Inclusion and Exclusion in the NHS: Power, Innovation and Rejection in Nursing
Marriott, Sheila Christine
In this thesis, I investigate my professional practice as an independent health adviser in the UK National Health Service. Inclusion and exclusion, power, innovation and rejection in nursing are themes that have emerged from my work within a milieu where the dominant discourse is systems thinking. I have analysed why systems thinking predominates in UK healthcare services, and examine the benefits and limitations of this approach. Similarly, I have studied complex responsive processes theory and assessed the value and drawbacks of this way of thinking. A key focus of this research has been to consider how innovation occurs in organisations. NHS policymakers include examples of good practice in a number of recent policy documents and encourage staff to emulate these examples to improve their services. This overlooks the unique setting in which staff work, and disregards their collective working styles and roles. Power relationships, local ideological perspectives, histories and pertinent environmental factors all render the adoption of established blueprints inadvisable. Nor do such policy documents consider potential unintended consequences of the innovation: for example, reducing the waiting times to access treatment in one area can have a detrimental effect on other services. Using narrative accounts from my professional practice, I critically evaluate the concepts of power, innovation and systems thinking. I draw attention to a number of particular dissonances that I consider many nurses and health care workers to be experiencing as rejection within their work-based relationships. These challenges include a fear of job loss, the difficulty of managing national targets and local service delivery, a loss of consumer confidence in clinicians, the pressures of increased regulation, and tensions between clinical and managerial staff. These concerns led me to examine the nature of the employer–employee relationship. The psychological contract is a way of describing the relationship between employers and employees in terms of optimistic reciprocal agreements and expectations. These positive assumptions tend to underplay or overlook the unpredictability of organisational life, such as financial constraints that might threaten job security. When disruption arises, employees may feel wary of their managers and distressed that their psychological contract has been violated. I argue that trust is a concept requiring continual renegotiation through the ongoing patterning of relationships that emerge through the conversations between people as employees participate in the organisation’s development. My thesis departs from the traditional view of positing the psychological contract as a central feature of employment. Instead, I propose that the complex responsive processes perspective offers a legitimate and useful way of deepening our understanding of employer–employee relations. I have used a reflexive research method, challenging Alvesson and Skoldberg’s (2000, p.250) reflexive interpretation framework for its individualistic approach. I demonstrate that my method is social and iterative, and extend the framework in order to illustrate the way in which I developed my reflexive approach. This framework presents a way of demonstrating the movement of interpretation based on the researchers’ judgment and intuition that guides the research process (Alvesson and Skoldberg, 2000). My original contribution to practice offers a different way of looking at healthcare organisations from that proposed by many healthcare consultants. I engage with staff to analyse their day-to-day relationships by reflecting on their micro-interactions with colleagues as we try to make sense of what is happening in their departments. I introduce the notion of interdependence, and encourage clients to engage in dialogue and seek to influence what occurs through their relationships with their colleagues. There is no blueprint for success: rather than focusing on supposed ‘organisational systems’, we concentrate on what is actually happening in their ongoing work elationships.