Thesis (Ph. D.)--Open University. / A book by the author, "Talking about care", based on her thesis, is also available.

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The literature is dominated by prescriptive accounts of the application of Continuous Quality Improvement and care pathways in the acute hospital services sector. The authors assume that the organisation is a designed artefact (Scapens, Otley and Lister, 1984): goals can be achieved. This thesisr eports on the nature, processa nd consequenceso f a Nurse Manager introducing care pathways in a Children's Hospital It believes, in opposition to the conventional view, that the organisation is a culture. The actions and interactions of individuals and groups shape initiatives. This is within context and within time. The research investigation was conducted over a twenty-five month period, from February 1996 to April 1998. It was ethnographic in nature. Interviews were conducted with managers, nurses and doctors, formal meetings and activity in the Children's Emergency Department observed, and documentation collected. The findings are, however, presented from the nurses' perspective using their words. Files for newspaper clippings were created and maintained. The thesis contributes to the literature in three ways. In the main, it represents the first contextual and critical account of the implementation of care pathways than that believed to be contained in the literature. Further, it purposefully utilises for the first time two conceptualf rameworks in order to explicate the changep rocessesin the Children's Hospital. These are Watson's (1994) Strategic Exchange Perspective and Dawson's (1994) Processual Framework. It presents the descriptive part of the findings in the form of a narrative. The Nurse Manager established a project to multiskill experienced nurses in the diagnosis and treatment of minor conditions using care pathways as the vehicle. Her role changed during the process of implementation, but the project had little, if no, impact on power structures between and decision making of doctors and nurses

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This thesis is concerned with the issues of managerial effectiveness, organizational change and cultures in the National Health Service. Using the micropolitical and cultural perspectives it is concerned to offer an approach which builds on existing organization, management and change theory in order to further an understanding of these issues in relation to National Health Service organizations as well as other contexts. The focus of attention is on the relationship between structure and culture at both the official and unofficial levels of the organization. The three case studies of organizations undergoing organizational change have allowed the opportunity to understand the complexity of the relationship between the official and unofficial arrangements in the organization and the impact of this on managerial effectiveness and organizational change. The main finding of the thesis is that within organizations, structure and culture are inextricably bound and their consonance at both official and unofficial levels of the organization is a necessary condition for managerial effectiveness. The types of organizational culture developed during the investigation indicate how the plurality of interests, beliefs and cultures within an organization make it difficult to achieve this condition. Concerning National Health Service organizations, the researcher argues that the recommendations contained within the Griffiths Report (1983) have offered a model of management which is based on cultural assumptions which are different to those which have traditionally underpinned the managerial process in the NHS. Following this, the researcher demonstrates via the cases, that the introduction of these recommendations has served to offer greater scope for a diversity of managerial style and philosophy at Unit level. They have also served to raise conflict between cultures, in particular the medical and managerial, to the point that the conditions needed for achieving managerial effectiveness do not exist.

This qualitative study IS underpinned by interpretive-constructionist methodological governing principles, and took shape around a developing research focus and aim rather than in relation to pre-existing research questions. The focus of the research is on clinical supervision activity. This refers to formal and informal research encounters with participants and significant others in the organization in which the study was carried out, about: the experience of the practice of clinical supervision; attempts to translate textual prescription and description of clinical supervision into organizational reality; finally, the meaning endowment placed on both of the above by myself, my participants, and significant others associated with my research. In order to address an important gap in the literature, the aim of the research developed as the need to unpack and clarify the meaning, and the affective and organizational theoretical implications of clinical supervision activity. Part one of the ethnographic report is constructed around three overlapping categories: owning, resisting and feeling. These categories are developed around the proposition that the bureaucratic rationality inscribed within both the literature on clinical supervision, and in organizational attempts to implement it, fails to take account of both the emotional underlife of the organization and otherorganizational factors. Specifically, I argue that clinical supervision activity, and my inscription within it as 'insider' researcher', was influenced, shaped and constrained by the pre-existing interpersonal rules and norms of the organization in which my research was conducted. Those governed what could and could not be done or said in or about clinical supervision activity, arguably undermining organizational goals to implement it. Part two of the ethnography explores the maIn theoretical and conceptual implications an sIng from the preceding ethnographic construction, around structural organizational power and politics. This addresses a significant gap in the contemporary literature in clinical supervision in nursing and mental health nursing. I conclude with a critical auto-critique of the study itself, around a discussion of its strengths and limitations and possible future research directions

This study investigates the ways in which nurses socially construct their health value systems and the ways in which they interpret their nursing practices. On the basis of the contradictions uncovered by the research, a new approach to health education is suggested, structured around a Lived Experience Model of Health Education the core of which is an intensified reflective practice. The model seeks to build the capacity for critical practice, closely integrating theory and practice, into nurses' modes of constructing a lay ideology based on their clinical and personal experience. Herein lies a fundamental difference between this model and other health education models, which have tended to be too narrowly focused on the individual and as a result have perpetuated a victim blaming ideology. The thesis begins with a desk study of the British dimension of a coming international crisis in the funding of public health, to which the general response has been a shift away from state support for bio-medically dominated health systems to systems based on the central concepts of health promotion and health education. The desk study argues that in Britain this has become as much an ideological issue as a practical one, with liberal notions of free market individualism prominent in public policy, and relevant sociological findings played down. Before embarking on the field study, the thesis considers whether or not a Health Locus of Control study might give enough insight into the basis for nurses' health education practices to explain why many nurses seem resistant to change, and therefore why perhaps they have had so little effect on patterns of social morbidity. This was rejected partly because of the methodological problems uncovered in a range of prior Locus of Control studies, but mainly because the method offers no way of engaging with sociologically identified inequities in morbidity and mortality rates. Nor was it felt that standard quantitative methods of research would enable the study to explore the complex ideological issues involved in nurses' social constructions of health. The decision was taken to employ a methodology based around qualitative interviews using the method of hierarchical focusing, which allows the interviewer to probe seamlessly matters at different levels of generality and specificity. In the field work study the general ideological tendency revealed in the desk study is shown to have a marked effect on nurses' constructions of their roles as health practitioners. The subjects, a group of experienced nurses, were asked a number of questions concerning their views of what constituted good and poor health and the causes for this. When the transcripts of the interview recordings were analysed using content analysis, it was clear that much of what was said was logocentric and heavily influenced by bio-medical discourse in spite of the subjects talking freely about holistic nursing. In fact there were contradictory and anomalous messages throughout the transcripts, so it was decided to subject these to a form of discourse analysis which revealed the existence of two opposing value positions held without any feeling of contradiction by a number of respondents: a holistic view - the public account, and a victim-blaming view - the private account. In order to gauge the effect of such views on nursing practice a further group of experienced nurses was given a series of nursing vignettes to analyse. The results showed that there appear to be two types of nurses: a reflexive group that is able to take on the complex issues involved in caring in the postmodern context and one, much the larger group, whose members have failed to resolve the contradictions in the prevailing ideology, who tend to fall back on victim-blaming and on bio-medical perspectives. Of course, this needs much more research to establish as a general pattern. However, there was enough clear evidence of ideological influences blocking the development of nurses' understanding and health practices to suggest the need for a new way of working with trainee nurses, much more sharply aimed at the development of critical consciousness in the practice situation. All the lessons of the research have been incorporated in the design of the new model.

There is a long-standing shortage of occupational therapists (OT's) in the United Kingdom. Commentators suggest that this is partly due to the withdrawal of qualified practitioners, but the contribution to this situation of such therapists' withdrawal early in their career seems to have been largely ignored to date. This study explored junior occupational therapists' withdrawal from practice, within one year of qualification and their likelihood of withdrawing within the following year. The focus was on the early work experience of 206 newly-qualified British occupational therapists. It investigated the potential influence of a number of independent variables which have been associated with the retention, turnover and attrition of other health care workers. These included workers' age, gender, occupational stress and trait anxiety levels, as well as a discrepancy between their expected and actual practice. The study was longitudinal in nature collecting data from respondents both before, and one year' after, qualification. A range of purpose-designed questionnaires and a semi-structured interview were used. A variety of factors were found to be of influence. Respondents' retention in practice was linked to issues of support, resources, success with clients, job satisfaction, the desire to make use of and increase their skills and the extent to which work matched their personal values. Their likelihood of leaving practice within two years of qualification was associated with both their level of occupational stress, and a perception that practice had failed to meet their expectations. Respondents' tumover level was linked to issues of support, autonomy, respondents' desire to increase their skills, and a perceived discrepancy between their expected and actual practice. Finally, attrition was linked to this same discrepancy, as well as to issues of support, autonomy, respondents' health, job dissatisfaction, level of responsibility and unmet expectations of practice. Those who left practice also noted longstanding uncertainty about the wisdom and permanence of occupational therapy as a career. These results provided both fuel for discussion and the opportunity to make recommendations for future occupational therapy policy, education and practice.