Making sense of change in primary health care : a complex responsive processes perspective
This research arose from my curiosity about change, and my dissatisfaction with models and tools which do not explain my real life, messy, and sometimes disappointing, experiences of trying to instigate change. My aim, therefore, has been to explore what is it like to experience and make sense of change as it is happening in my working life as a Nurse Practitioner and Primary Care Trust Board member, in primary health care in the National Health Service. Essentially I argue that the dominant way of thinking about change assumes it is a "thing" to be planned and then applied. I believe the error is in thinking we can produce change as if we are in control of a system. An alternative way of thinking about change arising from my experiences is that it can only express our intention for the future but is not controllable in the way often implied. I also suggest change is experienced as movement in the present where, often with hindsight, we experience a shift in patterns of how we speak about or experience something. Early on, my search was for a way of explaining my experience of change by initially drawing on the theories of complexity, which point to emergent pattern which arises spontaneously from local interaction, without any external blueprint or plan. I then turn to the theory of complex responsive processes of human relating (Stacey et al, 2000) which views human interaction as itself inherently pattern forming and therefore ordinary everyday interaction as the source of change. I take the theory of complex responsive processes as the foundational theory for my research by asking "What is it like to experience change in primary health care from a complex responsive processes perspective? " My methodology, which is consistent with this perspective, focuses on my own experiences, as emergent exploration of experience (Stacey and Griffin, 2005). In other words I am reflexively exploring my own experience by using narratives, stories and analysis intertwined, to reflect as closely as possible the messy reality of the way we are continuously making sense of experience and change. My experience seeing patients in primary health care; managing a nursing team; and sitting on the Board of a Primary Care Trust highlights the emotional, fantasy laden aspects of experience which are often disregarded or viewed as common knowledge. Similarly, there are feelings of anxiety surrounding any change where my identity feels threatened and there are changes in power relating between people (Elias, 1939). I argue that tools, models and labels serve to relieve feelings of anxiety, by providing an illusion of control, but may in themselves also increase anxiety and block the potential for change. During the research, my own practice has changed by becoming more reflexive as I focus on my own participation, whilst adding further dimensions to the theory. Firstly, I argue that focusing attention in this way implies a heightened awareness of responsibility and potential for one's own actions. I cannot know the result of my actions but know that they may have some effect, large or small. Secondly, I argue that the dominant discourse may perpetuate the way change is viewed as a "thing" external to every day experience. Rather than focusing on control, process thinking conveys a different reality of continuous sensemaking. Lastly, I argue that focusing attention on feelings, emotions and the environment as simultaneous rather than separate aspects of experience becomes important when experiencing and making sense of change from this perspective. I argue, therefore, that a complex responsive processes perspective challenges the dominant perspective on change by providing a way of understanding which resonates with my experiences, has significant implications for my own practice, and validates paying attention to ordinary everyday experience in which change is continually emerging.