreaks, outbreaks that are “slow and sustained” may be more common to units with strong existing infection prevention practices such that a series of breaches have to align to result in a case. We identified a slow outbreak that persisted among staff and babies and was only stopped by identifying and decolonizing persistent MRSA carriage among staff. A repeated decolonization regimen was successful in allowing previously persistent carriers to safely continue work duties.
A new policy environment and new organisational arrangements should make co-operation and collaboration easier than it has been in the past. But real success will depend as much on the determination and creativity of practitioners and managers as it will on Government edict and structural change. (Poxton, 1993: 3)
This chapter opens with short overview of public management, focusing on its context and character, capturing the role of public managers in general operating in this environment, and specifically highlighting any references to the behaviours of middle managers. It proceeds to review the diverse and interdisciplinary contributions that form the theoretical backcloth to collaboration, before proceeding to examine the literature on management between organisations and the role of individual actors in this setting.
The purpose of this opening section is not to indulge in a lengthy discussion around the contested notion and nature of public management that can be readily found in numerous textbooks (Lynn, 2006; Osborne, 2010a), but simply to outline some relevant background to support and frame some of the later discussions addressed in this book. Historically, the design and delivery of public policy and management have been characterised by a number of dominant approaches – from Public Administration to New Public Management and, arguably, to New Public Governance – although in practice differences between these can be confused (Table 2.1).
The focus of public administration is on the delivery of public services prescribed by legislation, with public administrators governed by various rules and procedures. Here, there is a clear divide between politics and the administration; bureaucracy is central to making and delivering policy; and the role of professionals is dominant, reflecting the ‘institutionalisation of the impartial expertise necessary to meet the complex, technical needs of the modern state’ (Lynn, 2006: 260). In contrast, public management is driven more by public purposes and the process of strategic choice (Ranson and Stewart, 1994: 34), and where management tasks involve policy planning, staff development, organisational development, engaging with the public, and reviewing and evaluating practices. Management is seen as a craft and the product of actions and decisions of public managers. Bovaid and Loffler (2003: 5) define public management as: ‘an approach which uses managerial techniques to increase the value for money achieved by public services‘.
Well, now, here's the thing about trust. There's nothing to it. Trusting people is simply a matter of ignoring your best instincts and all your experience and suspending belief. The fact is, the only way you can ever be sure if you can rely on someone or not is to go ahead and rely on them. But that doesn't always work out so well. People usually behave like people and let you down and that's that. Of course, if you know they’re going to let you down then you won't be disappointed. (Kerr, 2018)
There is a keen debate as to whether particular organisational structures and frameworks enable or obstruct collaborative working, or whether outcomes are largely dependent upon agency – the commitment and behaviour of like-minded managers and other actors working together to achieve results that could not be realised by them acting independently. Certainly, a strong consensus of views from a wide range of middle managers in my research in Wales comes down on the side of agency, as is suggested by this selection of opinions:
• “You can have the best, most effective and streamlined structures, but if people can't trust each other, any partnership will fail.”
• “The thing that makes it work in any type of structure is the commitment of the person – structures can be enabling or difficult.”
• “It isn't about organisations getting on with one another, it's individuals sitting around a table. It's about trust between individuals – me knowing who to contact, who is going to be an ally and who I need to work on; each individual has his/her reputation; I’m someone who says it, and does it; I am straight to the point and tell it as it is; people need to be prepared to put the energy into personal relationships – it's about finding people who want to talk and nurturing that relationship; that's the way to influence people.”
• “Honesty is what sees relationships through tough times” and “I have to look my colleagues in the eye knowing I haven't pulled the rug from under their feet.”
In a study of a cadre of middle managers in a Welsh local council, the essence of working effectively in collaboration was widely considered to be dependent upon building and sustaining relationships with all the stakeholders involved.
“There is always a bit of ‘giving your own kids away’ in collaboration and a consequent feeling of loss of control and power.” (Local Council manager)
The very essence of collaboration lies in the quest for common purpose among participating actors and organisations. Without such an understanding, this type of endeavour is doomed to failure. It is critical, therefore, for middle managers who are engaged in this form of working, to fully appreciate what is involved in ‘managing for common purpose’, what form it takes, and how it can be developed and sustained at different levels – personal, professional, organisational and sectoral.
Understanding what might constitute ‘common purpose’ derives from the diverse motivations underpinning the drive to collaboration. These can broadly be grouped under three forms – efficiency, effectiveness and responsiveness. The efficiency discourse relates to the need to make the best use of limited resources – particularly financial – and is especially prominent in the austere times of countries such as the UK over recent years. Local councils in England, for instance, have had their budgets reduced by roughly 25 per cent between 2010 and 2017. Other public authorities such as the NHS have experienced equally challenging financial difficulties – exacerbated by the ever-rising demands upon its services. It would appear a ‘no-brainer’ to many, that such a situation would be a catalyst for agencies looking for ways in which they might pool/share/combine their resources to make the most efficient use of them – especially when they often serve the same clients and operate in matching geographical areas. Countless examples of this happening can be evidenced, but the downward financial pressure on some organisations is not always a fillip to collaboration. Paradoxically, the reverse can occur where managers and organisations consider that working in collaboration is too risky and time consuming with outcomes that are not guaranteed. So, rather than providing a stimulation to collaboration – ever increasing financial pressures can result in a withdrawal from existing initiatives and a reluctance to venture into new ones. This can be underpinned by a need for some authorities to seek to fulfil at all costs their statutory duties in relation to particular services. Failure to deliver on these can be a source of embarrassment and legal risk.
Even those career executives who have a singular agency focus (and there will always be some) will have to be able to demonstrate the ability to lead across boundaries as the things government does become more and more interconnected, co-produced, and net-centric. (National Academy of Public Administration, 2007: 303)
The factors and determinants that shape and influence the course of collaboration are highly complex and interrelated. They are nested in a multifaceted and tangled web consisting of contextual, governance and agential elements – context shaped by institutional and structural factors, legislative arrangements and statutory duties, financial regimes, broader economic and social drivers, and local history of collaboration; governance moulded through culture, decision-making structures, accountability and performance management frameworks, and role and purpose; agency manifested through leadership, professionalism, experience and personal characteristics of public leaders, practitioners, politicians and managers.
The focus of this book lies squarely on the role and contribution of ‘middle managers’ in this mosaic of collaborative machinery. Previous chapters have examined some of the theories and research available on this subject, and presented additional insights particularly from my own research studies in this area. This chapter responds to the ‘so what does this mean for policy and practice’ question. What lessons can policy makers and practitioners take from this analysis to help shape the design and delivery of future collaborative interventions, and how might it inform the progress and trajectory of existing management practice? In particular, it explores some of the implications of this book for learning – for the education, training and development of middle managers. As a general statement, the thrust of middle management training and development is still heavily biased towards intra-organisational management and not managing in collaboration. This might be considered somewhat perverse given the exponential growth of collaborative working which is likely to be sustained into the future. A report of the National Academy of Public Administration (2007: 273) was stark in its message that:
The reality is that…senior executives (SES members and otherwise) are almost exclusively agency-centric in skill set and mindset, as functionally and organizationally stove-piped as the government itself. Most have remained in the same agency for their entire careers, often promoted for their technical skills and never venturing across (much less out of) the Federal enterprise to broaden their experience or their expertise. The result: few are equipped to lead the whole-of-government enterprise.
Managing interorganisational networks is unquestionably a difficult job. At the least, it is most certainly a different job that requires different skills. (Kettl, 2006: 16)
This chapter explores some of the existing evidence and contested positions around the contrasts and comparisons between managing within the confines of organisations, as opposed to managing between organisations in forms of collaboration. Researchers and practitioners come to various conclusions on the key questions relating to the extent to which managing in collaborative forms of governance requires a unique form of management or not, and if so, the skills and competencies middle managers need to be effective in this form of management. Figure 6.1 suggests that these can be crudely mapped across a spectrum of positions from those who see it as broadly the same, those who judge it to be not quite the same, and those who see it as definitely different.
The school of thought that considers that management in the two forms of governance is different, takes the view that this stems from broadly contextual reasons relating to the form, structure and purposes inherent in the respective contexts. The consequence being that the management and behaviour of middle managers needs to be different. O’Toole and Meir (2010: 324) underscore this perspective in their observation that:
inducements to and constraints inhibiting cooperation across organisational boundaries in networked and collaborative settings are different from – and typically more challenging than – generating successful cooperative implementation via unified organisations. Authority is typically weaker in interorganisational situations, and encouragement toward cooperation must perforce rely less on established communication channels, routines, and shared worldviews than it does within hierarchical agencies.
The broad conclusions of my own research also consider that the central concerns and activities of management in each of the respective settings are fundamentally different, primarily because of the focus of management in the respective forms as illustrated in Figure 6.2. Middle manager's tasks and functions within their organisations revolve around human resource management and financial budgeting set within the boundaries of defined professionally based departments. In public service agencies, purposes and roles are often defined by statute, systems of accountability and performance management are prescribed through hierarchical structures, and power relationships and status are widely acknowledged.
No single actor, public or private, has the knowledge and information required to solve complex, dynamic and diversified problems; no actor has an overview sufficient to make the needed instruments effective; no single actor has sufficient action potential to dominate unilaterally. (Kooiman, 2000: 142)
Contemporary societies are faced with a seemingly neverending torrent of complex, stubborn and sometimes intractable problems and issues. These are diverse in nature, crossing time and space – they can be local, national, global or intergenerational – and their management and resolution challenges public agencies and governments to the utmost. Climate change, sustainable development, health inequalities, asylum seekers, terrorism and crime, poverty and exclusion, poor housing, unemployment and lack of educational attainment are but a few of these ‘wicked issues’ – but they all share a common thread – they do not respect conventional boundaries of profession, organisation and governance. Rather, they are entangled in a complex web of problem definition, causes, solutions, priorities and resources. What is most important is that it has been the increasing recognition by policy makers and governments over a number of years that the management of these types of problems and issues cannot be resolved by single agencies and actors operating independently, instead, they demand collaboration – forms of cooperative behaviour designed to secure the most effective, efficient and responsive outcomes for service users, citizens and communities.
The nature and trajectory of this collaborative imperative has been manifested in different ways in the UK and across the world, but there is little doubt that it will continue to shape the character of future public policy and management. Arguably, the enduring ‘age of austerity’ has placed increased demands upon public authorities to work together towards jointly agreed goals and outcomes. A considerable body of research and experience has been accumulated on the practice of collaboration in public policy. What is particularly apparent from this work is how complex and challenging it is in design and delivery, and most salutary of all, the evidence of its success is far from overwhelming. Researchers and practitioners have invested significant time and resources into endeavouring to understand what makes an effective collaboration – the determinants and factors that combine to deliver agreed upon outcomes. The evidence suggests that these are a complex interplay of both structure and agency, but with considerable debate as to their interaction and precedence.
This appendix is designed for use with students, policy makers, managers and practitioners in group discussion sessions such as workshops and learning sets. It is envisaged as a resource for academics and trainers who are keen to explore and facilitate discussion around the themes and topics considered in this book. The questions can be tailored to the needs of particular audiences, and are organised around the material, arguments and content stemming from individual chapters.
The following questions primarily concern notions of collaboration; the implications of the prevailing policy context; the nature, role and behaviours of middle managers; the skills and competencies of middle managers; inter-departmental working; understanding power and trust; and the challenges of collaborative working.
1. Identify the key features – social, economic, environmental and political – of the prevailing public policy landscape in your area. What are the implications of these for the manner in which public management is approached and organised, and the role that public managers perform?
2. What are the benefits of, and enablers and barriers to collaboration?
3. Is the notion of ‘collaboration’ clear or are there multiple interpretations of working together with other managers and organisations? Can you devise a typology of relationships, perhaps along a continuum, that characterise different expressions of collaboration?
4. What challenges and barriers do middle managers encounter in the course of discharging their roles and duties?
5. Catalogue and discuss the tensions, ambiguities and challenges of working both within and between organisations, and explore the strategies involved in managing them.
6. Consider the various sources of power you have as a middle manager working within your organisation, and then compare and contrast these with the sources of power you have working between organisations. Think of examples of how you use them and discuss the issues associated with them.
7. What shape will collaboration take in the future? What forces will drive it and will it increase in its intensity and scope? What will be the implications for approaches to public management?
8. Identify the ‘middle managers’ in your organisation. Do they constitute a clearly defined group of managers, and if so, what characterises them from other managers in your organisation? Alternatively, is the notion of a ‘middle manager’ too broad and captures many different types of manager at this level in the organisation?
Everything is connected – a global economy of haves and have-nots; rising regional, international, and transnational tensions; the explosion (pun intended) of two-edged technologies that can help us or hurt us, often at the same time; climate change and all of its adverse effects; inexorable demographic trends across the globe; the list goes on. (National Academy of Public Administration, 2007: 235)
Unquestionably, the crux of a middle manager's ability to engage effectively in collaboration is underpinned by an understanding of connections and the complexities and interdependencies that flow from them. This concerns knowledge of flows, relationships and linkages of various types over time and space – problems, organisational responsibilities, financial frameworks, governance and accountability systems and policies. The knowledge base centres on the system and how it is connected and works, and not so much on the individual constituent elements. Each middle manager participating in a collaborative is likely to provide some expertise/knowledge, but in addition, this needs to be accompanied by an understanding of how the collaborative system is structured and operates. The concept of ‘wicked issues’ provides one of the best explanations and justifications for collaboration – issues and problems that are cross boundary in character, socially constructed and not amenable to single organisations acting autonomously. Whether the problem is one of lack of educational attainment, poverty, crime and antisocial behaviour or sustainable development and cybercrime, the challenge for middle managers is to understand how elements are connected, and what these mean for potential collaborative engagements. Practitioners of collaboration often refer to ‘seeing the bigger picture’ or ‘understanding the jigsaw’ and how it fits together with a knowledge base of the connections and relationships – the public policy context, the organisations that are involved in delivering services around a particular wicked issue; the political and governance landscape; and funding possibilities. This narrative emphasises the ‘policy aspects’ of wicked issues but, as McConnell (2018) argues, it is also important to explore this notion through the lens of a ‘political approach’ that focuses on issues of reputation, political capital, the politics of managing dense and conflicting policy agendas and the promotion of ideological visions.
A middle manager in the Fire and Rescue Service in South Wales provides two practical examples from his policy area that demonstrate how he is able to make connections that benefit both his service and the services of his partners working together in a Community Safety Partnership.
Many of government's most important programs require effective horizontal communication and management, yet too much of government still operates within vertical silos that hinder horizontal collaboration. The government increasingly suffers from what we call an advanced case of bureausclerosis, caused by increasing administrative layers and walls between policymakers and the administrators charged with carrying out policy. (National Academy of Public Administration, 2017: 10)
This final chapter brings the book to a conclusion with a summary of, and reflections on the main themes, arguments and perspectives examined in this book. It aims to place this contribution within the existing literature, as well as setting out a future research agenda on this topic of study in terms of research questions, themes, methodologies and areas of study. This book has explored the implications of the changing face of public management, policy and governance on a particular cadre of public managers – the ‘middle managers’. It has not been a straightforward task to clearly demark and categorise this group of actors. The term ‘middle’ suggests a positional perspective that locates these managers in a particular tier within a traditionally organised bureaucratic organisation – sandwiched between a top tier of executives, and a bottom layer of primarily frontline professionals, administrative, support and clerical staff. However, middle managers can also be categorised by role, nature of work and activities. It has been argued that they represent a potentially influential group of actors who wield power and influence through their position and control over financial resources and staff. Their power is invariably underpinned by a professional grounding in a specific area of knowledge and expertise. Arguably, middle managers comprise the heart of an organisation, but their role is challenged by a myriad of tensions and competing accountabilities. Managing people and budgets, meeting targets and mediating between upward and downward pressures are uncomfortable facts of their working lives – hence, frequent complaints of being a member of the ‘squeezed middle class’.
The design and delivery of public services has been driven by different approaches over recent decades – moving from Public Administration to New Public Management and more recently to New Public Governance.
This important book examines the role, behaviours and management practices of middle managers operating within the context of collaboration, and sets out the implications of this research for policy and practice, offering practical recommendations to policy makers and managers working in this area.
To evaluate a relatively new half–face-piece powered air-purifying respirator (PAPR) device called the HALO (CleanSpace). We assessed its communication performance, its degree of respiratory protection, and its usability and comfort level.
Design and setting:
This simulation study was conducted at the simulation center of the Royal Melbourne Hospital.
In total, 8 voluntary healthcare workers participated in the study: 4 women and 4 men comprising 3 nursing staff and 5 medical staff.
We performed the modified rhyme test, outlined by the National Institute for Occupational Safety and Health (NIOSH), for the communication assessment. We conducted quantitative fit test and simulated workplace protection factor studies to assess the degree of respiratory protection for participants at rest, during, and immediately after performing chest compression. We also invited the participants to complete a usability and comfort survey.
The HALO PAPR met the NIOSH minimum standard for speech intelligibility, which was significantly improved with the addition of wireless communication headsets. The HALO provided consistent and adequate level of respiratory protection at rest, during and after chest compression regardless of the device power mode. It was rated favorably for its usability and comfort. However, participants criticized doffing difficulty and perceived communication interference.
The HALO device can be considered as an alternative to a filtering face-piece respirator. Thorough doffing training and mitigation planning to improve the device communication performance are recommended. Further research is required to examine its clinical outcomes and barriers that may potentially affect patient or healthcare worker safety.