In an attempt to understand the effects of managerialism on university managers in a developing country, we set out to gather rich data on the strategy work of middle managers through a single case study at a South African university. Managerialism has the potential to solve inefficiencies in university systems and processes, as it could help to simplify the complex university management environment. Yet, our findings show that middle managers at the chosen institution are constrained by the effects of managerialism. Managerialism has resulted in a tyranny of bureaucracy which translates into disempowered middle managers, a culture of conformance over collegiality, control at the cost of innovation and experimentation and an over-articulation of strategy which devalues the strategy. To cope with the identified negative effects of managerialism, middle managers create their own systems outside the bureaucracy and provide more support to peers and subordinates.

In recognition of middle managers as influential strategists we collected 654 responses from South African middle managers detailing their spontaneous and unguided descriptions of their strategic roles in the organisation they represent. The results show that middle managers generally associate their strategic role strongly with the traditional perspectives on the roles as implementers of strategies and communicators linking their subordinates and higher levels of management. We add the roles of 'advocacy' and 'improving operational performance' to the conventional elements of strategy implementation, and the roles of 'managing performance' and 'driving compliance' to the role of downward influence. Focus group discussions contextualised and authenticated these roles within the South African private and public sectors.

Writing guidelines on procedural sedation and analgesia is a formidable and challenging task. There are many disciplines and societies at international level now involved in writing guidelines and we need to be aware of what they see as important in their guidelines. We always need to identify new trends in sedation; for that we need to be involved at international level. Our aim with these guidelines is to provide a guidance for safe sedation practice for all healthcare providers who are involved in sedation practice. In this issue we have added adverse events and record-keeping, accreditation and the importance of simulation training to our recommendations under clinical governance. We would like our sedation practitioners to keep records and report adverse events to our societies, e.g. SOSPOSA, so that we all can benefit from the information we get. It is also crucial that sedation practitioners keep their logbooks and update them regularly – “if it is not written down, it never happened”. All aspects of accreditation remain an important issue and we need to address this urgently. This forms an important part of safe sedation practice, also done at international level, and we need to follow this. The facilities where we work, especially outside the operating theatre, must meet the requirements for safe practice. It is our responsibility to see that this is the case. In the appendices there is a practice appraisal protocol that should be filled in by sedation practitioners doing sedation outside the operating theatre. We do not cover sedation techniques in the guidelines. We believe sedation practitioners must learn the techniques with supervised clinical training. Capnography for sedation outside the operating theatre will become a focus point in future. We are only supposed to be doing ASA I and II patients outside the operating theatre so there may be a feeling we do not need capnography. There is pressure to include capnography under monitoring as a minimum monitoring standard, like pulse oximetry and blood pressure monitoring. Our appendices have been revised with more information on what patients need to know about sedation e.g. an example of a cover letter to the patient. This will include information to the patient, as well as information from the patient. Sedation is today one of the fastest growing areas in anaesthesia care. Our research studies show a low incidence of side-effects, and a high incidence of patient satisfaction. To all our readers we wish you a safe sedation journey.

No abstract