The Struggle to Stay in Relation: How the Dominance of an Ideology of Certainty Marginalises Practical Judgment and Political Action, from the Perspective of a Senior Manager in the NHS

Abstract

In this thesis I explore my everyday work as a director of research in an NHS mental health trust. I use collaborative narrative autoethnography to explore episodes where research activity and evidence is contested, questioned, and sometimes causes conflict. In a health and care environment such as the NHS, it is often assumed that producing evidence of a high quality puts an end to politics and dispute. Drawing on the complexity sciences, pragmatism, and process sociology, I claim that, in addition to the scientific and bureaucratic rationality of evidence-based medicine (EBM), undertaking and using research is a complex and relational process that involves contestation and working with conflicting notions of the ‘good’. Evidence may be (more or less) clear about an area of practice, but producing research and deciding what should be done with it involves human, social, and political activities characterised by strongly held values, contested meanings, and conflicts. Through the research I have done for this thesis, I found that the production and use of clinical research in healthcare is dominated by an ideology of certainty, which manifests as EBM, and bureaucratic rationality in health service management. This ideology of certainty closes down discussion in favour of bureaucratic or scientific ends. In turn, this may lead to conflict and the breakdown of working relationships. In the course of my research for this thesis, I found that it is impossible to run clinical research without exercising practical judgement, taking political action, and being immersed in the social melee of human relating. I have argued that navigating this ongoing and dynamic process in a way that might be less harmful requires practical judgment. My research contributes to the ongoing conversation that selves are social, and therefore, even the most scientifically rational research is also social, constrained and enabled through differing ideologies, thought styles, beliefs, and values. Even research that is described as objective (for example, Randomised Controlled Trials [RCTs]) involve processes that are relational, political, and processual, by nature of the everyday activities undertaken to ensure that the research takes place. By improving our understanding of the challenges that arise from the relational nature of research and by exercising practical judgement, it may be possible to help to sustain research activity, reduce the potential for conflict and harm, and, ultimately, make the research more useful. My thesis concludes that although EBM and RCTs are essential in how the health service operates, practical judgement (phronesis) and political action are important when managing research activity. Working with conflict, ambiguity, and uncertainty is not easy. However, engaging reflexively — in particular, with prior assumptions, differences of views and beliefs, and within a community of inquiry — can increase confidence of managers and clinicians in dealing with the complex everyday work that they are involved in when it comes to research activity.