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AbstractNew skills must be learned and a new self‐image must be developed by a clinician who assumes a middle management role for the first time.

AbstractEffective services for trauma survivors rely on addressing the support and care needs of clinicians and administrators.

Social workers in direct practice make policy decisions that have actual and potential effects on policy at various levels. These decisions, which are made in regard to ideology and intervention, may coalesce to affect policy for an agency, an agency-interagency group, or the broader community.

Is politically correct but is costly and lacks evidence to support it

The World Health Organization 'My five moments for hand hygiene' has been globally adopted and compliance with this practice has been the focus of this thesis. Face touching by healthcare workers may contaminate hands and become a transmission opportunity. The frequency of face touching was examined in medical students as healthcare workers' movements prevent continuous observations. 26 medical students observed over 4 hours demonstrated on average 23 face touches per hour. This frequency is high and healthcare workers should be made aware of this behavior and the need for hand hygiene after face touching to prevent potential transmission of pathogens to vulnerable patients. To improve hand hygiene and the 7 hand hygiene poses an automated training system to improve technique was introduced into a tertiary teaching hospital and used by 789 healthcare worker volunteers (79% of total staff). The highest pass rate, 77%, was with pose-1 (rubbing palm to palm) and the lowest pass rate, 27%, was with pose-6 (cleaning thumbs). The novelty of the training system was short lived with most, 95% to 99.8%, of all failed poses not being reattempted. The training system did not improve the hospitalwide compliance during the implementation period or 8-months post-training; 74% (95%CI 72%-76%) versus 72% (95%CI 71%-74%). To improve hand hygiene compliance by providing daily compliance rates an automated hand hygiene surveillance system was installed in the largest tertiary public hospital while quarterly mandatory human audits continued. The automated system identified compliance for the surgical ward at 49%, 38 percentage points lower than the quarterly audits. The automated system identified compliance on the medical ward compliance at 30%, 55 percentage points lower than the quarterly audits. After 4 months of daily feedback, the compliance improved by 17 percentage points on the surgical ward to 66% while compliance on the medical ward remained at 30%. Qualitative interviews identified the surgical ward culture was one of a strong socially cohesive team compared with the medical ward. Changing hand hygiene behavior and sustaining high compliance is challenging and the findings suggest social cohesiveness on the wards assists the diffusion of a hand hygiene program.

Maintaining social workers at management levels rests on their ability to develop programs, be aware of the stresses of front-line jobs, and be effective in distinguishing between the needs and wants of clients. However, to be effective as managers, clinicians have much to unlearn from their clinical training.

Health care is changing rapidly. Unacceptable variations in service access and quality of health care and pressures to contain costs have led to the redefinition of professional roles. The roles of nonphysician clinicians (nurses, physician assistants, and pharmacists) have been extended to the medical domain. It is expected that such revision of roles will improve health care effectiveness and efficiency. The evidence suggests that nonphysician clinicians working as substitutes or supplements for physicians in defined areas of care can maintain and often improve the quality of care and outcomes for patients. The effect on health care costs is mixed, with savings dependent on the context of care and specific nature of role revision. The evidence base underpinning these conclusions is strongest for nurses with a marked paucity of research into pharmacists and physician assistants. More robust evaluative studies into role revision are needed, particularly with regard to economic impacts, before definitive conclusions can be drawn.