Rolling with the Punches: Clinician Resistance in a Managerial NHS Hospital...

Mogamat Reederwan Craayenstein, University of the Witwatersrand, South Africa. Teresa Carmichael, University of the Witwatersrand, South Africa. Awaatief Musson-Craayenstein, University of the Witwatersrand, South Africa. Abstract The substantive area explored in this article is hospital consultants in an English Acute NHS hospital dealing routinely with increasing managerialism. Data were drawn from 49 interviews with hospital consultants, at one English Acute NHS hospital Trust. The classic grounded theory named “Rolling with the Punches” that emerged was enriched by literature relating to everyday resistance, labour process theory, institutional complexity and organisation studies by considering public and private (internal) scripts. Interpretation of the emergent theory also drew from everyday resistance narratives from rural peasantry applied to the highly qualified public sector hospital professionals. The theory reiterates the role of discursive resistance in the workplace. Keywords: hospital, managerialism, resistance, NHS, workplace, resistance, professional, doctor Introduction The National Health Service, NHS in the United Kingdom has come into its own as crown jewel of the public services. What happens in the NHS affects the entire UK. For the past 30 years, the NHS has experienced radical changes in its organisation structures and managerial regimes (Ackroyd & Thompson, 2003b; Thompson & Ackroyd, 1995). Healthcare delivery has been transformed with metrics-based performance management, electronic monitoring (Farrell & Morris, 2003), and enhanced audit and accountability (Ferlie, McGivern, & FitzGerald, 2012). Work intensity increased. Changes in the modes of control have resulted in shifting power relations between non-clinical managers and clinicians, especially hospital consultants. There is a lack of understanding about how clinicians and non-clinical managers routinely interact (Kuhlmann et al., 2013b). These changes mean that professional agency within a managerial context should be clarified (Correia, 2013; Muzio, Brock, & Suddaby, 2013). Dissatisfaction is evident (Dickinson, Ham, Snelling, & Spurgeon, 2013; Exworthy et al., 2010; Morris & Farrell, 2007; Spyridonidis & Calnan, 2011); however, the repertoires of dissatisfaction in such a context are not well-studied (Reay & Hinings, 2009) (Bélanger & Edwards, 2013), highlighting an opportunity for exploration. This study goes beyond a simple binary of non-clinical managers versus hospital consultants. It shows that the responses of doctors are socially constructed, situated, complex and complicit. Managerial initiatives shape, constrain and stimulate clinical practice in non-hegemonic ways and doctors find spaces to evade managerial control (Ackroyd & Thompson, 2016).  Clinicians do not have grand visions of resistance, but they do whatever they can, as bricoleurs (Levi-Strauss, 2004), using the tensions between structures that constrain and those that enable (Giddens, 1984). This study illuminates the routine responses of doctors as they encounter managerialism in their clinical practice in an acute hospital setting. Methodology: Classic Grounded Theory The researchers followed classic grounded theory procedures during data collection, coding, and analysis. The emergent grounded theory and its constructs were the basis of the literature review that followed. We conducted 49 interviews that were recorded in mind-map format and written up as field notes immediately after the interview. Audio recording and transcription were deemed unnecessary (Glaser, 1998), and the participants were unwilling to be recorded for fear that the recordings, with their recognisable voices, may fall in the wrong hands. In addition to the interviews, 20 observation encounters were captured, also in mind-map format. These observation sessions allowed the researchers to view the participants going about their everyday work within the research context (Barley & Kunda, 2001; Zilber, 2002). The observation sessions were those of a “complete” (or detached) observer (Burgess, 2006). Documentary evidence from the Trust website and other relevant NHS bodies...

Positioning: A classic Grounded theory on nurse researchers employed in clinical practice research positions...

Connie Berthelsen, RN, MSN, PHD, Aarhus University, Denmark Abstract The purpose of this classic grounded theory was to discover the general pattern of behavior of nurse researchers employed in clinical hospital research positions. Internationally, efforts have been made to strengthen evidence-based practice by hiring more nurses with a PhD for research positions in clinical practice. However, these nurse researchers are often left to define their own roles. I used data from a Danish anthology of six nurse researchers’ experiences of being employed in clinical hospital research positions. The theory of Positioning emerged as the general behavior of the nurse researchers, involving seven interconnected actions of building an identity and transformations of self, which varied in intensity and range of performance. Positioning characterized nurse researchers’ actions of following and connecting two paths of working as a postdoctoral researcher in clinical practice and moving towards a career in research, both guided by their personal indicators. Keywords: nurse researchers, grounded theory, positioning, clinical hospital research, building an identity Introduction Traditionally, nurses with a PhD degree are employed at Universities, where they educate nurses in scientific and academic programs, supervise PhD students, and conduct research (Orton, Andersson, Wallin, Forsman, & Eldh, 2019). However, times are changing and the paths into hospital positions are steadily growing worldwide for nurses with PhD degrees. In Denmark, we see an increase in nurses with a PhD in clinical hospital settings, where they are employed in academic positions such as clinical nurse specialists, postdoctoral researchers, senior researchers and clinical professors (Berthelsen & Hølge-Hazelton, 2018a). However, academic nurses holding Master’s degrees are also finding their way into hospital and primary care settings as clinical nurse specialists, advanced practice nurses, and PhD students. Due to the low level of evidence-based practice in nursing, academic nurses are needed as role models and leaders of research and development in clinical practice (van Oostveen, Goedhart, Francke, & Vermeulen, 2017; Orton et al., 2019). Even though nurse researchers, holding PhD and/or Master’s degrees, are multiplying in clinical practice, their roles and specific tasks are somewhat ambiguous, which can create insecurity and confusion about how to perform at their best (Berthelsen & Hølge-Hazelton, 2018c ). This aspect was seen in an intrinsic single case study of nurse researchers in clinical hospital positions, where the main theme of being “Caught between a rock and a hard place” identified the nurse researchers’ experiences of being in clinical practice in hybrid roles, feeling that they did not fit in anywhere (Berthelsen & Hølge-Hazelton, 2018c ). The nurse leaders play a particularly important role in the integration of nurse researchers in clinical practice, as they can help to create and support the optimal environment for research in the department (Bianchi et al., 2018). Data from a Danish anthology of six nurse researchers’ narratives about being employed in clinical hospital research positions were used in an attempt to discover the actions, processes, and behaviors of nurse researchers in clinical practice (Hølge-Hazelton & Thomsen, 2018). The aim of this study was to generate a classic grounded theory on the general pattern of behavior of nurse researchers employed in clinical hospital research positions. The research question that guided the study was: What are nurse researchers’ main concern in their clinical hospital research positions and how do they resolve it? Methods Classic grounded theory, based on Barney G. Glaser’s (1978, 1992, 1998) methodology, was chosen in order to discover a substantive theory on the general pattern of behavior of nurse researchers employed in...

About the Authors

Connie Berthelsen, RN, MSN, PHD.  Dr. Berthelsen completed her MSc in 2007 and her PhD in 2013 at the Section of Nursing, Aarhus University, Denmark. Dr. Berthelsen has a strong background in classic grounded theory. In her PhD, she generated three grounded theories of relatives’, patients’, and health professionals’ patterns of behavior in relation to relatives’ involvement in older patients’ fast-track programs during total joint replacement, using Dr. Glaser’s classic grounded theory method. She also teaches Master’s and PhD students in grounded theory methodology. Dr. Berthelsen is currently employed as an associate professor at The Research Unit of Nursing and Health Care, Institute of Health, Aarhus University, Denmark, where she is conducting research concerning building nursing research capacity in clinical practice. Teresa Carmichael, BSc(Hons), MM(HR), PhD. University of the Witwatersrand, Johannesburg, South Africa. Professor Carmichael was born in Zimbabwe and undertook her tertiary education in South Africa. Her first degree was in microbiology and biochemistry, which lead to her initial career choice in agricultural microbiology. Subsequently she moved into the pharmaceutical industry, doing marketing and staff training, before taking a post as faculty member at the Wits Business School in Johannesburg. Her research interests lie in management education, diversity, entrepreneurship and the discipline of qualitative research methodology; she has several publications in these areas. In addition, she is very involved in teaching and research supervision of Master’s and PhD students. Email: terri.carmichael@wits.ac.za Awaatief Musson-Craayenstein, MBBCh, MMed, MBA. University of the Witwatersrand, Johannesburg, South Africa.  Born and educated in South Africa, Dr Musson-Craayenstein has been a consultant radiologist for over 23 years, 20 of which have been in the NHS in the UK. She has a strong interest in the development of both organisations and people, leveraging her status as a certified coach and mentor in the London Deanery and Royal College of radiology. Her inclusive approach to the growth of individuals and groups demonstrates the caring nature that is such a priority in her life. In collaboration with the General Medical Council she is conducting a comparative investigation of academic standards in her field, specifically with regard to benchmarking various overseas radiology qualifications with the NHS. Ruth Tiffany Naylor, BA (Wells College), MSc (Tufts University, MBA Hons (Boston University), AA Hons (Montgomery College), DipAT (British Autogenic Society), DipCBH (UK College of Hypnosis and Hypnotherapy), PhD (Canterbury Christ Church University, 2013) is currently practicing as a psychotherapist and autogenic therapist in Hastings, England. She is a Trustee of the British Autogenic Society, the society’s representative to the British Psychological Society, and a tutor on society courses. Email: ruth@ruthnaylor.com Mogamat Reederwan Craayenstein, BSc, BA(Hons), MBA, PhD. University of the Witwatersrand, Johannesburg, South Africa.  Born and educated in South Africa, Dr Craayenstein’s main concern is about people operating and interacting in their everyday lives, and how they identify with and address the contextually-relevant issues they must deal with. In this vein, his MBA research sought to identify the reasons why affirmative action was perceived to be failing in post-apartheid South Africa. His research is cross-disciplinary, but always deals with issues of humanity; he has been involved in social movements in various countries trying to make the world a better place. His interest in classic grounded theory is well-suited to his field of study. He has also been a long-time Director of various companies and a part-time faculty member at the Wits Business School. Ramona Rolle-Berg, Ph.D., is the Co-Founder of Rolle Integrative Healing Solutions, LLC, in Conroe, Texas.  As an integrative medicine...