Referral to Occupational Health: A Foucauldian
discourse analysis of statutory documents and
student nurses’ perceptions.
Thesis submitted in accordance with the requirements of the
University of Chester for the degree of Professional Doctorate in Education
Alan Massey
November 2015
Table of contents
3 List of tables
4 Referral to Occupational Health: A Foucauldian discourse analysis of statutory documents and student nurses’ perceptions.
Alan Massey Abstract
This study was carried out using a Foucauldian discourse analysis and involved the examination of three statutory reports into the provision of occupational health in the workplace. The reports analysed were the Report of the Select Committee on the Bill for the Regulation of Factories (1832); the Safety and Health at Work Report (1972); and Working for a Healthier Tomorrow (2008). Additionally, analysis was carried out on oral events with nursing students, which sought to understand their perceptions of referral to occupational health. The objective of this study is to explore how referral is constructed through discourse, categorising how this practice is constrained or liberated by specific discourses and how nursing students are positioned by these discourses. My study highlights both structural and subjective barriers to the use of occupational health. At the structural level, it is observed that referral to occupational health commenced as a form of governmentality, introducing dividing practices which subjected the workforce to forms of classification and surveillance. For those classified as healthy a culture developed within workplaces in which health behaviours needed to comply with the standards set down by occupational health and by the risk management approach. Risk management processes and stigmatisation are used to ensure compliance with the state’s wishes for a healthy and productive workforce. This trend is seen across the reports analysed, and is increased within the Black Report to the surveillance of health both in and out of the workplace for those of a working age. Subjectively, occupational health was identified as a disciplining and subjugating structure by the nursing students. The students evidenced notions of Cartesian duality in their discussions of the outcomes of referral, as they readily accepted surveillance of the body whilst seeking to avoid surveillance of their mental health capabilities. Through observation of architectural signs and organisational images of discourse, students categorised occupational health as an instrument of the higher education institute and not as a form of holistic health support. The research highlights how occupational health acts as a barrier to the students’ fulfilling their societal roles as good students and good nurses. The research also highlights a desire on the part of the student nurses to utilise occupational health within a public health framework which addresses their health in a preventative rather than punitive manner.
5 Acknowledgements
I would like to express my deepest gratitude to my supervisors: Professor Dean Garrett, Dr Andi Mabhala and Dr Jane McKay. Thank you for your knowledge, enthusiasm, and inspiration. My journey as a student on this programme has been enriched by your wisdom and patience. Without your insightful and constructive comments, my journey would not have been as rich or as enjoyable. I thank my employers for the time, effort and resources they have invested in me to allow me to undertake this study. Without their financial and pastoral support this study would not have taken place. Particular thanks go to my colleagues Janet and Abe for their unwavering enthusiasm and confidence. Finally, my thanks go to my wife Diane, without whom this study would not have been possible. Your support has provided me with the strength and space to complete this work.
6 Preface
Background to the study In 1974, the Health and Safety at Work Act (HSWA) evidenced a change in philosophy toward the provision of health and safety in the workplace. Rather than the use of prescriptive legislation to protect employees from exploitative employers, the HSWA adopted a preventative philosophy with partnership as its core value (Kloss, 2010). These themes were re-emphasised during the development of the European Union (EU) due to the necessity to harmonise EU legislation in the fields of health and safety (Kloss, 2010). At this time, there existed a need for the development of an effective occupational health (OH) infrastructure across Europe. According to the World Health Organization (WHO), this needed to reflect core public health principles such as structural transformation, the development of inclusive practice and capability building (WHO, 2002). However, across the EU the development of OH services is fragmented. Different countries implement differing approaches to OH based on attitudes towards legislative control and free market principles (Kloss, 2010). Within the United Kingdom (UK), development of OH has occurred sporadically despite several attempts by way of government policy to encourage progression. This lack of progression is partly because OH policy has been tied to safety policy since it became necessary to control the use of machinery and heavy equipment during the industrial revolution (Abrams, 2001). Despite increasing regulation towards safety issues within a mandatory framework of risk management, provision of OH services remains deregulated. Risk management or the risk agenda has come to dominate the health agenda (Kloss, 2010). The risk agenda, which is associated with economic and harm reduction strategies based on principles of instrumental rationality, is contrasted by humanistic principles evident in the health agenda. One of the outcomes of this issue is that the partnership approach to the development of health and safety in the workplace has been slow to materialise (Kloss, 2010). One outcome of limited partnership is that preventative measures to improve health become marginalised, due to a lack
7 of quantitative evidence surrounding the impact of health initiatives on factors such as productivity improvements or reductions in sickness-absence rates. The slow or absent development of preventative health structures is also evident within the higher education sector (Dooris, 2009). According to Wells, Barlow and Stewart-Brown (2003) the student population is neglected in terms of health provision and students experience poorer physical and psychological health outcomes than their counterparts. This is particularly true in terms of preventative services based on public health ideologies. Public health is provided in the UK along the principles of a lifespan approach, which sees the young (0 to 5 years) have their health needs catered for by health visitors, and those of school age by school nurses; adult health is addressed through OH services for those in work. Whilst health visiting is universally provided, the remaining two areas of public health are not. School nursing ceases once a child has left school, whilst occupational provision does not occur until employment commences. This leaves the majority of university students within a public health vacuum. The exception to this is those students who attend university to undertake professional courses, which have a work placement. These students are required under the HSWA to attend for health surveillance, and in the case of nursing students (NS) to attend for vaccinations to prevent nosocomial transmission of disease (Kloss, 2010). As such, NS come under the remit of OH provision due to the legal requirement to protect them from the health risks they face in the workplace. In addition, the Nursing and Midwifery Council’s Code (2015) indicates that steps must be taken by the student professional to protect the public from their acts and/or omissions. Within this study, this issue is important as NS are seen as vectors of disease and required to take steps to reduce the risk they pose to others. This requires mandatory contact with OH irrespective of the students’ wishes; this creates disconnect between the philosophical principles of autonomy and beneficence evidenced within public health practice. Therefore, it is important to understand in detail the tensions and complexities arising from the juxtaposition of policy and practice. These principles of public health practice are representative of the key drivers for change in this area of health provision. Principally, the
8 transformation of traditional reactive OH services to a preventative public health approach is required due to the changing nature of working life, the reduction in the role of institutions via the drive for liberal paternalism, and the need to be cognisant of the organisational movement towards quality management systems. Total quality management is supportive of public health as it ensures consideration of environmental, organisational, and individual protection based on pluralistic perspectives (WHO, 2002). Greater awareness via total quality management systems has increased knowledge of the settings and cultures of institutions and systems thinking on health outcomes. Exploring the role of institutions in health from a sociological perspective, Giddens and Sutton (2013) indicate an institution has a social purpose, which structures individual behaviour by organising the rules that govern behaviour. Liberal paternalism is leading to greater awareness of individual choice and self-management. This issue is important, as choice and self-management are central to the development of an effective infrastructure for health to meet changing health concerns (WHO, 2002). Finally, the changing nature of work has meant that traditional threats to health have reduced and there is a need to address the new threats to health via collaborative multi-sectorial provision. The blurring of traditional boundaries of service provision and the growing influence of a mixed economy of care mean that the settings in which people live, work, play and are educated become central in shaping health (WHO, 2002). My intellectual biography Life is full of choices; you just don’t get to make any! (Shultz, 1976, p.68).
Exploring the settings in which people work has come to form a central part of my academic development. The intention of this study is to explore the implications that compulsory contact with OH has on nursing students’ interactions with this service. This will be undertaken within a Foucauldian perspective. This is due to a desire to identify why – despite several attempts to promote OH by the nursing profession, government, industry and global institutions – improvements in OH have been slow to materialise. Inherent power struggles and fragmented models of practice exist due to a lack of consensus into the aims and objectives of OH (Black and Frost, 2011).
9 Behind this specific area of enquiry are several broad fields of research of interest to me. These include the concepts of structure and agency, social justice and institutional mechanisms of control. According to Shenton (2004), within the social sciences it is important to explore via reflexive analysis the bidirectional relationship between my own socialisation and my ability as a free agent to engage critically with my own subjectivity in the process of constructing the other. This is important, as the researcher is the major instrument of data collection and analysis. Therefore, researchers are social actors who are embedded within their own cultural and social backgrounds, which shape their values, attitudes and beliefs towards the research question (Shenton, 2004). Reflexivity should occur at all stages of the study and I will utilise Pillow’s (2010) framework. This entails the researcher seeking to be critically conscious of their self-location within the research to ensure awareness of their own identity and positionality in their work. The remaining sections of this preface contain a reflective outline of several significant life events which have shaped my attitude toward the research question. This element seeks to outline the concept of ‘know thyself’ (Pillow, 2010). The quote from Shultz is indicative of how I feel regarding the major career ‘choices’ which have influenced my life and this research topic. At the commencement of this study, I represent an experienced nurse educator undertaking research. However, I did not choose to be a nurse, a nurse educator, or an academic; rather they were chosen for me. Here Nancy (1991) would indicate that these choices are seen as a direct challenge to my self-identity. The horizons of actions presented are in contrast to my aspirations. In placing me in employment which I would not have chosen for myself, then the binary of control between the self and other emerges as a key theme. This creates a rupture for me in terms of the relationship I have between my conjoined self and the other in terms of the communities of occupation I inhabit. The daily challenge I face is that by entering professions in which I have a duty to put others before myself, I have become a nurse, educator etc. simply by being with others, and I do not exercise the control over my career that I would have wished. In reflecting on how I have arrived
10 at this point then several questions are posed: have I arrived at this point by design or accident? How effective have I been in shaping my life or have other forces been more influential? These questions outline a recurrent theme to be played out in this thesis, that of the role of structure and agency. It is important to highlight the use of binary opposites here. According to Jenkins (2013), the human brain prefers generating opposites. Bourdieu (1977) indicates this opposition is a deep, primeval structuring principle of culture. In the concept of structuralism which is the search for underlying patterns of thought in human activity (Blackburn, 2008), conceptualisation of the universal structures of the mind tends to operate based on pairs of opposites such as hot-cold, male-female, culture-nature. Nancy (1991) indicates that my deconstruction of the role of self and community is impossible because the community is emergent in my development. Nancy (1991) continues that in looking backward towards my socialisation I must guard against retrospective creation of the self as having full or partial autonomy. Nancy indicates that my senses of self and of my autonomy are influenced by my socialisation within communities. The relational element between my community and me is not linear: rather, it is spontaneous. This element is important, as the role that structure and agency play must be understood in terms of a deeper understanding of the structuring principles of the influences which guide my work. To help contextualise this study, I shall now undertake three reflexive accounts of the drivers behind it. First reflective account This first reflective account is utilised to outline the experiences that have driven the academic element of this study. In doing so, I hope to provide the reader with the answer to the question: what are the key factors which have influenced this line of academic inquiry? As a young man, I was reasonably good at sport. Indeed, at one point I had hoped for a career in professional sport. However, my inabilities to remain injury-free meant that a sporting career was closed to me. At the age of twenty-one, I was too old! My father, an ex-serviceman, was keen that I should develop a ‘trade’. Therefore, I joined the Army to become an engineer. Whilst I waited for my training to begin, the issue of sporting ability was to change my life. In the Army, sporting competition was seen as a good
11 mechanism to develop the values of teamwork and belonging amongst others. These community values are in line with Nancy’s ideas on immanentism (Nancy, 1991). This term is used to describe the horizon of our attitudes towards community and self. My inherent agency was consumed by the structure of sport. Commanding officers would recruit able sports people to represent their corps or regiment. I was entered into what can only be described as a human auction and was informed that I would be travelling to Hong Kong in one month’s time. My training as an engineer was put on hold for two years. On arrival, I was informed that in the interim I was to commence nurse training! This point is important as I arrived in Hong Kong excited, apprehensive and bitter. In being told directly what to do (by an organisation which is built on command and control), I felt angry at the removal of choice and I immediately resented the circumstances in which I found myself. As I travelled the globe enjoying what can only be described as a wonderful life, this feeling of bitterness did not reduce. I have often reflected on the fact that the removal of autonomy must form part of an institution such as the Army. However, it occurred to me that to exercise power in this way would be ultimately self- destructive for this organisation. I began to observe that the bitterness I felt towards authoritative actions was rare amongst my peers. Power and therefore control must have been organised in more subtle ways. At this point, I became aware of the role that teamwork had in structuring the culture of the Army. What struck me the most was that power was not often utilised by the hierarchical structure inherent in an organisation of this kind, as was my initial observation. Rather, power was often exercised via psychological factors, and by the creation of cultures conducive to shared identity and a sense of ‘them’ and ‘us’. Although I did not know it at the time, the psychological concept of ‘othering’ was utilised to create a sense of shared purpose. Othering refers to the idea that we are influenced by those values shared by our peers and by the systems around us (Taket, et al. 2009), rather than our own drives and needs. The culture and systems which surround us, in conjunction with the need for social acceptance, are the factors that provide us with a sense of self. In the Army, our self-interest and our attitude towards making choices via our own agency were discredited. It
12 was instilled in you repeatedly that as a single entity you had inherent human flaws. However, as a team you could overcome all obstacles. Strength in numbers created the possibility of success. You had a sense of responsibility to those around you, which overpowered frailty and fear. Ultimately, people were structured to protect and where necessary to fight for their friends and to protect the vulnerable. This insight into how people can be structured to achieve goals and objectives, which may be detrimental to them, has stayed with me. Similarly, the concept that humans can achieve great things when they work in partnership has always played a part in my mentality. The irony of using inclusive psychological techniques to create a culture which ultimately removes a sense of self-interest was not lost on me, and has been significant in my observation of health behaviours since that time. This is particularly true in respect of what happens when the systems and values of an institution such as the Army are removed and one is left with one’s agency, which to a certain degree has been eroded. Academically, the influence of structure and agency on individual behaviours has intrigued me since that time. Similarly, the idea that settings and institutions can be structured to create conditions of possibility in line with Foucault’s ideas is also intriguing. I use Foucault’s term the conditions of possibility to emphasise the simple fact that I approach this study as a person whose glass is half-full and not half-empty. I instinctively believe that practice enhancement is possible and is the fundamental purpose of research and enquiry. In transferring this background information from an institutional to a sociological setting, I also observed that the phenomenon of social acceptance via cultural influences is evident in our health behaviours. I have often been amazed at how, for example, people with diabetes will ignore the advice of health professionals in favour of social acceptance even though they are aware of the damage they are doing to themselves. In public health circles, the fundamental question of, ‘why do some people listen to health advice whilst others do not’ remains largely unanswered and has intrigued me since I started my career as a nurse. Second reflective account
13 This is intended to highlight to the reader my inherent drive and passion for this study. In line with my earlier discussion highlighting that I have made very few conscious decisions in respect of my career choices, this is also true of my interest in OH. In writing a report for my manager into the survival rates of Army personnel upon retirement, I noted that the average age from retirement to death was six months. This issue struck a chord with me because at that time most of my male role models apart from my father were reaching or had reached retirement age. Out of six relatives, five of these men never saw the anniversary of their retirement date. There appeared to be a clear pattern amongst this group. They were all working as many hours as possible in the latter stages of their careers so that they could retire to do the things they had always wanted to do. The act of work and the role demands placed on them, whilst appearing to provide them with the means of a fruitful end of life, were actually decreasing their chances of achieving this goal. Having been raised within a family structure which respected the protestant work ethic, the concept that work was harmful and the personal realisation that these men had literally worked themselves to death was to say the least troubling. I began to question the concept of how institutions such as a workplace and latterly a university could structure systems to be conducive to health. I have always considered myself working class. In reflecting on the concept of othering, then, it is clear that on a psychological level I have an innate desire to protect fellow workers from exploitative others. Ethically, the innate need to address social injustice to those I consider to be one of us is the driving force behind this study. It should be borne in mind that I do not consider this study to be politically motivated. Clearly, political factors underpin this study as social justice is tied into the fair distribution of resources and the equitable treatment of workers. However, I would point out that my personal view is that two dominant resources for life are health and education. On a superficial level, within the UK, these are free to all. For ethical reasons we as practitioners need to ensure that these factors are protected via the simple process of research. After all, knowledge is power! For me, then, the drivers are ethical.
14 In response to my repeated questions towards my manager regarding creating environments conducive to health, I was placed on an OH training programme and asked to ‘fix’ the problem. I really must have been persuasive (irritating) at this stage of my career, as the Army did not have an OH service and as far as I was aware had no intention of creating one. I was placed on a programme of study for which I had a clear drive. However, I had not asked to be placed on this course and, at the time, it looked more like an exit strategy for me than a sensible management decision. After all, I was getting too old for sport! Third reflective account The final element of this reflection will hopefully bring the reader to the point of understanding what is it I hope to achieve via this study. I hope it is reasonably obvious from the above reflections that I consider myself an interventionist and anti-behaviourist. I clearly believe in the premise that people interact with their environments, be they physically, culturally or politically constructed, at all times during our existence. I contend that it is these interactions which have the greatest influence in shaping our health map, rather than our independent activities. I believe that institutions such as the workplace and higher education institutes (HEIs) can be structured in a way to enhance health behaviours via a preventative approach based on partnership and informed decision-making. I also believe that it is an ethical imperative to address concepts such as social justice and empowerment to improve health. This view that an individual is a holistic entity and consideration must be given to all elements of a person’s environment has shaped this study. It is intended to provide new insight into how the barriers evident in processes such as compulsory health provision can be overcome. Finally, the research method chosen reflects a need to understand in detail the influences upon a person’s ability to interact with preventative health resources and of the conditions of possibility inherent in one HEI. Organisation of the study
This study is divided into the following chapters: chapter 1 acts as an introduction; chapter 2 explains the theoretical framework and the methodology used; chapter 3 presents a genealogical analysis of key policy
15 texts, whilst chapter 4 presents a discourse analysis of nursing students’ dialogues; chapter 5 summarises the study.
16 Chapter 1: Introduction
The impetus for this study came about during a discussion between lecturers on what best to do with a student who was struggling to meet the requirements of a pre-registration nursing programme for ill-health reasons. One of my colleagues stated that the student should be ‘sent to OH’. The use of this phrase has always created disquiet in me as a lecturer in OH, as I perceive it to indicate a limited understanding of OH. Whilst the use of this phrase is not new, its use becomes an anomaly when contrasted with the latest health policies, which have as underpinning philosophies increased individual responsibility, autonomy and empowerment toward health. These concepts seek to place service users at the heart of the decision-making process (Department of Health [DH], 2010). Galvin (2002) highlights how health care systems are evolving to reflect neoliberal principles and, in particular, systems and processes are evolving so that individuals can become autonomous, active, responsible and self-managing individuals who require reduced input from institutions such as the National Health Service (NHS) or OH (Galvin, 2002). This drive for increasing responsibility for health led me to reflect on the incongruence between policy drivers for increased autonomy and traditional forms of practice within OH. When reflecting on this knowledge I was stimulated to ask questions such as, how do service users perceive OH? How is OH organised? How has the organisation of OH changed over time and what needs to change in the future? In seeking to answer these questions, I sought to explore how ‘being sent to OH’ is constructed in and through the discourses of those who are sent. With this, my intention is to identify the effect of social construction on service users’ perceptions of OH. The focus of this study, therefore, is to analyse contemporary practice in OH through the discourses of those who use the service and to analyse the policy drivers that shape contemporary practice. It is hoped that increased knowledge of these two factors will lead to improvements in the services offered by OH to those in a university setting. 1.1 Historical development of OH
17 Within this section, I will briefly provide an historical outline of the development of thought towards OH and the state of research in this field so that I can position my own research. Discourse towards OH emerges in antiquity via Hippocrates in his outline of the effects of environments on health (circa 400 BC). During antiquity, OH was predominantly utilised to protect the health of military personnel (Gochfeld, 2005). Here the need to safeguard the health of those seen as central to the protection, development or maintenance of society becomes evident (ibid.). Gochfeld continues, stating that occupation was central in the maintenance and development of social stratification. Occupation was seen as harmful to health and was given to the lower social classes to undertake. From antiquity to the enlightenment period, the working environments for people in the working classes were generally not conducive to their health, due to the sociological acceptance that work was an undertaking for the lowest layers of society, and those who became involved in this process were replaceable and could be treated with contempt (ibid.). Abrams (2001) indicates that the provision of healthy occupational environments is seen as central to understanding relationships between human beings and in understanding social justice. Discourse about OH shifts to a scientific footing through the research of Ramazzini (circa 1700), who discusses OH within a preventative discourse which includes scientific analysis and the development of thought surrounding the efficiency of work and the effects of work on mortality (Weindling, 1983). Scientific discourse of this nature continues until 1746 when Arkwright’s spinning frame was utilised in workplaces for the first time. Discourses of OH expand within the scientific paradigm to include notions of risk management. Arkwright’s invention saw the birth of the modern factory and fundamentally changed the nature, place and risks associated with occupation (Thomas, 1948). Modern factories contained large mechanical devices powered by external forces, paid individuals for their labour and placed them at risk from physical, chemical, biological and psychological harm. Paid labour replaced traditional feudal systems, the worker became a distinct sociological entity and the economics of human labour became evident (Weindling, 1983).
18 Discourse towards OH remained entrenched in sociological, economic and scientific debates until the 1950s when the WHO and the International Labour Organisation (ILO) refocused OH to include discourses of wellbeing. The Second World War evidenced the need for social reforms and the need to develop mechanisms of the state to increase liberalism (Thomas, 1948). The ILO/WHO met this need by expanding understanding of OH from a predominantly reductionist discourse of risk to an holistic understanding of the interface between humans and their workplace, which focused OH toward the public health principles of prevention, protection, promotion and restoration of optimal health (ILO/WHO, 1950). As such, OH shifts from an acceptance that work negatively effects health, to an aspirational approach which embodies the concept that settings such as workplaces and universities can be shaped to enhance health and wellbeing (Tones & Green, 2010). This element coalesces into the settings approach. This form of discourse provides conditions of possibility for OH to expand its role and scope of influence. It challenged traditional understandings of the role of the work setting in society (Tones & Green, 2010). Discourses emerge reflecting advancing social attitudes towards work, where the quality of work is increasingly important and the notion of the control individuals have over their working environment becomes central to our understanding of how work affects health (Guzik, 2013). Wellbeing emerges at this time due to the successful management of risk in Western societies. It is our mental health which is increasingly challenged by contemporary workplaces, rather than our physical health (Guzik, 2013). This development sees a wealth of research into the role, causes and outcomes of stress in the workplace. Increased research on the inherent risks in the workplace includes a focus on ergonomics and the interface between humans and their environment, and societal roles and how these structure behaviours. Finally, there is an economic research focus on the effects of differing managerial approaches to productivity and morale via consideration of the working environment (Guzik, 2013). Influential in the development of research in contemporary times are the Whitehall studies (1967 to the present). These have evidenced a sociological gradient of disease with individuals in the lower socioeconomic grades having mortality
19 rates three times higher than the highest grades (Tones & Green, 2010). These studies stimulated a wealth of research which looked at the sociological and psychological outcomes of socioeconomic deprivation and the role that work plays as a determinant of health. It is now widely accepted that the psychological effects of work and the individual control we have over our work have a significant impact on our morbidity and mortality (Tones & Green, 2010). In 2005, the UK government responded via the creation of a health, work and wellbeing strategy. This set out the need for partnership working and highlighted the responsibility individuals have for enhancing their own health and wellbeing. The rise of mental health problems following successful measures to deal with risks to physical health and a change in industrial practices means that evidence is required for management of increasingly sophisticated social and cultural problems (Marmot & Bell, 2010). To address this issue Black (2008), Boorman (2009), and Black and Frost (2011) have undertaken research to identify barriers to the uptake of OH services from an organisational perspective. However, at this time there is an absence of research into service users’ perspectives of the barriers to accessing OH in all settings. 1.2 Research question and aims The aim of this study is to use Foucauldian discourse analysis to explore the perceptions of nursing students (NS) into the OH referral process. To meet the aim, four research questions are proposed, designed to investigate the ways in which NS perceive referral to OH: 1. What are the trends for structuring referral to OH within health policy? 2. What functions does the referral process have in constituting subjects? 3. What can be considered as valid knowledge at this time within one HEI in respect of being referred to OH? 4. How does knowledge surrounding contact with OH emerge and how is it passed on? 1.3 Research design This study seeks to answer the research questions through an appropriate research design. This is based on a theoretical framework which addresses the effects of policy approaches and referral to OH in two ways. Questions 1
20 and 2 will be addressed via Foucault’s genealogical method focusing on UK government policy since 1832, whilst questions 3 and 4 will be addressed via Foucauldian discourse analysis of students’ interviews. 1.4 Significance of the study This study is split into two sections. Firstly, I shall undertake a Foucauldian genealogical analysis of the development of OH within health and safety policy since its inception as a distinct form of practice in 1832. This section is significant for two reasons. Firstly, my study presents an overall picture of the development of OH practice, which is essential in understanding how OH needs to adjust to meet the evolving liberal-paternal policy environment. Similarly, this study seeks to explore how OH practice needs to respond to the restructuring of contemporary health services, so that it can position itself to meet the WHO’s settings agenda. This study uses the conceptual framework of genealogy to explore the ethical, political and technological aspects of OH reform. Whilst genealogy has been utilised within other health care sectors, a genealogical analysis has never taken place in OH. The second element of this study is to explore students’ perceptions of referral to OH. This element is undertaken using Foucault's notion of critique to identify the process of how discourses shape the phenomena of referral to OH. According to Foucault (1988, p.154): A critique is not a matter of saying that things are not right as they are. It is a matter of pointing out what kinds of assumptions, what kinds of familiar unchallenged, unconsidered modes of thought, the practices that we accept ... Criticism is a matter of flushing out that thought and trying to change it; to show that things are not as self-evident as we believed; to see what is accepted as self-evident will no longer be accepted as such. Practising criticism is a matter of making facile gestures difficult. Central to this conception of critique is the revelation of power relations in which subjectivities are constituted. Consequently, critique seeks to inform people of how the subject positions are shaped by governmentalities and strategies (Rose & Miller, 2010). This element is significant as NS are used to gain insight into this construction from a service user’s perspective. This has never been undertaken in a UK setting, as historically within OH, service users’ voices have been silent.
21 1.5 Limitations of the study This study is restricted to one university setting. The results therefore cannot be generalised to other HEIs, although there may well be resonance in what is found, which may influence practice. The study explores the perceptions of one group of NS whose experiences have been shaped by a distinct rather than homogenous student profile. The study, whilst exploring UK policy within the development of OH, seeks to explore the policy/practice divide with reference to one small student cohort, and again these results are not generalisable.
22 Chapter 2: Methodology
This chapter will be divided into two sections. Section 2.1, entitled ontological and epistemological considerations, will outline the theory I adopt, namely social constructionism. This section will discuss the philosophical considerations and the assumptions underlying the choice of social constructionism and subsequently of Foucauldian discourse analysis. Section 2.2, entitled methods in action, will address how the methodology was put into practice, focusing on the choice of policy texts, the recruitment of participants, ethical considerations, and procedures of data collection and data analysis. 2.1 Ontological and epistemological considerations It is generally accepted that in providing a context for this study I need to clarify my ontological and epistemological approach (Taylor & Medina, 2013). I am paradigmatically and ontologically positioned as defined by Taylor and Medina (2013) in the critical paradigm. This emphasises the need to engage in interpretive research that deepens understanding. Sustaining this ontological stance is the notion that an individual’s reality exists with real consequences, but that reality is interpreted through discursive constructs in language, which are influenced by socio-cultural factors (Taylor & Medina, 2013). The underpinning principle of the critical paradigm is its commitment to identifying and transforming socially unjust social structures, policies, beliefs and practices (Ibid, p.5). According to De Gialdino (2009, p.1), epistemology encompasses analysis of the theory of knowledge, which explores how we come to know what we know. There is also an emphasis on understanding whether this knowledge is reliable. The issue of reliability is central to research within the critical paradigm, as notions such as reliability should be challenged: they are representative of dominant discourses or communities of knowledge, which seek to disadvantage certain groups and positions. Notions such as reliability derive meaning from their social context. Social constructionism as an approach to seeking out knowledge differs from other forms of enquiry as it examines the source of claims of
23 knowledge. It carries out this examination by de-justifying knowledge claims through analysis of how knowledge is constructed via factors such as discourse (Puwar, 2001). As Puwar continues, social constructionism allows the exploration of social positions via analysis of social interaction and how individuals can be subjectified and subjugated. It also encourages researchers to seek new understandings of what knowledge is and how it is preserved and advanced (Puwar, 2001). This critical disposition allows greater insight into how those with a privileged social position may disenfranchise other social groups by highlighting potentially unjust social practices such as health care. This point is important for me as, in seeking to understand the barriers to the development of OH, I need to understand why the development of OH as a practice is consistently discoursed in policy texts, but to date has yet to materialise. 2.1.1 Social constructionism What is important within this study is the concept of representation. In seeking to understand an individual’s worldview, it is impossible to look into their mind. Rather, the best we can hope to achieve is to understand how they represent themselves through factors such as language (Denzin & Lincoln, 2005). Given that the primary aim of this research is to explore and reveal the effects of referral to OH as perceived by NS, then it is for these reasons that the methodology chosen for this study is critical discourse analysis. According to Stevenson (2004), having reached this conclusion I am faced with two choices: to undertake Foucauldian discourse analysis (FDA) or to undertake radical social constructionist discourse analysis (RSCDA). Pragmatically, if researching issues of power then Foucault becomes the logical choice, as RSCDA is better suited to analysing issues of embodiment and materialism (Stevenson, 2004, p.1). This study will utilise FDA in two distinct ways. Firstly, a genealogical analysis of policy texts will be undertaken to analyse the discourses on which contemporary policy is built. Secondly, service user perceptions will be analysed via two focus groups and a subsequent round of individual interviews. This decision is based on my desire to reveal the structures which underpin language, utilising an historical analysis of policy discourse to consider the wider socio-cultural factors that structure referral to OH and the
24 students’ perceptions of how these constructions affect their use of OH. By opting to approach data collection within a social constructionist perspective I have taken the view that, whilst analysis of language is important, analysis of wider socio-cultural factors is just as significant (Willig, 2012). This wider perspective will include using awareness of social semiotics to explore the meaning derived from language and multimodal factors such as visual communication. Therefore, historical deconstruction of accepted givens becomes essential. Foucault indicates the rationale behind this approach: …criticism is no longer going to be practiced in the search for formal structures with universal value, but rather as a historical investigation into the events that have led us to constitute ourselves and to recognize ourselves as subjects of what we are doing, thinking, saying (Foucault, 1984, p.42) We should question the existence of givens, and focus on the practices which contribute to the creation of the social world. Social constructionists accept that discourse does not signify reality directly. Rather, other forms of evidence should be analysed to support claims of truth and knowledge. In outlining how our world is socially constructed then I am accepting, as Foucault (1971) indicates, that a complex and intricate relationship must exist between knowledge and power, and that these factors have tangible effects on people. In seeking to analyse the effects referral to OH has on NS as perceived by them, then according to Foucault it is possible to trace the effects of discourses surrounding OH. 2.1.2 Issues of position As Taylor and Medina (2013) indicate, our epistemological position is based on a set of assumptions which influence the research approach. I accept that these realities, as I perceive them, create ontological assumptions that will influence the way I gather, interpret and present the data collected within this study. Similarly, these assumptions create knowledge of key terms and my understanding of them. As such, my underlying assumptions regarding discourse as a concept are positioned with Foucault, for whom discourse means a set of implicit rules which oversee the formation and use of knowledge and meaning in cultures. Consequently, for me knowledge and culture are socially constructed, and discourse has institutional roots and
25 obligations which are embodied in historical practices and behaviours (Foucault, 1971). In exploring my axiological assumptions, then, I believe that human nature is intrinsically good and that both health and education should be utilised to create a fair and just society. My interest within this study lies in understanding on a deeper level how NS perceive OH, so that improvements in this service can be explored via further research for those students who inhabit a ‘public health vacuum’. 2.1.3 Discourse analysis Within the social constructivist perspective, discourse analysis emerges as a form of enquiry which rejects the idea of binary correspondence between knowledge of the world and the terms used to describe those factors (Ennis, 2012). According to social constructivists, if consideration is given to the way language is used to define the world, then new insights can emerge into the factors which have shaped the definition (Ennis, 2012). This author continues that our world is constructed through language as much as through our senses. Through its use, language expands or contracts our possibilities of knowing. Therefore, those determining what constitutes valid knowledge should consider the fact that our experiences of the world are subsumed by our linguistic descriptions of it. The realisation that language does more than mirror reality through binary opposition, and that language is constitutive of our view of the world, provides discourse analysis with credibility as it allows contextual analysis within social and historical contexts (Ennis, 2012). 2.1.4 Rationale for Foucauldian discourse analysis FDA diverges from other methods of discourse analysis as it is based on the premise that social structures and practices are governed by discourse. In particular, language is a mechanism to give meaning. However, language is more than a simple medium for conveying meaning; rather it is a constitutive practice (Wrbouschek, 2009). Therefore, this method goes beyond indicating what discourse means. To investigate how meaning is constituted through discursive practices and what is included or excluded in this process, Foucault (1994) outlines how subjectivity is constituted within specific configurations of power and knowledge. Power is recognised to be a core constituent of all discourses and one of the reasons why we participate in
26 discourse (Foucault, 1971, p.12). Power produces and defines knowledge and as such, they imply one another (Foucault, 1975a, p.32). Power influences knowledge so that discourse becomes a matter of inclusion and exclusion. It frames specific views and legitimises truth. This allows people to participate or not (Foucault, 1976:133). Foucault continues that power is more than repression: it is concerned with discipline, over both the human body and relational factors. However, it need not be a negative force, as power cannot be possessed in any sovereign sense, and therefore it is how power is accessed and exercised that we need to explore. Stahl (2004) offers the analogy of a marketplace to understand how power might be considered. The marketplace is understood as a place where people come to buy and sell goods. Power is seen as a marketplace for negotiation, where different participants have different market power and the creation of discourse depends on factors such as political, social or personal capital. Thereby, language sets the structures of meaning, within which individuals and communities act (Wrbouschek, 2009). Foucault (1979) termed this process an observing hierarchy, one that produces dividing practices and allows differential access. Additionally, Foucault approaches the participants of research differently from traditional researchers. Rather than see participants as deliberate users of discourse, Foucault (1979) considers them as bodies that are constructed and positioned by historically grounded discourses (Willig, 2012). As previously stated, what draws me as a researcher to Foucault’s work as opposed to other accepted forms of critical analysis is the focus Foucault has on the development of ideas across time and how he views power within the research process. To help undertake research within this approach, Foucault (1969) became interested in a form of enquiry which he termed genealogy. In exploring discourse via genealogy, Foucault (1969) offers an insightful way of looking at systems of knowledge. 2.1.5 Analytical considerations When commencing the process of familiarisation with Foucault’s work, it was appropriate to familiarise myself with his major theories. To undertake this I read four key texts: The order of things: An archaeology of the human sciences (1966); The archaeology of knowledge (1969); The order of
27 discourse (1970); and Discipline and punish (1979). To validate my initial considerations I undertook reading of secondary sources of information including Rabinow (1991) and Veyne (2010). According to Stozier (2002), Foucault challenges the accepted wisdom of research within structuralism, which is based on the synchronic study of language. Rather, Foucault offers a diachronic approach to the analysis of discourse. This is congruent with Foucault’s desire to allow for a framework of possible approaches to research, rather than a prescribed method. According to Jacobson (1971), synchronic discourse research is concerned with a single moment in time. Opposed to this is diachronic research, which concerns itself with the development and change over time of the concept under analysis. Foucault is advising us, therefore, to search for linguistic development through time and to explore generalisations as opposed to exact meanings (Jacobson, 1971). Within this study, given its focus lies in the analysis of the development of referral to OH across time, then diachronic investigation is appropriate. In seeking to turn this theoretical awareness of his epistemological basis into a method that could be applied to practice, I considered several models of analysis and ultimately decided to utilise that adopted by Dryzek (2005). This was chosen as it complements my stated research aims as well as providing a fluid approach to analysis. Dryzek focuses on the basic entities whose existence is recognised or constructed; assumptions about natural relationships between different entities; agents and their motives; and the key metaphors or other rhetorical devices that figure in the discourse (Dryzek, 2005, p.19). Dryzek’s model was utilised to analyse both the genealogical and interview discourse elements of my work. 2.2 Methods in action 2.2.1 Recruitment and sampling I am employed in the Faculty of Health and Social Care within a university, and my aim was to recruit NS from one cohort (30 students) during their final year of study within the university. Third year students were chosen as all would have been in contact with OH on at least three separate occasions. Sixteen students were recruited using purposive sampling to take part in focus group research and potentially in a subsequent semi-structured
28 interview. The participants were then divided into two focus groups of eight. Baker and Ellece (2011) indicate that purposive sampling is utilised when the researcher wishes the participants to have knowledge of the research issue and a willingness to participate. These two factors acted as the inclusion criteria for this study. All students were invited to take part in a subsequent interview, and five were actually interviewed. This number was arrived for practical reasons: Bryman (2012) indicates that small numbers of interviews are acceptable to allow in-depth analysis to take place; and, pragmatically, the length of time between the focus groups and the interviews meant that students were no longer in the university environment and access to students was reduced. In providing a rationale for the recruitment of NS, then two factors require explanation. Firstly, as NS are embarking on an educational programme which incorporates work placements and the programme is funded by an employing organisation (NHS), then contact with OH is compulsory to assess health status and fitness for work. No student can commence a work placement within the NHS without due regard to the legal concept of ‘a duty of care’ held by the employer to the employee (Health and Safety at Work Act, [HSWA], 1974). This means that NS have experience of the concept under analysis (Baker & Ellece, 2011). Secondly, from a practical perspective, these students are accessible to the researcher. 2.2.2 Participants The students who agreed to take part in this study were between 21 and 52 years of age. Of the sixteen students, fourteen were female and two male. Within the semi-structured interviews, four were female and one male. All described themselves as being from a white British ethnic background. All respondents had been employed as NS for two and a half years, and had been in contact with OH. Table 1: Demographic data for focus group participants Demographics for focus group Value participants Gender Men 2 Women 14 Age 18-29 11
29 30-49 4 50-52 1 Ethnicity Black 0 White 16 Number of contacts with OH 3 12 4 2 5 1 5+ 1
Table 2: Demographic data for interview participants Demographics for interview Value participants Gender Men 1 Women 4 Age 18-29 3 30-49 1 50-52 1 Ethnicity Black 0 White 5 Number of contacts with OH 3 3 4 0 5 1 5+ 1
2.2.3 Participatory research Baker and Ellece (2011) indicate that when undertaking FDA, the concept of power relations between the researcher and researched must be considered due to the unequal relationship between both parties. Therefore, I adopted a participatory research approach. This views the researched as active participants in the research process, in an effort to reduce power imbalances as much as possible (ibid.). To assist in this process focus groups were undertaken to determine the concepts to be debated in a subsequent round of interviews; this participatory approach allows participants to set the agenda for the next stage of the process (Baker & Ellece, 2011). Focus groups are useful in the preliminary stages of research, allowing exploration of participants’ attitudes, feelings, beliefs and experiences in a way which
30 other methods do not (Gibbs, 1997). This process was helpful as I felt it minimised potential power differentials and ensured the process and focus of enquiry were not predetermined (Wilson, 2001). In line with Bryman’s guidance, small numbers of participants were utilised for both the focus groups and subsequent interviews, so that in-depth idiographic analysis occurred (Bryman, 2012). 2.2.4 Location of texts In addition to analysis of discourses within the transcripts of the focus groups and interviews, analysis of historical texts representing major developments in the use of referral to OH is required. This process is relatively straightforward, as three major junctures of policy development exist. These are the introduction of compulsory referral contained within the 1833 Labour of Children and Young Persons Factory Act; via the legal mechanisms of certification of fitness to work and the duty of care held by the employer to protect employees’ health; the 1974 HSWA, which changed the duty of care criteria and expanded the scope of OH provision; and the 2008 Working for a Healthier Tomorrow, which indicates the need for expansion of OH and the referral of unemployed people receiving welfare benefits. 2.2.5 Analysis of texts Dryzek’s (2005) model was followed with an emphasis on identifying variation and inconsistencies. This was achieved using the following process: Firstly, reading and re-reading of the policies and transcripts at the micro level, focusing on the text to explore the linguistic and rhetorical techniques employed, which position the speaker in a certain way within a particular discourse. This technique involves key words, and the repetition of certain expressions and metaphors or other imagery, which are utilised for the purpose of persuasion (Wilson, 2001, p.297). Secondly, the discourse process is analysed to take account of the types of discourse present and how they are enunciated. This includes the identification of dominant, contradictory or silent discourses, and an analysis of what meaning the presence or absence of these discourses serves in the texts. This seeks clarity on how the respondent positions themselves in the discourses (ibid.), and was undertaken via the interpretation of the elements identified for variability and prevalence of patterns. The final analytical method involves
31 the analysis and clarification of the wider social, cultural and historical conditions in which discourses are fixed, providing opportunities to expose and scrutinise the effects of the larger forces at work in the composition of subjectivity and power relations (ibid.). Again, this was undertaken by exploration of the elements identified for variability and patterns. 2.2.6 Research and reflexivity As highlighted in the preface, Pillow’s (2010) reflexive framework will be utilised throughout this study to understand the influence I exert over the collection, analysis and presentation of data, as well as analyse the relationship I have with the participants. Pillow indicates that reflexivity is a methodological tool to analyse the process of representation, and emphasises the need to reflect upon the ways in which my own values, beliefs, and interests can influence my ability to represent the data. Reflexivity will be utilised throughout this study as an on-going process of becoming self-aware, to make visible where possible how the research process and I (ibid. p.178) have affected the products of this study. However, Foucault (1997) outlines how the process of critique should not be reduced to simple reflexivity, as reflexivity is constrained by our own subjugation. Rather, the critique should be utilised so that we have a critical attitude towards our own ways of thinking, to challenge our own regime of truth (subjection) so that we may develop new mind maps anchored in notions of transparency that expose our own power/knowledge influences (Jordan, Messner & Becker, 2009). Foucault proposes that we engage in a ‘critical ontology of ourselves’ (Foucault, 1997, p.319) by seeking to isolate, from the contingency that has made us what we are, the opportunity of no longer being, doing or thinking what we are, do, or think (Foucault, 1997, pp.315-6). Therefore, reflexivity should seek to consider the limits that we take for granted and to challenge them. Within the FDA chapters in this study, this element will be included as a series of footnotes. The rationale behind this is twofold. Firstly, due to the large number of direct quotes within the analysis sections I feel interruption of this data would detract from the analytical process. Secondly, reflexive footnotes are appropriate, as I wish readers to form their own opinions on how I have represented the discourses according to how the self (or
32 researcher selves) is conjoined to the other in the process of constructing data. The process of reflexivity was undertaken via the use of a reflexive journal, which utilised Pillow’s (2010) reflexive taxonomy. 2.2.7 Data recording and transcription Both the focus groups and the individual interviews were recorded in audio format and transferred to a computer, which could only be accessed via password to comply with the Data Protection Act 1998. Both the focus groups and the individual interviews had a typical duration of forty minutes. The audio tapes were transcribed using Express Dictate. All transcripts were made anonymous to protect confidentiality. All transcripts were paginated and line numbered using Microsoft Word to enable points of reference when conducting analysis of the data. Similar to the audio files, the transcripts were stored in two separate locations, both of which were password protected. 2.2.8 Ethical considerations This study was undertaken after submission of an application to the responsible ethics committee. In addition, permission was sought from the managers responsible for the welfare of NS. In compliance with the ethics committee and in conjunction with my own ethical beliefs, this research reflects the ethical principles of autonomy, justice, beneficence, non- maleficence and veracity (Bryman, 2012). Participants were therefore fully informed of the nature and purpose of the research. They were made aware of potential harm that might arise via the focus group and interview processes, and of their right to refuse to take part in this study and to withdraw from it at any time. They were made aware of the purpose of this study, that it was part of an academic programme of study, and that it would be examined in future. The mechanisms for confidentiality within this process were made clear. The participants were made aware of and consented to the audiotaping of the focus group and subsequent interviews. An outline was provided as to how I would comply with the storage and management of the audio recordings in line with the Data Protection Act 1998. They were also informed that these materials would be destroyed on completion of the research and its subsequent examination. Following the focus group and individual interviews, participants were allowed to discuss via a de-briefing session any feelings of unease with the conduct of this research or with the
33 subject matter. (Please see appendix 1 for copies of invitation letters, participant information sheets and consent forms distributed to the sample group). 2.2.9 Selecting extracts Extracts were selected in accordance with Dryzek’s criteria. These focused upon trends across policy texts that shaped surveillance of the body, and the development of technologies of the self; the variety of functions the referral process has to constitute subjects within their own taxonomy of acceptance; strategies of avoidance regarding surveillance and knowledge surrounding referral to OH; and what counts as accepted knowledge. Having identified the dominant constructions, decisions were made on which to include: the rationale for inclusion was based on the consistency with which they appeared in the texts and across the oral events, with the intention of showing the perceptions of the NS toward OH. Selection of quotes was undertaken to capture this element in detail. Table 3: Data extraction process (Statutory report element) Data extraction Method process (Statutory report element) Identification of Literature search statutory reports Data analysis of Thematic coding using Dryzek’s analytical coding statutory reports framework First interpretative Action Process Outcome cycle (micro level; Identification of the basic entities of existence) Making notes Reports read 1. Read in Knowledge of three times sequential order tone and 2. Read in structure of reverse order reports 3. Read in random order Exploration of Coding for Identification of Categorisation linguistic and themes, 187 codes of 7 themes rhetorical concepts, terms, and 5 sub- techniques keywords, key themes. expressions, Categorisation imagery and of 4 dominant subject rhetorical positioning techniques
34 Data extraction Method process (Statutory report element) Second Action Process Outcome interpretative cycle (identification of assumptions about natural relationships between different entities; agents and their motives) Identification of the Reports analysed Identification of Further 9 types of discourse for dominant, five dominant themes present and how contradictory or policy identified they are silent discourses discourses enunciated Identification of the ignored discourse of industrialists. Identification of three silent discourses Reports analysed Reports analysed Five dominant 5 forms of for variability and for identification assumptions social prevalence of of incomplete identified. apparatus discourse patterns logic and taken- Identification of identified. for-granted materialised 4 dominant assumptions forms of rhetorical apparatus of techniques control utilised Third interpretative Action Process Outcome cycle (macro level; all of the above) Identification of the Reports analysed Application of Identification of wider social, for evidence of Foucault’s forms of cultural and power relations techniques of sovereign, historical and subject government, disciplinary and conditions in which positioning forms of biopower discourses are knowledge, fixed fields of visibility and formation of identity criteria Reflective cycle Action Process Outcome Codes and themes Dryzek’s coding Dryzek’s coding 7 dominant reviewed and frame reviewed frame re-applied themes categorised in line identified with Dryzek’s criteria
35 Data extraction Method process (Statutory report element) Comparison Themes identified compared with themes from oral process events.
36 Table 4: Data extraction process (Oral event element) Data extraction Method process (Oral event element) Purposive sample Purposive sampling applied to identify one cohort of recruitment from nursing students (30 students) case university Contact Invitation letter, participant information sheet and information consent form distributed to sample group (please see provided to appendix 1 for copies of these documents). purposive group 16 positive responses received Unstructured 45 minute focus groups held focus groups X 2 (8 per group) All focus group 5 X individual interviews. members invited to individual interview Data extraction Action Process Outcome from oral events Transcription Use of Express Manual Text generated Dictate transcription. Paginated and line numbered First interpretative Action Process Outcome cycle (micro level; identification of the basic entities of existence) Making notes Transcripts read 1. Read in Knowledge of three times sequential order tone and 2. Read in structure of reverse order oral events 3. Read in sequential order Exploration of Coding for Identification of Categorisation linguistic and themes, 215 codes of 9 entity rhetorical concepts, terms, themes and 7 techniques keywords, key sub-themes. expressions, Categorisation imagery and of 4 dominant subject rhetorical positioning techniques
37 Data extraction Method process (Oral event element) Second Action Process Outcome interpretative cycle (identification of assumptions about natural relationships between different entities; agents and their motives) Identification of Transcripts Identification of Awareness of the types of analysed for seven dominant pictorial and discourse present dominant, student architectural and how they are contradictory or discourses importance enunciated silent discourses Transcripts Transcripts Two dominant 5 forms of analysed for analysed for assumptions social variability and identification of identified. apparatus prevalence of incomplete logic Identification of identified discourse patterns and taken-for- materialised granted forms of assumptions apparatus of control Third interpretative Action Process Outcome cycle (macro level; all of the above) Identification of Transcripts Incomplete logic Hierarchy of the wider social, analysed for accepted support cultural and evidence of without identified historical power relations challenge conditions in and subject which discourses positioning are fixed Reflective cycle Action Process Outcome Codes and Dryzek’s coding Dryzek’s coding 4 dominant themes reviewed frame reviewed. frame re-applied themes and categorised in identified. line with Dryzek’s Reduced to criteria four themes for discussion. Comparison Themes identified compared with themes from process statutory reports
2.2.10 Summary This chapter was divided into two parts. Part 1 sought to clarify the underpinning epistemological assumptions on which this study is based, in
38 an attempt to be transparent about the influences which I may translate to the study. Part 2 outlined the decision-making processes undertaken in the choice of research methods.
39 Chapter 3: Genealogical analysis and discussion of statutory reports
This analysis seeks to historicise the implementation of policies which give rise to current practices in OH. Foucault (1973b) indicates researchers need to challenge accepted heterotopic classification of forms of practice, in order to gain insight into how bodies of knowledge and the use of power develop to become accepted regimes and forms of truth and knowledge. Foucault outlines that we need to examine the creation of these regimes, determining how political and economic forces exert power over individuals and construct truth and knowledge as systems; those who construct the system create regimes in which their values and beliefs are favoured over other forms of truth and knowledge (Foucault, 1973b). Foucault indicates that processes construct possibilities for individuals and so play upon their practice. Processes objectify the truth, and it is the role of the researcher to identify the processes which create truth by exploring the discourses (Foucault, 1973b). This chapter will analyse three government reports which are pivotal in the development of OH. The first two documents to be analysed led to the development of government Acts, whilst the final document led to amendments of previous legislation. The documents to be analysed are: Report of Select Committee on Factory Children’s Labour 1832 (‘the Sadler Report’); The Safety and Health at Work Report 1972 (‘the Robens Report’); and Working for a Healthier Tomorrow 2008 (‘the Black Report’). The analysis has three aims: to determine 1) the grounds on which a system of classification can be founded; 2) the extent and character of the operation of ordering systems; and 3) the relationship between historical continuity and discontinuity (Foucault, 1973b). 3.1 The Sadler Report The Sadler Report (SR) 1832 was chaired by Michael Sadler MP, and his cross-party committee of enquiry comprised thirty-seven MPs. Their remit was to advise on how to construct a Bill to Regulate the Labour of Children in the Mills and Factories of the United Kingdom. The excerpts chosen from the SR are considered under four headings: 1) the nature of the problem; 2) changing the landscape of care; 3) work as a form of welfare; and 4)
40 regulation and certificates of the age at which work should commence as mechanisms to improve health. 3.1.1 The nature of the problem The factory system (FS) became the focus of discourses on health due to the introduction of machinery into the workplace during the industrial revolution. Industrialisation was felt to be creating widespread ill-health amongst the working classes, causing civil unrest (Nardinelli, 1980). Reform of conditions within the factories had been sought for some time, but had never been implemented due to the refusal of parliament to interfere with the economy (Hutt, 1925). Sadler seeks reform by utilising discourses of physical and moral degradation leading to a reduction in the ability of the nation to defend itself against economic threats and an increase in social confrontation. Sadler constructs the solution to these problems as the development of intervention in the form of OH certificates, and the development of the social apparatus of mandatory education for children. To achieve reform, Sadler uses rhetorical devices such as repetitive questioning, emotive language and comparison with competitors to structure a conceptual understanding of factories as a risk to health and morality. Additionally, the adverse health consequences suffered by women and children within the factories is constructed as a form of national shame. I contend1 that Sadler’s Report was actually a mechanism to develop control over the emerging industrial class and to maintain traditional social stratification.
1 This contention is influenced by two elements. Firstly, my own historical awareness that Sadler’s reforms, whilst hugely influential in addressing child labour, had very little effect on the rights of working class people. It is impossible to transcend my cultural awareness of this fact. However, in seeking to challenge my own prejudices, I extensively researched the views of historians in this field. Sadler’s work took place during a period of social upheaval including the abolition of slavery. It is accepted that legislation of this time was infused with a desire to alter social structures. I can see no contradictory evidence to challenge this assumption. The only conclusion I can draw and that others have drawn is that Sadler’s work was utilised as a mechanism to structure society to maintain power differentials. Secondly, one of my core ethical values, which underpin my own subjectivity, is a desire to address social injustice. Clearly, this period was significant in improving the lives of the lower social classes. The realisation that Sadler’s work was manipulated to allow the expansion of statism towards the developing industrial and working class is enlightening. I stated previously that this study is not motivated by politics. However, the realisation that liberalism was utilised to prevent civil unrest and that this pattern re-emerges after the Second World War has altered my mental map. My view of social injustice has moved from one of cynicism and concepts of actions with unintended consequences, to one of scepticism and a growing awareness of politics as a structuring system. This element has probably influenced the consistent assertion that social stratification lies at the heart of the reports analysed.
41 It should be noted that due to the technique of repetitive questioning, large sections of text from the SR will be presented for analysis. In total Sadler called eighty-nine witnesses, of which sixty-six were directly involved with work in the factories. The remaining witnesses were predominantly medics and clergymen who were called to give evidence regarding the deleterious effect of factory work on the health and morals of women and children. The following is a typical example of the questions asked to witnesses directly involved in factory work. Please note, in the extracts below, the number in the citation following the extract refers to the line number on which the commencement of the text can be found. Within this excerpt, Sadler is questioning William Cooper, a 28 year old who has been employed in a factory since the age of 10: Sadler: What were your usual hours of working? Cooper: We began at five, and gave over at nine; at 5 o'clock in the morning. Sadler: And you gave over at 9 o'clock?-At nine at night. Sadler: At what time had you to get up in the morning to attend to your labour? Cooper: I had to be up soon after 4 o'clock. Sadler: Every morning? Cooper: Every morning. Sadler: What intermissions had you for meals? Cooper: When we began at five in the morning, we went on until noon, and then we had 40 minutes for dinner. Sadler: Had you no time for breakfast? Cooper: No. Sadler: Had you any time for an afternoon refreshment? Cooper: No; when we began at noon, we went on till night; there was only one stoppage, the 40 minutes for dinner. Sadler: During the 40 minutes which you are allowed for dinner, had you ever to employ that time in your turn in cleaning the machinery? Cooper: At times, we had to stop to clean the machinery, and then we got our dinner as well as we could; they paid us for that. Sadler: At these times you had no resting at all? Cooper: No. Sadler: To keep you at your work for such a length of time and especially towards the termination of such a day's labour as that, what means were taken to keep you awake and attentive? Cooper: They strapped us at times, when we were not quite ready to be doffing the frame when it was full.
42 Sadler: Were you frequently strapped? Cooper: At times, we were frequently strapped (SR, 5). The majority of the sixty-six witnesses called to give evidence at this stage are questioned in this repetitive manner. Repetition is utilised to create a discursive regime, in which the view that work is harmful to health and is a moral threat is naturalised. Consequently, rules for understanding the nature of work as a risk to health are created and the practice of managing risk is spoken into existence (Schirato, Danaher & Webb, 2012). This allows control of the agenda of the Committee so that dissenting discourses appear abnormal as they infringe upon the rules of the discursive regime. The outcome is that work in the factories, the conditions in the factories and the methods used to ensure children did not become ‘inattentive’ to their work are constructed as dehumanising and harmful to health. Towards the end of the SR, this discursive regime expands to include words such as bad and evil, which are utilised to outline how the factories are a threat to individual workers and society, and that they become an ontological concept worthy of reform: Sadler: Have you remarked and do you believe that this excessive labour has a bad effect upon the morals of the children? Urquhart: [factories overseer] Very much so (SR, 8333). Sadler: Do you think that the Sunday-schools of the country can, under existing circumstances, remedy the evils brought upon the community by the excessive length of labour wrought by the children during the week? Fraser: [factories manager] I think they are not calculated to counteract the bad effects of the FS, much less to give useful instruction (SR, 9250). The word evil is utilised 170 times within the SR and the word bad 302 times. The repetitive use of these words allows Sadler to construct a dominant negative regime of truth, which creates knowledge of the need for reform. In focusing on health effects, evidence is heard of how deformity and impaired growth are commonplace. For example, the evidence of John Hall, a factories supervisor, is typical regarding the effects of factory work on physical health: Sadler: Will you describe to the committee the position in which the children stand … as it may serve to
43 explain the number and severity of those cases of distortion which occur? Hall: I knew a family, the whole of whom were bent outwards … and one of those boys was sent to a worsted-mill, and first he became straight in his right knee, and then he became crooked in it the other way (SR, 3033). Within Sadler’s questions, we can see that he creates a link between work and deformity. This link constructs health as a form of aestheticism, which is altered by labour. The use of aestheticism occurs due to the limitation of scientific knowledge of the adverse effects of work on health. Therefore, concepts of health were constructed on appearance rather than on fact. The function of this discourse is to create knowledge that labour creates the physical deformities suffered. Within this construction of health as a physical manifestation, I observe elements of Cartesian duality as the mind and body are treated as two separate elements. Sadler focuses on the body and identifies the risks to the body from labour. The mind is created as a form of moral endeavour for the state to cultivate. In utilising Cartesian duality, Sadler creates dividing practices to achieve his aims (Foucault, 1973b). The workplace becomes a disciplinary institution by creating notions of people as healthy or unhealthy. Those classified as unhealthy are divided from the workplace. Consequently, health is normalised as a disciplinary mechanism and the worker utilises measures to comply with normative standards of health within a technology of the self, which structures the workers as masters of their own subjugation (Schirato et al., 2012). Within the workplace, health is examined by OH to identify those who do not conform to normative standards. Consequently, the worker takes on a subject role and comes under the scrutiny of OH. By seeking to normalise moral behaviour both in and out of the workplace, the state also creates a dividing practice due to its ability to classify people as morally reprehensible (Foucault, 1973a): Sadler: What moral effect do you think it has on the minds of the children who labour thus at this early period of life? Hall: They would have a better opportunity of learning domestic duties, and of having their minds cultivated, and their morals preserved (SR, 467).
44 The inference from Hall’s evidence is that traditional roles are threatened. This theme is developed within the next excerpt which outlines the threat to traditional family life. Within this construction of the family unit, contradiction is evident as although the family unit is threatened by the FS, the parents are constructed as neglectful of their responsibilities, or as victims of a system which destroys the health of adults so that children must become the main source of income. In ordering the responsibility of the families in this way, Sadler creates people as both the master and slaves of their own regulatory subjugation. The family becomes both responsible and victimised at the same time for their behaviours (Schirato et al., 2012): Sadler: Is it not peculiarly distressing to those parents who are not so degraded in their minds, and so utterly debased in their feelings, that they have to subsist upon the labour of their children, themselves remaining idle? Osburn: Many of them have expressed that sentiment to me and very forcibly (SR, 9908). It is argued that the outcome of this discourse is to create a mentality that only the state has the ethical fortitude to protect the child from manipulative others. Sadler continues upon this theme when questioning Hall about the steps he takes to ensure the health of the children he oversees: Sadler: Do you select healthy children whom to take into your mill? Hall: Yes. Sadler: Are you particular in so doing? Hall: I am particular, and so are we all; we have often rejected children that we thought were not healthy looking. Sadler: When your fresh hands have been employed for some length of time, do you see any alteration in their appearance? Hall: Yes, I think I can see a marked difference in the course of a month or five weeks; when they come into the mill they look rosy, and they are plump and fat, and are generally lively and spirited; but in the course of a few weeks I can see a falling in their faces and a paleness in their countenance, and they grow spiritless and languid (SR, 3027). This discourse constructs children entering the factories as a homogenous group who are ‘rosy’, ‘plump’ and ‘spirited’. Following a short period of time the children become, ‘spiritless’ and ‘languid’. Sadler constructs work as the reason for this outcome. Therefore, he introduces the
45 concept that work is a risk to health and gives rise to the link between health and environmental risk factors. Consequently, Sadler gives scientific credence to the sanitary movement of which OH is a part. The grounds for the development of OH as a form of classification system are laid out and the ordering of priorities for practice is made clear. The sanitary movement aims to address hazardous environments and, within this construction, workplaces become dominated by notions of risk, rather than a place in which health can be improved (Weindling, 1983). The function of this discourse is to clarify the need to protect workers via the use of an observing hierarchy for transmitting authority. This is achieved through disciplinary, social and self-regulating methods of control. In constructing the factories in such a manner, Sadler seeks to create a truth about the FS. However, the creation of this truth should be challenged. For example, in creating work as a risk to health, the option that work is advantageous to health needs to be considered. In seeking to understand what appears to be a counterintuitive approach adopted by Sadler, whereby the earning potential of the family and therefore the ability of the family to access resources for health is reduced, then further analysis is required.2 By constructing workers as worthy of intervention from the risks faced via employment, Sadler maintains a ready supply of healthy individuals for use by the state, but reduces the families’ role as agents by reducing the
2 In exploring why I have chosen to analyse Sadler’s assertion that work is a risk to health, I feel explanation of my own thinking is required. Until recently, I would have accepted the premise that work is good for health. However, awareness that both health and education have been utilised as mechanisms of social control challenge this assumption. Is the concept that work is good for health a regime of truth to which I have become blind? Certainly, the accepted wisdom in this field indicates that since antiquity, work has been recognised as injurious to health and as such was considered an undertaking of the lower social classes. Similarly, since antiquity wealth has been considered as a foundation of good health. If ancient civilisations have been aware of the fact that wealth rather than work is central to good health, then I assume that Sadler must have been aware of these givens. As society was changing from a feudal system to a capitalist system, I contend that Sadler must have been aware that work in the factories would increase the wealth of the lower social classes. As such, health emerges as an area that must be controlled to maintain social order. This contention is based on the assumption that Sadler saw an opportunity not only to protect young bodies for the safety of the state; he also saw an opportunity to create productive minds. These two elements create the conditions under which docile bodies can be developed to maintain social order. This analysis is clearly influenced by my own subjugation within this mode of thought.
46 autonomy of the family to increase earning potential. It is argued that health inequalities and social stratification are maintained by reducing the ability of healthy children to contribute to the health of their relatives. In placing notions of social class before notions of evolution, the working class have one pathway from poverty removed, as health as a mechanism of escape comes under the control of the government. Sadler advocates for compulsory education to be introduced, as a mechanism to ensure children must be absent from work for a set period of time to protect their moral development. However, it is observed that compulsory education is used as a form of social control over the industrial and employed classes. Reay (2001, p.334) draws on research from scholars such as Green (1990), Plummer (2000), and Egerton and Savage (2000) which indicates education has been utilised to ensure the dominant classes maintain control over the lower classes as education is utilised as an instrumental rather than an emancipatory tool. This is achieved, as the standard of education provided to the working class is inferior to that offered to the higher social groups (Reay, Davies & Ball, 2005). Compulsory education allows Sadler to address the perceived decline in moral standards and ensures the support of large sections of society towards reform. The industrialists lose access to a large section of cheap labour and come under the control of legislative disciplines. Health becomes a form of social control through compulsory surveillance. For Foucault this development is important as it allows the state to exercise power over the industrialists. The industrialists can exert power over the worker through employment; however, the state controls the flow of workers, and the education and health of workers, entering the factories because the state has greater access to power as it circulates. Thus, disciplinary power is now in the hands of the state (Foucault, 1973b). According to Schirato et al. (2012), this construction is indicative of Foucault’s concept of governmentality. Within governmentality, the state replaces notions of sovereignty and religion with science and rationality. In doing so, it creates a need for data on those it governs. Health surveillance emerges as one form of data, and the ownership of this knowledge is used to exert power and to construct workers
47 as manageable subjects. Foucault indicates that governmentality allows the state to create regimes of truth based on six rules (1979, p.94): 1. The rule of minimal quantity – there should be greater interest in avoiding the penalty than committing the crime; 2. The rule of sufficient ideality – punishment has to use representation to deter; 3. The rule of lateral effects – punishment should have an effect over the observer; 4. The rule of perfect certainty – there must be an unbreakable link between crime and punishment; 5. The rule of common truth – punishment must be subject to the common idea of truth; 6. The rule of optimal specification – that offence must be classified. Health certificates and surveillance allow the application of these rules to ensure development of governmentality. The consequences of this construction are that knowledge is created that the health of children is more important than the earning potential of the family and the structure of British society is altered. Children become a formalised mass in need of sociological interventions such as health and education to construct them as distinct members of society. The risk agenda is utilised to construct children as not only at risk from exploitative adults, but also as a risk to moral standards and to the structure of society (Lupton, 1999). This promotes both autonomy and responsibility, and is a challenge to the role of the family in protecting the rights of the child. Childhood becomes a distinct concept in the industrial age, and self and civil developments become the dominant forms of social control (Hutt, 1925). Foucault describes this form of disciplinary technique as the concept of care of the self. Here, liberal expressions of freedom for children are played out within power/knowledge boundaries. Freedom, according to Foucault (1978), is concerned with the possibility of movement. In seeking to understand their place in society and the movement to which they can aspire, children must first understand themselves in line with the Cartesian concept of knowing thyself. To know ourselves we must have awareness of our self- limitations and communal responsibilities. This element is important as it
48 shapes our attitudes and dispositions, and helps the state to create normative values to which people will aspire and conform (Foucault, 1978). In seeking to look behind these discourses, Weindling (1983) indicates that the changes in attitudes towards the FS by parliamentarians came about due to awareness of national physical and moral degradation caused by work in factories and its impact on the armed forces. Weindling indicates that the Act which followed this report sought to increase the percentage of the population able to fight. In utilising the Act to create discourses to address working conditions, the state is able to introduce statism at the expense of the free market (Weindling, 1983). The development of OH, then, has little to do with preventing harm; rather it is about keeping people healthy so that they might endure the greatest harm. This construction is possible due to the inability of industrial capitalism to have its discourse heard and by the production of docile bodies, based on the need for an economy of performance. 3.1.2 Changing the landscape of care The theme of oppression was utilised by Sadler to create public anger towards the laissez-faire parliament. It is observed that Sadler utilises the rhetorical technique of comparison to create knowledge sets which portray industrialists as greedy, self-serving and manipulative. Sadler indicates that the factory children are not free-agents and are worthy of protection. He invokes comparison between the treatment of ‘factories children’ and of the treatment of ‘slave children’ in Barbados, the treatment of adult soldiers fighting for the British Army and of the treatment of children in French factories. Perhaps the most influential example of this rhetorical mechanism is the evidence given to the Committee by John Farre MD, who was called as a witness to compare the children of the UK with those of Barbados. Within his questioning Sadler is outlining how the care provided by the owners of the slave children is better than that provided to children within the FS: Sadler: So that you consider that the limitations of the length and degree of the labour of the children and young persons in Barbados is eminently advantageous to the planter himself, with a view merely to his own interest and future advantage? Farre: Certainly, it is necessary. In English factories, everything, which is valuable in manhood, is
49 sacrificed to an inferior advantage in childhood. You purchase your advantage at the price of infanticide; the profit thus gained is death to the child. Looking at its effects, I suppose it was a system directly intended to diminish population. Sadler: What have been the provisions to guard against the ill effects of excessive labour? Farre: The provisions consist in the proper management of the youth, in not sacrificing them (SR, 11536). The inference that the children employed in the factories are subjected to deliberate infanticide, which could easily be remedied by appropriate management, constructs the factory owners as wilful in their neglect. In outlining the profit gained from the FS as the death of the child, the industrialists are constructed as deliberately destructive and this allows the state to discuss interventions to protect the needs of the workforce. Here, Sadler is able to utilise governmentality within the need for the state to act rationally to protect the vulnerable from exploitative industrialists. By highlighting both external political and internal security threats to the nation, Sadler is able to identify women and children as a resource of the state, creating knowledge that the role of the state within the factories is population management (Schirato et al., 2012). In looking behind this discourse, we can see that the concept of population management further embeds networks of power for the continuance of social stratification. In ordering responsibilities of care in this way, the trajectories of responsibility come under the control of the state. In seeking to end the oppressive conditions within factories, the state is seeking to create the conditions for progressive power relationships between the industrialists and the workforce. Similarly, the state is seeking to create a set of values regarding the purpose of the factories as institutions, which support rather than hinder the development of productive citizens (Foucault, 1979). 3.1.3 Work as a form of welfare State intervention in respect of employment has interested politicians since the time of the Black Death (Higginbotham, 2014). Within the Elizabethan Poor Law of 1601, the creation of workhouses occurred based on the model of forcing those unable to find work to undertake work so that they could receive state assistance. Being sent to a workhouse was constructed as a form of personal disgrace, due to the dominance of the protestant work ethic
50 (ibid.). The workhouse approach was maintained until after the Napoleonic wars when it became unsustainable due to mass unemployment (ibid.). In seeking to alter this normative practice, Sadler constructs ill-health caused by the risks of working in factories as a burden on society. The thought of large numbers of sick or injured individuals roaming the streets with no access to resources created widespread fear of a decline in moral standards and of a rise in crime (ibid.). Within the SR, the government is seen to be addressing the issue of parish assistance by removing children from the workplace and replacing them with men. Additionally, the government creates new normative understandings of responsibility via discourses of a duty of care, to ensure that the cost of replacing children with men via compulsory education is incurred by the industrialists and not by the state: Sadler: Are you aware that occasionally parents apply to mill owners to be allowed to send their children to the mill? Bradshaw: [Factory worker] Yes, I am aware they do. Sadler: But you still think that they would not object to such a regulation? Bradshaw: I do; and my reason is simply this, that when they make application for parochial relief, the parish tell them to send their children to work at the mill; but were the mill owners prevented from taking children under a certain age, the parish would relieve them, but the unemployed parents being able to get nothing from parish to support their helpless children with, they are compelled to send them there, and they make application to that effect at an early age; but if the mills were prevented taking them so early, it would be a great benefit. Sadler: Would not the consequence of such a limitation be to throw a greater number of children on parish rates? Bradshaw: I believe you take a great number of adults off, and that there would be equilibrium. In a word, parents would be able to keep their children comfortably without having to trouble the parish (SR, 3526). Within the excerpt, the family are constructed as the ‘keepers’ of children, which is a further contradiction within discourses of statism and the role of the family. In highlighting that the employment of children is a threat to the employment of adults, the rhetorical technique of the narrative present is used. This technique creates a vivid image of history where parents could
51 and did care for their children in an appropriate manner. This form of nostalgia is used to invoke a desire to recoup a lost construction. The discourse further indicates that the state now needed to address the FS, which had caused a fracture in traditional values. The new normative structure became men in the workplace and children in schools. The workhouse became obsolete due to the knowledge that work took place in factories for which men would be compensated via the wage packet (Hutchins & Harrison, 1911). 3.1.4 Regulation and certificates of the age at which work should commence as mechanisms to improve health As we have seen, the effect of work on growing bodies was seen as injurious to the health of workers, and classified as a risk to the health and morals of the population, requiring intervention: Sadler: Do you think it would do good, in regulating the mill and FS, to prevent children going to mills until a later age than they do at present? Bradshaw: I believe it would (SR, 3523). Sadler: What age would you propose to fix as the period at which they should commence labour in the mills? Bradshaw: I cannot answer to that as it must be according to their constitution; but none I think are fit to go till nine or ten years of age (SR, 3522). The interventions sought were that factory doctors would certify the age of children to be no less than nine years and that children could only undertake work for a set period of time so that their ‘constitutions’ could develop. To ensure compliance with these proposed regulations, it was outlined how children under the age of 18 must attend compulsory education for two hours per day. Certificates of age were utilised, as birth registers did not exist until 1837 and therefore certification was seen as the best method of removing children from the workplace (Thomas, 1948). The rise in scientific rationality via the use of age certificates leads to forms of self-discipline, due to the knowledge that deformity and visible, physical manifestations of disease lead to exclusion from the workplace. Certification allows OH to define reality and therefore define deviance. OH is ontologically constructed within two distinct forms of social structure: namely, health surveillance and ill-health concealment. The effect of this ontological existence for OH is that resistance to contact with OH becomes the norm due
52 to anxieties on behalf of the workforce, and the threat of OH to employees’ sociological construction as a provider (Peterson & Bunton, 1997). This is due to the threat of the subjective sense of the self within the individual by the ontological institution of OH. A paradox is created between work as good for the body, due to the economic ability to access resources for good health, and work as bad for health due to the erosion of physical and mental capability. This creates a tension between the medical construction of work as good for health, and lay concepts of work as a mechanism for eroding physical and psychological resilience – the outcome of which is avoidance of the gaze of medicine where possible (Peterson & Bunton, 1997). Certificates take the form of a mediating factor between the industrialist and the worker, and are accepted due to the assumption that medicine is a rational profession and that certificates speak the truth about a person’s health (Miller & Rose, 1993). Within the SR, workers are positioned as a homogenous mass, constructed grammatically as docile bodies within technologies of the self and disciplinary control, which exposes them to risk. They are ontological victims of a system designed to erode their health and wellbeing in the pursuit of wealth. The function of this discourse is to make plain the need to protect this homogenous mass via the use of an observing hierarchy for transmitting authority. 3.2 The Robens Report Lord Alfred Robens, a trade unionist, politician and industrialist, chaired his committee of enquiry, which comprised six members and produced the Robens Report 1972. The remit of the committee was to review and make recommendations for the safety and health of persons at work and that of the public in connection with activities on industrial, commercial or construction sites (Robens, 1972). The excerpts chosen for analysis from the Robens Report (RR) are entitled: 1) the nature of the problem; 2) OH as a threat to the NHS; 3) response to the problem; 4) changing the landscape of care; and 5) health surveillance as a mechanism to improve health. 3.2.1 The nature of the problem – work as a risk to health At the time of the RR, the UK was one of the safest places in the world to work and one of the most regulated societies in the world (Browne, 1973).
53 Browne continues that despite improvements since the SR, a plateau of enhancement had been reached and trends indicated a growth in industrial accidents and illness. By the late 1960s it was obvious there was too much legislation, that legislation could not keep pace with technological advances, and that this had created a culture of apathy and avoidance (Eaves, 2014). The master and servant relationship where the master has responsibility for addressing health issues had, in Robens’ opinion, created passive recipients of care. The outcome was apathy, with a cultural understanding that accidents were survived and that occupational ill-health occurred and brought with it long-term consequences for which the employee would be compensated (Eaves, 2014). Legislative and societal interest was only piqued if a disaster occurred. Tragedies such as Aberfan (1966) highlighted regulatory gaps and a lack of interest in work as a risk to health, which had deadly consequences for the public. Additionally, by structuring legislation that focused predominantly on safety issues, little legislation which focused on improving health had been introduced (Browne, 1973). New manufacturing techniques and materials meant that new threats to health were emerging; in particular, the rise in the use of carcinogenic materials meant a rise in occupational cancers (Eaves, 2014). The dominance of discourses of safety over discourses of health, and a growing awareness of the scientific limitations of predicting safety and health outcomes, meant that a change in approach from all parties was required (Robens, 1972). The philosophy behind the RR is the need to reduce state regulation and to increase self-regulation, so that increased ownership, responsibility and involvement could occur. Please note, in the extracts below, the number in the citation following the extract refers to the paragraph number on which the text can be found. In setting out his plans, Robens is clear on what needs to happen: We suggested at the outset that apathy is the greatest single contributing factor to accidents at work; this attitude will not be cured so long as people are encouraged to think that safety and health at work can be ensured by an ever-expanding body of legal regulations enforced by an ever-increasing army of inspectors ... The point is quite crucial. Our present system encourages rather too much reliance on state regulation, and
54 rather too little on personal responsibility and voluntary, self- generating effort (RR, 28).
Within this extract, we can see that health becomes the responsibility of all parties. Robens highlights a lack of agency via the use of the phrases ‘too much’ and ‘too little’. These construct all parties as passive and it is the clear intention of the RR to create a system based on active involvement. Here we can observe the expansion of technologies of the self (Foucault, 1982). By structuring the need for reform as a public imperative, Robens creates the conditions in which workers must now alter their actions for the betterment of society. In outlining that apathy is the dominant issue in the workplace, Robens uses the rhetorical device of generalisation to create acceptance as a fact that apathy is endemic. I contend that in doing so the ontological separation of mind and body created by Sadler continues within the RR. Physical manifestations of health in the form of accidents and diseases dominate discourses. The body that occupies physical space can be measured and controlled by notions of risk. However, in utilising apathy as a reason for accidents and disease, the individual is made aware that the reason for physical injury and illness is an affective characteristic of the mind. The actions of the mind can only be measured and controlled by the self. The self needs to be ‘cured’ of its deviance and this can only be achieved by the withdrawal of the state and an increase in self-control. The need to address the mind via self-improvement remains a moral imperative for the state. The reduction of the state is a diachronic phenomenon, indicative of a move towards governmentality via development of technologies of the self (Foucault, 1982). Statism is discoursed as inappropriate, and the moral responsibility for health becomes a concept of the self in tandem with significant seen and unseen others within an environmental construction of risk. The risk assessment (RA) process, which is constructed as a form of disciplinary power via the use of hierarchical and normalising judgements, hypothesises the workplace as an environment which is harmful to health. The outcome of constructing the workplace in this way is that the body
55 becomes part of the solution, which is controlled and ordered by the concept of risk to the self, others, and the organisation (Schirato et al., 2012). In looking behind this discourse, Smith (1997) indicates that workers’ compensation lay at the heart of the RR. According to Smith, the real motive for the RR was unease with the compensation ethos and a desire to avoid the litigious culture evident in the United States of America (USA). Moves towards shared responsibility based on agreed goals were felt to be the most effective way to avoid this development. Prevention would move beyond a narrow focus on safety to address issues of health. Smith (1997) continues that the Department of Employment provided a compelling argument to Robens: they indicated that whilst compensation was the norm, then a prevention culture could not emerge: It is no part of our task to try to explore the legal complexities, which surround the action for damages for personal injury; nor is it within our terms of reference to pursue these criticisms of the system as a method of compensating the victims of industrial or other accidents. Our attention has, however, been drawn very strongly to the way in which the system operates to the detriment of the accident-prevention effort (RR, 433).
Robens then lists five main reasons for this state of affairs. The following excerpt best demonstrates this: First, the task of framing sensible and effective statutory provisions for the prevention of accidents is made much more difficult than it need be. This is because employer organisations, trade unions and others who must be consulted, inevitably and understandably tend to be concerned as much with the implications of such provisions in the compensation field as about their potential efficacy as means of preventing accidents (RR, 434).
I contend that Robens utilises rhetorical techniques such as logos and ad hominem argument to highlight the need to address the lack of benevolence towards the public, with the expressed intent of constructing a system based on risk where the worker becomes a part of the system and needs to develop self-regulating techniques. 3.2.2 OH as a threat to the NHS Within the RR, a great deal of time is spent defining OH. This is due to competing notions of OH provided by expert witnesses, and by a growing movement by the ILO and the WHO to replace the biomedical model of
56 health with a public health model. This new approach to addressing health would be focused on social justice by improving the settings in which people work, live and play (Mortishead, 1946; WHO, 1986). Within the SR, OH was given a clear preventative role via construction of health certificates. Robens continues with this judgement by indicating: The role of occupational medicine can be understood only against the background of the general structure of health services in this country. The main element is the personal and mainly curative work of the National Health Service, which is centred on the individual and family and not on the place of work. The second broad division of the health service is the environmental, preventive or "public health" service provided for the community as a whole… In the field of OH the working environment is of predominant importance, and it is engineers, chemists and others rather than doctors who have the expertise to change it (RR, 357).
In this excerpt, we can see that OH is constructed within a very narrow definition of health prevention. Medicine and by association OH remain entrenched in curative care. It is made clear that other health functions are the remit of the NHS. The call for a comprehensive OH service is constructed as a threat to the NHS. By constructing OH in this way Robens reduces the ability of OH to create environments conducive to health. The environmental movement, rather than expand into areas such as the settings approach, moves into areas of bio-ecology, which indicates that the biggest threat to the health of unseen others, the environment and themselves is human beings. Research now shifts from awareness of the effects of work on health, to awareness of the role of humans in degrading themselves and the environment. This allows the rise in behavioural explanations of health and reduces attempts to address the sociological determinants of health (Tones & Green, 2010). By rejecting an expanded environmental approach, safety continues to dominate health due to the focus on reducing risk. In highlighting the limitation of knowledge within the field of OH, the scope of practice becomes curtailed and the growing call for a nationalised OH service is dismissed. The rationale for this argument is put forward via an economic discourse of the threat of OH to the NHS: It should be mentioned at this point that a number of previous reports have examined various aspects of provision for OH,
57 and we note here some of their principal conclusions relevant to our subject. The Dale Report, 1951 surveyed the structure and functions of the NHS, the local authority health services and industrial health services. The Report recommended that development of private industrial health services should be encouraged 'with due regard to the demands of other health services for medical manpower’ (RR, 359).
This narrow view of OH meant that an opportunity to address health and rehabilitation was missed (Smith, 1997). The Act did not create a nationalised OH service, as was the case in the USA and Scandinavia. Robens’ observations were that private services had come to dominate provision in this area, the infrastructure needed to improve OH would be too expensive, and that no accepted standards of practice existed. To address this issue the HSWA (1974) introduced the Employment and Medical Advisory Service (EMAS), which provides advice to all industries on health matters. Though EMAS would be distinct from the NHS, Robens envisaged strong links between these two services; however, this element has yet to emerge (Smith, 1997). Smith continues that the possibilities for action created by the SR had fashioned a system where OH professionals were engaged in preventative, punitive and compensatory mechanisms. The RR did little to address this confusing set of aims. In constructing OH as secondary to environmental hygiene in terms of a preventative function, it is observed that OH could not become a central tool for public health and that the status quo of a curative biomedical system was maintained. 3.2.3 Response to the problem Robens indicates the need to move towards a system of self-regulation based on a partnership approach. However, in changing systems and processes to achieve this aim the RR becomes contradictory in nature: whist advocating for self-regulation via RA, Robens introduces three new authorities to oversee risk management. These authorities increase the role of the inspectorate and ensure paternalistic oversight from the state (Smith, 1997). There would be advantages in establishing such an Authority entirely outside of the central government machine… The question of how it would exercise its responsibilities for the preparation, revision and enforcement of statutory provisions is
58 one that raises Parliamentary and constitutional issues (RR, 120).
Here we can observe the development of regulatory mechanisms to achieve micro-political structures of governance and a continuance of statism toward industry. Robens, within discourses of liberalism, creates structures which ensure surveillance of industry is maintained. Foucault (2008) indicates that within the neoliberal agenda the requirements to create free individuals are offset by the need for freedom to be maintained by mechanisms of government control. Robens’ ideas of partnership working mirror Foucault’s outline of ‘the dream of a third way’ in which capitalism and socialism can develop for the benefit of all; the outcome of which is that all parties become investors in maintaining social stratification and the dominance of the state (Foucault, 2008). The paradox of liberalism is that security of freedom can only be guaranteed by the surveillance of society (Schirato et al., 2012). Surveillance within this report is evident with the introduction of the three new regulatory bodies including EMAS and is enacted through risk assessments. Rather than appease the market with a system based on purely goal-setting mechanisms, Robens advocated a mixture of prescription and goal-setting ideals. Of note is the idea that employers and employees must conduct RAs into the inherent risks of workplaces to identify imminent and subsiding risks to health. Where a risk to health is not imminent, then the employer must undertake a cost/benefit analysis of the risk to people versus the risk to the organisation, and deal with matters in a reasonable way. This stipulation was designed to ensure a collaborative approach. However, notions of cost, benefit and personal risk are subjective, and this fact led to conflict, which in turn led to the courts becoming the arbitrator of what reasonable meant (Smith, 1997). The use of contradiction by Robens constructed workplaces not as exemplars of co-operation, but rather as a space where power/knowledge became contested (Schirato et al., 2012). Contradiction continues as Robens outlines how co-operation should occur. Within the following extract, we can observe how the concept of self- regulation becomes entwined within notions of shared responsibility. Shared responsibility is impossible within Sadler’s construction of the master and
59 servant relationship as each party has differing responsibilities. Rather, the space created by adherence to forms of rational knowledge within RA and surveillance produces a trajectory of diminishing defiance within the employee. This is achieved by what Foucault describes as the concept of descending individualism. Here, individuals are made to appear as explicit entities, but the form this distinctiveness takes is subject to the power/knowledge nexus (Schirato et al., 2012, p.89). Individuals are made subjects of biopower, as the biology of human disease becomes a political strategy. Surveillance takes the form of a policing policy, which allows a regime of surveillance to mould the individual into an ethical and productive tool of the state (Schirato et al., 2012). A principal theme of this report is the need for greater acceptance of shared responsibility, for more reliance on self- inspection and self-regulation and less on state regulation. This calls for a greater degree of real participation in the process of decision-making at all levels. Responsibility lies with those who have a voice in decisions (RR, 114).
The report continues in its contradictory nature, as Robens does not create the infrastructure necessary for active involvement. Rather, the infrastructure introduced remains management and expert led, and follows the pattern set down by Sadler. I contend3 that the use of RAs means that the employee’s best avenue for the development of agency is through communication. For this to occur the worker must have a ‘voice’ that is heard. However, the RA process, which is based in scientific rationality and is constructed as a societal imperative, is afforded a voice whilst affective rationality, which is proposed as a form of self-protection, is discredited. At the top level of the new organisation there should be an identifiable person able to give the subject undivided attention and single-minded direction; one voice that can pronounce
3 Upon reflection, I feel that as with previous reflexive accounts, the reader should consider my own desire for social justice and the notion of hindsight as influencing factors in this contention. Clearly, I believe that all individuals within the workplace should have an equal voice. This is in line with Robens’ stated intentions. As an OH practitioner, I have knowledge that Robens tri-partite framework works well in OH settings in countries with a strong sense of social democracy. I have professional knowledge that Robens’ framework does not work well in workplaces that maintain hierarchical systems as is common in the UK. I believe that within hierarchical workplaces, voices are silenced for a variety of power/knowledge factors. In seeking to transcend my professional awareness that where voices are silenced power imbalances lead to poorer health outcomes, then I sought to only provide the views of accepted scholars in this field.
60 authoritatively on matters of safety and health at work (RR, 113).
Within this excerpt, it is observed that in favouring the authority of truth from a knowledgeable leader, the voice of the employee is silenced or brought into question. The notion previously discussed – that employees favour compensation over prevention – raises questions of truth-telling within the introduction of the RA system, which is counterproductive to the employee’s desire for compensation. RA takes the form of a normative ethic and via socialisation meta-ethics is evident in the construction of the employee’s self via games of truth, which are played out within the interaction between the code (RA) and the practice of seeking compensation (Schirato et al., 2012). Power/knowledge within the RA process is therefore not absolute, and the impact of this system for OH practitioners is that both the employer and employee create OH as an instrument of risk to themselves. The outcome of this construction is that neither adversary in the employee/employer game of truth views OH as trustworthy. Consequently, OH inhabits a space where the complexities of finding a third way are played out. I contend4 that the outcome of this construction is that the voices of the employee and of OH are reduced. As with the SR forms of social escapism, particularly compensatory mechanisms are lost whilst the voice of statism is favoured. In doing so, the state maintains its dominance over the industrialists and the workforce, and curtails the development of OH practice. In setting the context for the RR, it should be noted that during the 1950s and 60s the growth of the trade union movement was seen as a natural outcome of social liberalism. By 1978, six years after this report was published, the UK was described as the sick man of Europe due to the breakdown of relations between the trade unionists and the industrialists (Eaves, 2014). 3.2.4 Changing the landscape of care
4 It is clear that within political circles until recently OH was under-represented at the highest levels of decision-making within government. During the time of the RR, OH was a fragmented profession. This made it difficult for Robens to reach any other decision, but to seek to create a voice and professional standards for OH via the development of EMAS. What the reader may hear within this contention is my frustration that Robens via the use of EMAS could not create a culture conducive to health improvement. The voice of OH has been reduced, leaving it in a vacuum. I have sought to represent Robens as faithfully as possible; however, I do have the luxury of hindsight.
61 In stating that all parties within industry must become self-reliant, Robens introduces a contemporary view of the master and servant relationship. This relationship is based on the principles of modern liberalism and outlines that each party within the workplace has a responsibility to care for the other, but that they also have a responsibility to care for the public: We believe that the general principles of safety responsibility and safe working should be embodied in a statutory declaration, which would set all of the detailed statutory and other provisions in clear perspective. We recommend, therefore, that the Act should begin by enunciating the basic and over-riding responsibilities of employers and employees. This central statement should spell out the basic duty of an employer to provide a safe working systems … It should also spell out the duty of an employee to observe safety and health provisions and to act with due care for himself and others (RR, 129).
In this extract we can see that the notions of care which the state had responsibility for, constructed within the SR, are significantly altered. The state is able to withdraw from many of its statutory requirements for overseeing the workplace, to a system which increases the use of civil law. Civil law becomes the basis of legislation, allowing the state to distance itself from adverse incidents, and from claims of mismanagement and for compensation (Kloss, 2010). In chapter 5 of this report we have recommended that in the promotion of OH and safety more emphasis should be placed in future upon the use of non-statutory codes and standards, partly in supplementation of and partly in place of statutory regulations. This is one of our fundamental recommendations, and as it could have considerable implications for those involved in damages actions, it strengthens the case for a review of the present system of compensation at common law (RR, 448).
This system is enacted within the RA process. Additionally, RAs create notions of the good worker, and the remit of the master/servant relationship alters: the servant now seeks to conform to normative standards laid down by the master and by civil and legislative mechanisms, in the knowledge that non-conformity with legislation constructs them as being morally negligent. Consequently, this negligence becomes a threat to their advancement and
62 acceptance within the workplace (Galvin, 2002). Workers are constructed within categories of compliance. Within Sadler’s work, traditional notions of illness as a sin and as a personal responsibility were given voice via aesthetic acceptance of health. Robens expands notions of health as a personal responsibility, constructing notions of illness and injury as outcomes of people’s irresponsible behaviours and attitudes towards themselves and others. In doing so Robens alters the notion that machinery is the biggest threat to health in workplaces, replacing it with humans. Humans need to be controlled via increased governmentality, on the assumption that workers should strive for independence, self- resilience and increased responsibility, and that accidents and illness caused by known risk are unacceptable (Galvin, 2002). To expand on notions of control of the physical body, notions of wellness are created to control the minds of workers. Schirato et al. (2012) indicate that within this development Robens is using the governmentality approach of policing, whereby the state is able to adopt a pastoral role by creating knowledge of what a good citizen should think, do and feel. There is no single panacea and there are no simple short cuts. Progress in this field will rarely be dramatic. But we believe that by patient and unremitting effort it is possible to raise the status, so to speak, of the subject of safety and health at work in the minds of individuals. We should like to see it eventually command something like the degree of interest and attention commonly accorded to other subjects—such as industrial relations—where the problems may be more controversial but are often less real and important in terms of human wellbeing (RR, 13).
Here we can observe the criticism of paternalistic attitudes towards health and safety. The message that cultures need to change is re-emphasised and the way forward appears to be exploration of the concept of wellbeing. As we can see from the excerpt below, wellbeing in this sense is concerned with greater understanding of the factors which produce healthy, more productive workers (Tones & Green, 2010). In seeking to construct workers as docile-productive rather than purely docile in nature, Robens creates a vision of acceptable behaviour. This is centred on the idea of increasing productivity, reducing absences and of
63 blaming workers who become ill for their actions. In so doing, notions of sociological causes of disease are discredited in favour of behavioural explanations of illness. Similarly, this excerpt indicates how governmentality of the workforce should be changed to include monitoring of behaviours in work and of sickness absence (SA): We would expect the EMAS to become part of the Authority's organisation. Within that, it would continue to have a fairly distinct identity. It would not be concerned exclusively with occupational medicine as we have defined it, but also with the medical aspects of rehabilitation, training and other employment matters. We see this as an advantage. Overseas, rehabilitation is often included within the functions of the national occupational safety organisation, and we think that the medical aspects of training and the study of broad problems such as mental health in industry and sickness absence also fit naturally into this picture (RR, 374).
In comparing services with foreign competitors, and by indicating these countries are taking a broader perspective than the UK, a situation is created where a regulatory body is needed to expand knowledge and understanding of risks to health so that the UK remains competitive. The surveillance of society is discoursed as a national imperative in the face of a threat from foreign competition. This rhetorical tenor of the discourse utilised by Sadler continues within the RR. The idea that EMAS should regulate research into factors such as mental health and advise on matters such as SA is given credence. Here it is argued5 that by expanding the remit of investigation into developing factors in the workplace, such as a rise in mental health issues (MHI), the state is able to keep financial oversight of industry whilst placing the responsibility for addressing these issues within the private sector (Smith, 1997). Again, this discussion is full of contradictions, as EMAS is given the task of setting national standards for OH within a system which will be based on private provision. Similarly, by indicating that nationalised OH services overseas
5 This argument is based upon my own acceptance of Antonovsky’s (1979) sense of coherence theory and my rejection of blaming individuals for their health behaviours. Clearly, this judgement is based on my own assumption that structure influences the greatest effect on health in the majority of cases. Antonovsky observes that a potential outcome of a focus on behavioural explanations of health is an increase in MHI due to our inability to self- manage threats to health over which we have limited or no control. The reader should consider my acceptance of this premise.
64 function differently, Robens uses comparison to structure a system over which the state can control factors which have an effect on national interests, such as the rise in the cost of SA to the nation (ibid.). 3.2.5 Health surveillance and RAs as mechanisms to improve health The EMAS Act provides for abolition of the routine medical examination of new entrants to industry in favour of a much more selective system; and for abolition of the existing AFD service. A new EMAS will be established with a broad role in OH. This will include not only the provision to government and industry of medical advice on OH and hygiene, but also advice on the medical aspects of training, rehabilitation and other employment matters (RR, 372).
Within this extract, we can observe that the system of screening children and young persons is now removed. The AFD (Appointed Factory Doctor) system established by Sadler is abolished and replaced by EMAS, which will have an advisory role. RAs are now the chosen method of administrative control of the health of the workforce. In line with Foucault’s (1979) theories of governmentality, I contend that rather than risk being utilised as a form of liberalism within rationality, risk is utilised as a mechanism of control. In constructing the process of RA as a legitimate practice to protect all interested parties, Robens is able to legitimise the practice of self-regulation based on the principles of a moral endeavour, which has pragmatic and cognitive resonance. As such, the use of the RA becomes the ‘right thing to do’ and becomes a taken-for-granted mode of practice (Lim, 2011, p.16). This author continues that in identifying apathy as the dominant risk, then governmentality is used to address this risk. In doing so, it constructs the industrialists and the workforce as self- regulating forms of neoliberal agents, and the relationship between the state and industry is altered to the benefit of the state. The state is able to move from notions of direct government action to forms of social governance (Lim, 2011). In creating risk as a taken-for-granted mode of practice, the surveillance of the body becomes part of the mechanism for identification of the failure of risk management. Health surveillance is undertaken on humans to assess if the control mechanisms put in place by the RA process are suitable and sufficient to protect against adverse health effects (Rogers, 2002). Given the
65 technical nature of this work it is clear that, whilst Robens indicates that health examinations are to cease, in reality the requirement for health examinations is significantly increased due to the need to quantify the risk from the interaction of humans with working practices. This provides the employer and OH services with greater opportunities to scrutinise the body and to create normative standards of health. As with the SR, mechanisms and causative knowledge of how work affects health remain largely absent at this time. This simple fact explains why Robens favoured the dominance of scientific enquiry over mechanisms to improve health. The workforce remain positioned as a homogenous mass, constructed grammatically as passive recipients of physical and psychological risk, the ontological victims of a system designed to erode health and wellbeing in the pursuit of wealth. The concept of wellbeing now regulates the workforce within acceptable ways of behaving in light of the knowledge that employment has become the dominant means of social stratification. The workers are now constructed as a risk to themselves, their organisation and unseen others. The function of this discourse is to make plain the need for workers to become self-regulating agents, and to protect others and themselves via the use of disciplinary, social and self-regulating methods of control. In constructing workplaces as a distinct microphysical environment, the state is able to withdraw from responsibility for accidents and illness at work, whilst exerting greater control over this section of society. 3.3 The Black Report The Black Report 2008 was an independent review of the health of Britain’s working age population; Dame Carol Black’s remit was to advise the Department of Work and Pensions on improving their welfare. The Black Report (BR) was based on a consultation with 260 interested parties (Black, 2008). The excerpts chosen from it are discussed in sections entitled the nature of the problem; response to the problem; and work as a moral endeavour. 3.3.1 Nature of the problem The health of working age people became the focus of discourses on work and health for three reasons. Firstly, the worldwide banking crisis focused attention on the rising economic cost of illness to the state. Secondly,
66 changing patterns of health behaviours and their negative impact on future workforces were becoming apparent. Finally, the notion that work is good for heath was seen as a mechanism to address widening health inequalities (Black, 2008). Please note, in the extracts below, the number in the citation following the extract refers to the page number on which the text can be found. The costs to the taxpayer – benefit costs, additional health costs, and forgone taxes – are estimated to be over £60 billion. The annual economic costs of SA and worklessness associated with working age ill-health are estimated to be over £100 billion. This is greater than the current annual budget for the NHS and equivalent to the entire GDP of Portugal. There is, therefore, a compelling case to act decisively in order to improve the health and wellbeing of the working age population (BR, 10).
Despite life expectancy and numbers in employment being higher in Britain than ever before, and against a background of one of the best workplace health and safety records in the world, around 175 million working days were lost to sickness in 2006... In addition, around 7% of the working age population are workless and receiving incapacity benefits because of long- term health conditions or disabilities (BR, 21).
Here we can see that an economic discourse is used to construct the need to expand control of health beyond the workplace to consider the health of working age people who are workless or receiving state benefits. In doing so the criteria used for understanding the effect of work on health are expanded to include notions of the effects on health from unemployment. This breaks with the previous reports and indicates an expansion of the government’s surveillance of health. The rhetorical devices seen in the previous reports, of comparison with competitors, the threat of an uncertain future and logos based on social responsibility, continue within Black’s work to produce a ‘compelling’ argument for the expansion of OH provision beyond the factory. The rhetorical device of creating anxiety about an uncertain future is utilised extensively in the BR. For example, within the above statements the use of the phrase the ‘costs to the taxpayer’ outlines the state’s concern with the cost of ill-health. Here the economic cost of SA in work and the cost of incapacity benefits are discoursed with regard to the price paid by the state
67 and its effects on the state’s ability to deal with the financial crisis. This rhetorical device is used to create an assumption that taxpayers are owed improvement in health behaviours of those receiving benefits. Foucault (1979) indicates this form of disciplinary technique is used to construct notions of normality based on the needs of the state. In seeking to normalise opinions on SA and incapacity, the taxpayer is discoursed as acceptable to society whilst those receiving benefits are constructed as abnormal; the outcome is to indicate that abnormal individuals need to become the subjects of a system of change. The system recommended within this report is based on capability assessments, similar to that proposed by Sadler: those found to have capability both in and out of the workplace will be required to find work or have their benefits reduced (Black, 2008). In analysing this shift from notions of health to notions of capability, it is observed that whilst health is a contested concept based on individual needs, capability is an objective measure over which the state can set normative standards. This shift allows the state to increase control over its citizens by increasing the use of surveillance. Foucault (1979) indicates that whilst this system is constructed as addressing the need for rehabilitation and integration, and appears to be compassionate in nature, the aim is not only to rehabilitate individuals back into mainstream society, but also to confer on individuals a label so that the delinquent can receive treatment to correct their abnormality. Injuries and accidents are not utilised within Black’s work, as was seen previously. Since the time of the RR, accidents have reduced by 70% whilst SA has increased year on year (Black, 2008). Therefore, there is a clear focus on sickness as a threat to the state: Many common diseases are directly linked to lifestyle factors, but these are generally not the conditions that keep people out of work. Instead, common mental health problems and musculoskeletal disorders are the major causes of SA and worklessness. This is compounded by a lack of appropriate and timely diagnosis and intervention (BR, 10).
This excerpt evidences a return to the concepts voiced by Sadler, indicating that oppressive working conditions coupled with the effects of work on human anatomy are the dominant threats to health within workplaces. Shah and Bandi (2003) indicate that changes in manufacturing practices
68 have reintroduced the notion of the FS within advanced nations. Workplaces designed on rational principles (fixed targets, reduced individual control, cramped conditions, reduced certainty of employment via reduced hours contracts, and punitive actions for failing to meet targets) have re-introduced the factory concept into contemporary society. Workplaces have failed to learn the mistakes of the past as working conditions and practices are oppressive in nature (Shah & Bandi, 2003, p.418). The outcome of these oppressive modes of working is a significant increase in stress related illnesses (Shah & Bandi, 2003). Additionally, Black indicates a return of the phenomena of anatomical changes caused by repetitive work. Despite the rise of risk management, the adverse health effects of work identified in 1832 have been neither foreseen nor prevented. In line with Robens’ desire to understand in detail the effects of MHI in the workplace, research into the psychology of work has flourished. Of note within this development is the acceptance of the terminology used to discuss the factors responsible for the increase in mental health problems. The term a reduction in mental capital has become the accepted norm. This terminology indicates that our mental health is influenced by our attitudes such as optimism and resilience, and not by environmental systems known to be harmful to health (Guzik, 2013). By utilising these definitions based on subjective attitudes, the report is able to reaffirm the need for disciplines of the self to the detriment of improving the physical and psychological systems in which people work. Rather, workers remain victims of their inability to cope with the erosion of their health. The acceptance of this terminology continues the victim-blaming culture commenced by Robens into people’s attitudes towards their health. For most people, their work is a key determinant of self-worth, family esteem, identity, and standing within the community, besides, of course, material progress and a means of social participation and fulfilment (BR, 4).
Here, we can observe that in constructing individuals as victims of their own behaviours, maintenance of social stratification continues. If most individuals now gain their self-worth from their occupation, people in low paid occupations who are known to suffer higher levels of illness and, in particular,
69 mental ill-health are disadvantaged in two ways. Firstly, higher levels of mental ill-health restrict people’s ability to improve their occupational position due to societal attitudes towards mental ill-health. This in turn leads to a reduction in aspirational attitudes towards social improvement within individuals and their family (Johada & Rush, 1980). Foucault (1979) indicates that social stratification becomes a form of normalisation as those in the lower social classes are labelled as non-conformist with the dominant disciplinary order. Their position in society is maintained due to this normalisation process and because some sections of the socially disadvantaged adopt this situation as a model of resistance, thus stifling aspiration.6 The outcome of this response contributes to their own subordinate position (Schirato et al., 2012). Analysing why MHI are a problem for the state, we can see that the call within the RR to promote wellbeing has largely been ignored and MHI have significantly increased. In 2007, the Foresight Report (Department of Health) indicated that rates of mental health conditions would double by 2050 if trends continued. As with previous reports, Black uses the threat to the nation’s wealth and future prosperity as a rhetorical device to ensure a change in approach to addressing the health of the workforce for individual and collective gain. Black re-emphasises the need to adopt measures to improve wellbeing, but follows the pattern laid out by Robens of indicating that it is the attitude of those of a working age which needs to change. At the heart of this review are recognition of, and a concern to remedy, the human, social and economic costs of impaired health and wellbeing in relation to working life in Britain. The aim of the Review is not to offer a utopian solution for improved health in working life. Rather it is to identify the factors that stand in the way of good health and to elicit interventions,
6 In reflecting upon my own subjectivity towards the concept of othering this analysis has been influenced by my innate desire to increase fair and just systems, which address social inequality. As stated, I see health and education as the two dominant forms of social movement. I need to consider my own assumption that within workplaces the creation of others with limited aspirations or altered aspirations creates a sub-culture of resilience. I perceive the outcome of this resilience to be the creation of dividing practices. These practices not only allow individuals to choose to undertake health behaviours with short-term psychological benefits but long term health consequences (smoking, drinking to excess, etc.), however, they also construct individuals to adopt these mal-adaptive strategies as mechanisms of resilience. This strongly felt assumption needs to be investigated before any weight can be given to support this conclusion.
70 including changes in attitudes, behaviours and practices–as well as services–that can help overcome them (BR, 4).
Here, we can observe how health in the workplace is constructed as a mechanism of resilience and Black infers that changes to systems to improve health are a ‘utopian’ ideal. The ordering of the concepts expressed by Black is indicative of a focus on addressing the behavioural causes of illness, rather than the wider causes of disease. Within the BR, the contradictory construction of the individual as requiring assistance to move out of the cycle of worklessness is closed down by the notion of worklessness and illness as a burden to society. Hence, those requiring assistance for SA or incapacity are viewed as a homogenous group worthy of state intervention. The ontological reality of health in and out of the workplace is one of a failure of resilience by the individual, leading to financial hardship to the self and society, and results in the necessity of the state introducing mechanisms to control this deviant behaviour (Foucault, 1979). 3.3.2 Response to the problem Black outlines the requirement for expansion of OH to deal with the growing threat of illness to the nation. This requirement will be achieved via integration of OH into mainstream health provision; introduction of a fit note to replace the current sick note system for those individuals taking SA from the workplace; and introduction of Pathways to Work based on capability assessments for those receiving benefits. The historical separation of OH from mainstream healthcare has resulted in an inability to provide holistic support to patients of working age. As Chapter 5 set out, from its inception in 1948, the NHS only provided OH services for its own staff. Providing and funding OH for other workers was made the responsibility of their employers. These arrangements might have been right at the time, but it is clear they are failing to meet current needs (BR, 96).
Within this excerpt, a change in direction for OH is proposed. Robens’ analysis that OH was a threat to the NHS is now altered to a situation where OH is required. The rationale for this decision is to allow the NHS to provide OH services to small and medium sized enterprises (SMEs) that traditionally have not utilised OH. In addition, Black (2008) indicates that larger
71 organisations which do provide OH services might share these with SMEs, or outsource these services to meet growing calls for industry to evidence corporate social responsibility (CSR) towards the health of their employees and wider society. The call for CSR is not new and is evidenced across all of the reports analysed. Given that industry’s primary purpose is to generate wealth and traditionally CSR has failed to materialise, it is interesting to analyse why Black continues with this theme. Looking behind this report, I suggest that Black creates systems for the development of a marketplace for OH. OH now has a remit to provide health care to a growing section of the population. Greater integration of public and private provision via Pathways to Work and the fit note means that responsibility for the development of OH falls to the commercial sector in line with the neoliberal agenda (Waddell & Bunton, 2006). Within Black’s work, CSR does not retain many of the moralistic arguments of previous reports. Black (2008) offers opportunities for business to act ethically, whilst creating income streams for both industry and the state. Statism is expanded for those categorised as abnormal under the new system, who come under the control of the state, but costs are reduced as the service provider can be from the public or private sector. OH becomes a distinct industry, which is appealing to both the state and the marketplace. The economic argument for a change in approach from industry continues as Black emphasises the mantra that good health is good business: Evidence from the US analysed the relationship between employee satisfaction and long-run stock market performance. The balanced portfolio of the ‘Best companies to work for in America’ earned 14% per year from 1998-2005, over double the market return, outperforming industry and characteristic matched companies. Evidence from the Sunday Times ‘Best Companies to work for in the UK’ shows that companies who have higher levels of staff engagement (as measured by looking at parameters such as employee wellbeing, line management and team-working) have 13% lower staff turnover, less than half the SA of the UK average, and on the stock market they have consistently out-performed the FTSE 100 (BR, 59).
This mantra is not new, but has traditionally been ignored within countries without a strong sense of social democracy (Tones & Green, 2010). I contend that the true purpose of this discourse is to introduce mechanisms
72 which extend the forms of biopower introduced by Sadler and expanded upon by Robens to discipline people for their health behaviours. In particular, the use of surveillance to reduce the financial commitment of the state towards unemployment is evident. This judgement is based on the return of capability assessments as a mechanism of disciplinary control within the Pathways to Work scheme: Evaluation of Pathways pilots has shown an increase of around eight percentage points in six month off-flow rates compared to national figures. Fifty-six per cent of those coming off incapacity benefits in Pathways pilots enter employment of 16 hours or more, indicating the increase in off-flow is not resulting in a disproportionately high movement of people onto other benefits. Another encouraging finding is the early indication that this increase in off-flows is leading to a reduction in the total number of incapacity benefits claimants in the pilot districts. Although Pathways to Work results have been encouraging, evidence shows the impact for those with mental health conditions is much more limited. The number flowing onto incapacity benefits with mental health conditions has remained stubbornly high, and now accounts for over 40% of the overall caseload. Government is unlikely to meet its aims to reduce the number of incapacity claimants by a million, or its full employment aspiration, unless more of this group are helped back into work. It is essential that more innovative support is offered and targeted at their particular needs (SR, 87).
Within these two excerpts, we can see that the discourse of addressing health as a sociological necessity fails to make a convincing argument, due to the focus on economic discourses for cost savings within the benefit system. Additionally, the debate around the research conducted into Pathways to Work appears contradictory and its use therefore becomes contentious. Attempts to address physical health issues appear to be working whilst those to address MHI require further research. Popular opinion following the report’s publication outlines how it is seen as a punitive mechanism towards the most vulnerable in society, rather than a supportive development (Heyes, 2008). It has echoes of Sadler’s work, as it re- emphasises that work and health are moral endeavours and that deviation from these constructions justify cost-cutting measures. In changing normative attitudes towards SA and worklessness, Black utilises a mechanism called the fit note. A fit note will replace the traditional
73 sick note, which is issued by a general practitioner (GP) so that an individual can claim statutory sick pay. A fit note asks the GP to consider not why an individual should be excluded, but if an individual can be supported to stay in work (Black, 2008). This stipulation was supported by developments in the 2010 Equality Act, which seeks to address the stigma associated with various forms of difference. For Foucault (1982) stigma is a social fact. In seeking to challenge traditional notions of stigma towards those who have MHI, who are receiving state benefits or are absent from work due to sickness, this report constructs stigma around concepts of social justice, introducing a moral authority to its work. Whilst debating notions of an expansion of the state’s desire to reduce health inequalities, this report expands on the neoliberal principle of economic primacy, and constructs health as a series of personal choices in which sociological explanations of health are ignored in favour of psychological explanations of poor choice. The outcome of this is that social stratification is maintained (Galvin, 2002). Though this report seeks to move towards a mode of public health by discoursing contradictory notions of the sociological causes of illness, the solution offered within it is also contradictory, calling for biomedical interventions in the form of early rehabilitation: One of the most important aspects in enabling a return to work for people with health problems or disabilities is adequate provision of appropriate and targeted health services. In particular, vocational rehabilitation services address the specific health barriers to an individual’s employment, as well as providing a source of information for the patient on the types of work, which may be most suitable (BR, 88).
Black (2008) indicates the need for the expansion of OH and outlines the problems faced by the service. In constructing the appropriate responses to illness and incapacity as being surveillance and rehabilitation, this report – rather than expanding OH as a form of public health practice – restricts its development. In not seeking to expand preventative work by challenging oppressive working environments and practices known to be harmful to health, the report embeds notions of behaviourism and allows employers a free hand to construct workplaces based on outcomes of capability and not outcomes for health.
74 In seeking to develop OH and provide an improved service for NHS staff, OH enters the health education sector due to the need to assess the health of the potential workforce. Here the rhetorical techniques of comparison and portraying a more productive future are utilised and, in doing so, this discourse reinforces notions of health as a productive state and illness as a state of reduced capacity. Good physical health emerges as a necessity for the workforce. An image of aesthetic health returns, as to appear unwell is to become a bad worker (Galvin, 2002). The notion of risk is re-emphasised via this form of discourse, as people are at risk of harming their own health and productivity by choosing to think and behave in socially and organisationally deviant ways (Galvin, 2002). The biomedical model of health is also viewed as redundant within this form of discourse, as health moves from the mere absence of disease to a societal imperative, through the pursuit of holistic wellbeing via actively seeking, and aesthetically appearing, to be healthy. Inherent within this symbolic creation of health is the notion that the individual is committed to a productive life through mechanisms of self-discipline (Galvin, 2002). As such, HEIs become an integral location for improving the health of the workforce. In expanding the need for health examination and surveillance, potential workers such as NS come under the gaze of OH. The potential and current workforces are constructed as a homogenous mass. Their ontological reality is that they must appear physically and mentally well, within a system that observes them at regular intervals and classifies them according to risk to themselves, society and the state. Failure to comply with these risk categories allows the state to act paternalistically for the benefit of all parties. The function of this discourse is to make plain the need to protect this homogenous mass via the use of disciplinary, social and self-regulating methods of control. 3.3.3 Work as a moral endeavour Within the BR, the health of future generations is discussed in detail and the threat of current irresponsible health behaviours is made plain. In line with neoliberal principles, the outcome of poor individual choices to the self and wider society is discoursed, and the concept of health inequalities is utilised to reaffirm that the abnormal health choices of those in the lower socioeconomic groups need to improve. As such, the health inequalities
75 agenda is maintained as a disciplinary device of control. The following extract identifies the stated desire of the report to address social inequalities: The impact of parental ill-health and worklessness goes further than poverty; it also increases the risk of childhood stress, behavioural problems, and poor educational achievement. Children who grow up in low-income or workless households are also more likely to suffer worse health themselves, be workless, and live in poverty when they become adults. The prevalence of psychiatric disorders among children in families whose parents have never worked is almost double that among children with parents in low-skilled jobs, and five times greater than that among children whose parents are in professional occupations. Similar evidence is found in Scandinavian countries, with children in families where no parent is working having a higher prevalence of recurrent psychosomatic problems, chronic illness, and low wellbeing (BR, 104).
In analysing this extract, I would argue that the link between worklessness and illness is made explicit. Further, I contend that by implying that the twin concerns of worklessness and illness are the root cause of many health and social issues facing future generations, worklessness returns as a form of social ill. It is interesting to see the shift in terminology from Sadler (1832) (unemployment) to Black (2008) (worklessness) as a mechanism to shift responsibility for this ‘social ill’ away from the state and towards the behaviours of individuals. In creating this knowledge set, the state is able to justify the re-expansion of statism beyond the factory walls. The rhetorical device of presenting an uncertain future is used to shape attitudes towards this section of society and to indicate their lack of social cohesion. This stigmatisation is expanded upon by discourse relating to the notion that work is good for health, and that the workplace can be used as a mechanism to improve health. However, Black (2008) indicates there is limited evidence to support this claim, and what evidence there is has tended to focus on the psychological benefits of work as a means of gathering the resources necessary for economic prosperity, or as a mechanism to develop self-esteem in societies where work is a normalised mode of living. To create convincing arguments for change, rhetorical devices are utilised to construct normalised opinions. For example, in utilising phrases such as ‘on the whole’, work as a source of goodness is created as a vague concept. The outcome of this vagueness is that illness created by the workplace is absorbed within
76 notions of a general good. Similarly, worklessness is created as a concept which has notions of general harm. The outcome of this is the de- individualisation of people into a homogenous mass which threatens the prosperity of the state and wellbeing of future generations: Although there is now widespread understanding of the risks of damaging someone’s health through the workplace, the role it can have in promoting employees’ health and wellbeing is less well understood. The introduction drew attention to recent evidence that work is, on the whole, good for an individual’s health and wellbeing, and the reverse is true of worklessness (BR, 51).
As mentioned earlier, there is a large body of evidence that paid employment is the best avenue to attain the economic and social factors which provide us with the resources for health. What is known regarding how work directly affects physical health is linked to the notion of individual control of the physical and psychological risks inherent in workplaces (Waddell & Bunton, 2006). However, modern workplaces have tended to reduce personal control, leading to increases in mental health problems. The assumption that all work is good for health becomes the dominant knowledge set within this report, despite researched evidence that only work which meets psychological needs for control is known to improve health. Given the lack of evidence that work is good for health, what follows is an economic and moralising discourse on the need for employers to expand OH services to deal with the rising tide of ill-health. Employers are in a unique position of being able to educate, motivate, and support their employees in understanding and actively maintaining their fitness and wellbeing. The business case for promoting and supporting employee health and wellbeing is becoming increasingly clear. Employers can gain clear benefits in reducing employee turnover and increasing the productivity and engagement of employees (BR, 53 and 54).
Here Black is maintaining ideas that employers have a responsibility to educate and actively maintain the health of employees for moral reasons. As discussed, the notion that employers have a moral duty to improve the health of the workforce has largely been ignored within industry, due to the adversarial nature of the master and servant relationship. Black seeks to re-
77 package this idea by highlighting the benefits of improving the health of working age people for economic reasons. In doing so, the agency of the employee is further reduced as they are discoursed as lacking motivation and of being disengaged. The paternalistic attitude by the authors of these three reports indicates attempts at policing health, rather than the stated aims of emancipating individuals. They also evidence the desire by the state to construct cultures conducive to health within the workplace for the benefit of the state (Tones & Green, 2010). Within the BR, there is an attempt to address the cultural norms introduced by the SR (1832) that people need to be fit to work. Black challenges this attitude towards health in the workplace, indicating that traditional notions of health should change. The conceptual acceptance of excluding individuals who are ill or who have reduced capacity from the workplace needs to be replaced by an acceptance that people have reduced capacity, and focus should be switched to an understanding of what a person can do and to make adaptions to the workplace (Black, 2008). This alters the concept adopted via Sadler that sick people should be absent from the workplace for the sake of themselves and others, and indicates a challenge not only to attitudes towards sickness but also attitudes towards environmental sanitation. In parallel with a change in perceptions among employers, there is an urgent need for a shift in public attitudes. Too many people think that work is bad for health, that work should be avoided when they are unwell and that they should only return to work when they are 100% fit. These misconceptions are reinforced by family and friends, resulting in many people seeking to be signed off work by their GP while awaiting or undergoing treatment. We need to change this behaviour if we are to make real progress (BR, 64).
Here, we can see attempts by Black to re-normalise notions of capability so that absence from the workplace for health reasons and incapacity becomes unacceptable. The notion that work is deleterious for health is discredited, and the biomedical model of health becomes outdated due to its reliance on notions of complete health and the absence of disease (Tones & Green, 2010). Rather, psychological theories such as role adaptation are
78 given dominance. This allows the state to create an ontological reality that resilience is the major determinant of health. The security of the state is threatened by the deteriorating health of the population, and biopower in the form of health surveillance must extend to those beyond current forms of disciplinary practice. In seeking to ensure the security of the population, emerging threats to health such as the obesity and stress epidemics need to be controlled as they threaten the state’s ability to manage the flow of healthy workers entering employment and consequently the means of economic production (Schirato et al., 2012). This threat is also evident in demographic changes, which highlight an ageing population (Tones & Green, 2010). The government responds to these facts via an economic argument aimed at employers, which indicates that they need to improve the health of an ageing workforce due to the limited supply of replacement workers. The government discourse this argument via notions that health can be used as a means to increase profits for industry and via the use of the NHS OH services. Here the government is able to promote an economic and moral argument for change, whilst creating income streams for the state. Black seeks to create a truth about work, worklessness and health. However, this creation of truth should also be challenged. For example, in creating notions of behaviourism and poor choices as the dominant reason for the health crisis facing modern workplaces, the notion that proactive settings need to be implemented to improve health has been downgraded. In line with the WHO’s view of health within the 21st century, consideration of the environments in which people work, live and play needs to be advanced. By focusing on behaviourism, the state reflects the neoliberal principles of freedom. This has largely served the state well, based on the knowledge that wealth equals health (Tones & Green, 2010). However, knowledge is now emerging that this adage is true only to a certain level: there is a growing awareness that health is adversely affected by reductionist approaches to treating it as a series of risks. Similarly, evidence is emerging that in focusing on the creation of wealth, our health, and in particular our mental health, is being eroded (Tones & Green, 2010).
79 The philosophy of the settings approach challenges scientific rationality and its desire for reductionism. Rather, it takes an ecological perspective, which moves us away from the supremacy of personal risk and health behaviourism to a focus on the interface between man and the subsystems of the ecosystem (Tones & Green, 2010). The ecological model, which lends itself to MHI as it accepts people are not victims of their own behaviours but that they are shaped via complex environmental influences, appears to offer solutions to the health challenges faced by the developed world (Scriven & Hodgins, 2012). Within the three reports analysed, the construction of health in the workplace is deployed through a discourse of statism to protect the worker from adverse environments and manipulative employers. This construction of the need to protect the health of workers is undertaken via rhetorical threats of an uncertain future, and via the knowledge set that OH and by implication scientific rationality is the only form of truth that can offer a solution. This simplistic approach to the discourse of health in the workplace does not recognise the complex nature of the determinants of health within this specific environment, nor the breadth of interventions both proactive and reactive which need to occur to improve holistic health. The voice of those subjected to the approach evidenced within the three reports has largely been unheard or manipulated. The voice of those living within this process will be the focus of the next chapter, which is an analysis of oral interviews and two focus groups. The subjects of these processes are student nurses who are users of OH as the gatekeepers of employment.
Chapter 4: Analysis and discussion of the student oral events
This study seeks to explore nursing students’ perceptions of referral to OH. This study follows Foucault’s methods by investigating how discourses of referral operate to privilege particular subject positions and modes of practice, with the intention of showing how students’ perceptions of constructions of referral are part of a larger constructive process of self and society (Welch & Wright, 2011).
80 To achieve this aim it is necessary to analyse the perceptions of NS via unstructured focus group meetings and semi-structured interviews. The rationale for using these research methods was the need to identify the development of dominant discourses relevant to the referral process as voiced by the NS. Focus groups were the mechanism of choice for this element. The interview element was utilised to allow analysis of discourse positioning by the NS within the referral process, and of contradictory positioning. Discourse positioning is important as it allows insightful understanding of how discourses create subjects and the discursive space in which these subjects can exist (Foucault, 1994). The responses to the focus groups and interviews were read to form an impression of their diversity, the underlying assumptions and ways of knowing. These rough categories were coded for continuities and patterns of language. This suggested four dominant forms of discourse when discussing the referral process. The themes identified from the focus groups were: 1. The duality of meanings students attributed to referral, to occupational health, to the construction of health as a concept, and to the professional and educational environments. 2. How students engage in practices of self-regulation in order to be seen as a good student and a good nurse. 3. The knowledge surrounding compulsory referral and how knowledge is legitimised. 4. Modes of governing, the use of power and the consequences of referral. These themes then formed the basis for the individual interviews. Data taken from the focus groups will be prefixed by the term FG1 or FG2. A pseudonym will be utilised to denote the different speakers, along with reference to the place in the text where the discussion can be found. When an individual who was interviewed is being cited, a pseudonym with a text point will be utilised. From this point forward, the two methods of data collection will be termed oral events. It should be noted that any form of oral event is predisposed by identifiable and unidentifiable factors. As such, the oral events provide only a brief outline of a much wider picture. In seeking to capture the perceptions of NS, their spoken words within the oral events were tape recorded and then
81 transcribed into written documents. Analysis of the patterns of language utilised can then occur (Bryman, 2012). In analysing these patterns, I shall identify how shared meanings are derived from the representation of the referral process. Whilst this focuses on analysis of the spoken word, I shall initially highlight how verbal accounts utilise visual discourse, in particular architectural imaging, to symbolise the role of OH in the referral process. This will be followed by analysis of the stories students know and share regarding referral to OH. The knowledge students have of OH and finally knowledge of the referral process and its effects shall complete this discussion. Foucault (1973b) indicates that subjects are created in and through discourse. In this study discourse positions can be identified and analysed to understand the ways in which referral power/knowledge is contextualised in the spaces operating in the university and professional practice environments. Foucault indicates that contradictory positioning is important because evidence of how contradiction occurs between the constructions of us provides the dynamic for understanding (Peterson & Bunton, 1997). This analysis commences with exploration of the way in which NS utilise visual discourse to construct their responses to referral to OH. To assist the analysis of the oral events, Dryzek’s (2005, p.19) guide was applied. 4.1 Architecture Visual discourse analysis is a mechanism advanced by Foucault (1997), which seeks to allow researchers to broaden the use of discursive devices to include elements which provide a visual representation of the way knowledge and social practices are structured. It is intended to understand how visual representations are constructed by shared perceptions and differences, which assemble ways of knowing about social practices in detail (Berg, 2009). Berg explains that FDA is concerned with how not only language but also other communication methods are utilised to construct discursive subjects and the objects of which they speak. This allows the researcher to identify the conditions of possibility of institutional and political arrangements, and their effects. Within this section, the notion of architecture as a representation of how the NS construct understanding of OH as an object will be explored. Within this exploration I shall investigate how architectural structures become organising principles of discourse, and how phrases such
82 as halls, little office, campus, grim little building and so on, frame awareness of architectural terms to construct the body in space (Foucault, 1997). 4.1.1 Architectural responses I remember having to go to see them before I even started the course because you had to take your vaccination cards in. I remember looking around campus and looking for it for ages. It is not an easy place to find. It is one of the halls. It should have its own little office (FG1-35-Ann).
The whole campus was foreign to me and I had to go and look for that little building which isn't very well situated at all. I think they should have their own little part of the campus, because they are quite important people aren't they and they are hidden underneath the halls (Karen-21).
Within these quotes, we can see that the student is constructed as a physical body to be examined and scrutinised via the use of vaccination cards. The use of disparaging architectural terms, and comments on the positioning and limited space afforded to the OH services, outline awareness of the limited significance given to health by the university. Similarly, the use of the term hidden outlines how the students initially structure OH as a concealed system within the wider university. The incongruence of the role of the body to the individual and of the role of the body to the university is evidenced by the individual’s observations that OH should have a separate office and by the notion that OH professionals are important people. They're stuck out there in that grim building… The bottom floor… You do not know where it is, there is no sign outside I mean people would feel… how do they feel about it… that they are stuck in that grim building. There's not even a sign to say this is OH (Claire-27).
Claire is outlining the effects of the architectural features on the feelings of both the NS and what she thinks the professionals might feel in the construction of OH as a service. The reference to the absence of signs indicating the existence of OH and its location is an interesting theme
83 identified by the NS. The absence of signs can be read7 to support the notion that from an organisational perspective the health of the NS and the services supporting their health are afforded minimal attention. This form of symbolism constructs beliefs in the NS that within the university space their health is of little importance. According to Wickham and Kendall (1999) Foucault indicates that all words are symbols; and in analysing what the university seeks to make public to its students, the university is indicating what is sayable within discourses about, and of, OH. This element creates the rules of discourse surrounding OH and allows a corpus of statements to develop, which bring regularity and order. The lack of signs creates the rule that OH has a health function within the university, but that its function is limited. This has the effect of restricting debates and awareness of OH as a health service (Wickham & Kendall, 1999). There are no signs outside and if you were to say come from another campus to this campus. You would not know it was there. You would not know it was there and there is nothing to say that it is there because it is in the halls of residence as well. You have no reason to go in there whatsoever. It should be in the same building as the library or in the corridor where other student support services are. It should be somewhere where we have to walk past it. Unless you are aware that it is there, you would not go there. However, even though I did know it was there I would never have thought to nip in because it is out of your way (Richard-43).
Here, Richard is indicating the isolated nature of OH and how it is distanced in a spatial sense from other mechanisms of support. Notions of the relationship between OH and other mechanisms of support are given voice. Assumptions regarding the true nature of support services emerge, and subjective awareness of the limited importance of health of the body within the university is recognised. The assumption that the university considers notions of health less than the students themselves allows the
7 In reflecting upon this interpretation, I need to consider the assumptions and prejudices which underpin my analysis. I have concluded that my desire to see OH become a universally provided service based on the expansion of OH could have influenced the development of this theme. Similarly, the perception that the lack of attention a HEI has in the health of its students could be driven by my professionalisation as a public health nurse. I am professionally constructed to accept the adage that ‘prevention is better than cure’. This is at odds with any organisation which provides services based solely on notions of support.
84 construction of ideas that the assessment of health is undertaken for reasons other than a benevolent interest in students’ health. Within this next quote, Richard is indicating his ideas on why OH should be situated with the other support mechanisms: I think if it was somewhere that you had to walk past every day, for example on your way to a lecture it would jog your memory. If you saw the sign OH it would make you think well I need to speak to them about this and obviously they would have a massive increase in workload but I think that they would have students that are in a lot more control of their health and I think they would… Rather than have students struggling themselves to get through the course, I think that they would have somewhere and someone to speak to, because it's not something that's promoted. Once you have had your injections they do not even say to you if there is anything that you need etc. come and see us or make an appointment. No one has ever said that to me even when I had my jabs. It is something that if they had of said it would have stayed in my mind. It would always have been in the back of my mind but it is literally, they get you through your immunisations and then that is it. You know, see you later (Richard-45).
Richard continues: We have a corridor that has careers, finance, student support and guidance into the administration office, but in my opinion that's where OH should be because that's the hub of the helping services. I do think it should… especially… coincide with the health and social care faculty office. You think they would come as one because this is where all the students go for help. In effect, it should be one department. The fact that they are so far apart from each other baffles me a little bit… but I think there should be more of a health and social care department where it's altogether which looks after the health of students (Richard-49).
Within this excerpt, Richard is indicating an absence of a natural relationship between OH, the faculty and the other support services. The absence of a relationship between departments with the same aim and objectives leads to an awareness that OH support is different and isolated. The sequestered provision of OH (both connected and removed) is considered by Richard to have an adverse effect on the health of the NS, due to limited control over contact with OH. With the use of the term one department, the architecture of isolation emerges. The isolation of OH is then transferred to the NS via their struggle on the course. Here notions of ill-
85 health construct the NS as individuals who have to search for support without signs to assist them. Foucault (1995) indicates that this form of dividing practice allows the university and OH professionals to create concepts of normality which directly affect the students’ identity within the university. Additionally, the notion that health is separate from other support mechanisms allows OH to subjectify the NS as they develop individual forms of self-control within a cultural understanding of the scientific classifications needed for acceptance as a NS (Foucault, 1995). The latter part of Richard’s quote indicates that he feels the lack of promotion on behalf of OH, its lack of accessibility and its focus on the requirement to prepare NS for the practice environment, evidences that NS are aware that once risks are ascertained and managed then the students’ health status becomes unimportant to the organisation. The phrase, see you later indicates awareness of the construction of the body as a political entity within the risk agenda and the limited provision of a holistic concern for the health of the NS. Within the above discourse, two elements become important when seen through a Foucauldian lens. Firstly, by separating OH from other support services the university is able to maintain notions of medical dominance over student health. The separation of medical services creates notions of OH as an autonomous service whose purpose is to scrutinise the NS, thus making them vulnerable supplicants (Lupton, 1997). The autonomy of NS is reduced, due to awareness that OH has the knowledge and power to define the standards for entry into the university and work. Secondly, the clinical gaze of OH constructs the bodies of NS as objects of normative facts, which are shaped by political and social belief systems about what a healthy student should be (Lupton, 1997). Within Richard’s observation that there is a lack of preventative health activities within the university and, in particular, a lack of a health culture created by the Faculty of Health and Social Care, I observe8 that this
8 As a nurse educationalist, it should be borne in mind that I have been socialised to accept Rogerian theory. Carl Rogers indicates that education should be a balance between notions of education as a process and the product of education, which must be fit for purpose. Within Rogerian models, the process of education based on humanistic learning is seen as the best way to develop the product of critically reflective professionals. I feel that my observations of contemporary nursing curricula, which are product-centric, and the internal axiomatic response I have to this fact may have subjected me to reach this conclusion.
86 compounds feelings that the educational experience can be perceived as a system designed to produce docile bodies for employment. Rather than perceiving education as a process, this gives sufficient attention to the health and wellbeing of the body. The creation of docile bodies according to Foucault (1979) is a disciplinary mechanism aimed at subjecting, transforming and improving students’ bodies so that they are useful within the workplace. In utilising the term struggle, Richard is indicating awareness that the power exercised on the body is not absolute and students can, should they wish, resist the medical gaze through mechanisms such as health irresponsibility and hedonism. Nevertheless, the need to conform to cultural expectations is increased for this particular student group, due to the need for increased discipline of the self via the educational ethos of their own faculty towards healthism, and the university's need for them to construct themselves as ‘good students'. These conflicting aims and objectives reduce the space for resistance within the university. Claire continues discussion of conflicting aims within the university by outlining the political influence of the university upon the role of OH: I don't know, whether they think they've got a cushy little role here or on top pay and no one bothers us. I don't know if that’s their perspective, I don't know whether the university don't recognise them more, as they are there as a necessary thing or are they just there to make sure the immunisations are up-to- date, I don't know. It could be a combination of all three. They are stuck out there in that grim building (Claire-27).
Here, Claire is utilising a number of key metaphors to indicate her confused and conflicting understanding of the role of OH in the assessment of NS, which is seen as both a necessity for good health and a measure of surveillance to ensure compliance with statutory vaccinations. This subjective search for power/knowledge relationships can be read to imply an underlying distrust of the support services offered. Within analysis of the chosen statutory reports it was identified how OH certification defines reality for the students in terms of health surveillance enacted upon them and of the desire to conceal the nature, purpose and outcome of surveillance from those affected by this process. This discussion of architecture evidences elements
87 of concealment, both of OH as a practice and of the significance of OH for the students. The outcome for the students is awareness of incongruence between notions of support and the provision of support. 4.2 Pictorial representations As well as identifying the visual representations of OH through architectural structures and the symbolic interpretation of the absence of signs, the NS utilise pictures or more accurately the absence of pictures as a way of constructing OH. In addition, NS use the absence of the professional body in the shape of an OH professional to construct understanding of how they are constituted as an object to be governed: I think even just having a couple of posters around the campus, feeling sick come see us don't wait for a doctor’s appointment… There is that huge waiting area where they have the blue couches; they could have a desk there or a stand. There is a stand advertising jobs aren’t there. There are all sorts of materials there. I mean I don't look at them closely because it’s for the young ones anyway, lots of activities but I think a stand saying OH can do this. You know, if you hurt yourself on placement come and see us (Claire-25).
Within this discussion, Claire is indicating the idea of difference between the support services offered. The lack of visible material on behalf of OH is questioned and compared with the other services offered. The idea that OH is only involved in the health of individuals who are made sick by the risks within the practice environment is also identified. The lack of visible informative or proactive OH services aimed at students gives rise to notions that health within the university space is considered unimportant; attitudes towards student health are constructed by an awareness that, within the university space, health is not seen as threatened and is not worthy of proactive input. Every year we have we have updates for a lot of the things in the university but OH never gets involved, so you never see them (FG2-75-Susan).
It's not advertised is it? Once they have made sure that you are all right on placement and that you have your injections. Apart from the real functional stuff, the wider support stuff they don't do, do they? (Kirsty-40).
88 I just know that their offices are there and that's where they are. You never see them walking around campus or anything like that. Never (Karen-69).
Within this set of quotes, NS are discussing the visibility of OH. The lack of visibility outlined by the absence of the physical body of OH indicates awareness of the limited role of this service. Barr (2009) indicates that Foucault identifies how pictorial representations provide us with an understanding of the social space afforded to a subject; the absence of pictorial representation here creates a linear understanding of OH and reduces the possibility of its existence beyond the risk assessment process. The final element of visual representations of OH as a form of control mechanism is illustrated in the following dialogue with Melanie (AM = researcher): I am trying to think back now… Was OH proactive in giving me advice? I don't remember them giving me any advice (Melanie- 42). What do you remember them doing? (AM). I think I remember them just looking at me in the present. Looking at me in my present circumstances, I don't remember them… I remember them all being lovely. But I don't ever remember them looking too far forward. It was just sort of in the present moment really (Melanie-43). So what type of things can you remember OH doing then? (AM). I just remember them gathering a history really. Building a picture of me in terms of health and wellbeing from a present sort of scenario (Melanie-44). Within this dialogue, Melanie is indicating her construction as an artefact of the past and present. Here she is constructed as an individual with a history that is influential in her outcome as a product of a device of labour. She is also constructed as a threat to herself in terms of her current health practices. However, the lack of interest in her future is indicative of OH as a
89 mechanism of surveillance, which constructs her as an object to be judged9 (Foucault, 1979). Within these visual constructions, it emerges that OH is seen as a mechanism of control, which is part of a much wider social mechanism in the form of the university. Rather than taking a holistic interest in their health and championing their wellbeing, the university’s interest in the students’ bodies assumes a political and judicial aspect as the NS become aware of their part in compliance with organisational and statutory mechanisms. The reality of the impact of the statutory reports is made clear by the students within these debates. Biopower created within statutory provision is made real for the students and the associated loss of agency these developments bring is also made real. The notion of how their wellbeing is addressed is also evident in the way their ‘stories’ of OH are discoursed. The phrase stories is utilised to represent the discourses, which are recounted between the NS and provide an insight into the cultural connection between NS and OH. 4.3 Nursing students’ stories of OH Within the oral events, it is striking how often dual or contradictory perspectives of understanding are utilised as a mechanism of discourse; whilst this mode of discourse is expected within oral events, it was surprising how often contradictory positions were highlighted. For example, OH services are seen as supportive for the individual as well as supportive for the organisation. Though these two elements are not mutually exclusive, the participants discuss them as opposing concepts. These polarised viewpoints are surprising as NS are educated to utilise Rogerian argument theory. This
9 Within this excerpt the reader should be aware of my axiomatic response to this data and its influence on my ability to be unbiased. In describing her encounter with OH as set in the past and present, Melanie is evidencing Foucault’s concept of minimal quantity. Here, Melanie is constructed as an object of the past and present. According to Foucault (1973a) by focusing on the past and present, OH is able to create dividing practices due to OH adjudicating on peoples’ health habits and the impact they have on health status in the here and now. This allows OH to construct individuals as vectors of risk to themselves and others. Identification of the rule of minimal quantity is a pivotal point in the author’s journey within this thesis. The rationale behind this statement lays in the self-revelation that OH is not utilising these encounters with students to undertake proactive public health work; rather, there is evidence of OH as a form of governmentality. This revelation may have influenced the decision to include this theme due to awareness of the incongruence between my theoretical understanding of OH as an empowering process and the knowledge of OH practice as a mechanism of social control.
90 is based on the premise of conflict resolution and for the requirement of nurses to find common ground, to seek understanding of opposed positions and to show acceptance of all viewpoints (Kirshenbaum & Henderson, 1989). Several other concepts were defined in this polarised manner; most notably, the engagement with OH was described as desirable when discussed in conjunction with physical ill-health and as undesirable when discussing mental ill-health. Feldman, Skoldberg, Brown and Horner’s work (2004) indicates that, in this study, this form of polarised discourse is indicative of the influence that stories of and about OH have on students’ understandings of their construction within the referral process. NS utilise stories and debates to present and represent their understanding of the referral process and the implications of this system towards them as a group. According to Feldman et al., these stories are never innocent and are worthy of analysis as they reflect and simultaneously conceal a deeper more influential discourse regarding power/knowledge and the role of NS in the referral process. The influence stories have on students’ understandings of the referral process can be analysed using two complementary techniques: searching for opposites in which the storytellers see, for example, both right and wrong; and searching for enthymeme in which the storytellers offer incomplete logical inferences or taken-for-granted assumptions to avoid disagreement (Feldman et al., 2004). These two mechanisms will be utilised to analyse students’ discussions regarding the stories they hear of OH, and how these influence their understanding of OH. The stories that I've heard do shape your expectations of a service obviously. I just think that it would come out of context, that's what you would worry about. I think they don't always look at you; they look at you in terms of other people, in terms of… Instead of saying, this person is stressed, they’re having a bit of trouble, what can we do to help that person. Instead of doing that I think, they would say this person is stressed and they’re out on practice, how is that going to affect other people? I think that could happen and that would make you worse… that would make you worse and I have heard… I have heard the stories. I have heard the story… That’s what makes people worry to talk about things (Melanie-56).
Melanie is outlining how the stories NS hear shape their expectation of the service provided by OH. Within this quote, she is indicating that the
91 stories she has heard reveal and conceal the fact that OH can be utilised as a mechanism of control, and is a form of dividing practice. The form of dividing practice Melanie is outlining is utilised, according to Foucault, to alter her sense of identity, so that she divides herself from OH to avoid social classification within that specific cultural environment (Rabinow, 1991). Similarly, this form of opposite logic allows the student to understand notions of power/knowledge. The outline of how NS who are having a bit of trouble creates a need for scientific classification, and is also a form of dividing practice as it allows NS to subjectify themselves within the risk agenda (Rabinow, 1991). This observation that initial contact with OH creates a negative outcome is supported by comments such as: If you go to them then you get kicked off your course (FG1-75- Karen).
A few people in our cohort have had to go to OH. Not by choice and they have ended up being kicked off the course. I think we all got that impression it was because of going to see them; that they had decided that they could no longer be on the course, so we avoid them (FG1-23-Karen).
As well as the stories NS heard from their peers, discourses of OH from other sources were debated within the oral events. These discourses also shaped their construction of OH and led to them creating their own stories. For example, NS indicate that the negativity they held towards OH was shaped by the content and tone of discourse utilised by OH towards them upon initial contact: I'm sure that OH visited us in our first week here, and I always remember them saying that they offered counselling and support. That put a big fear in me, because I thought, am I going to need help, am I going to be the person who needs counselling and I thought what am I letting myself in for? At first I found that quite a big fear for me within the first week (FG2– 34-Oliver).
At first, I remember coming into the class the first week at the university and I think it was the fact that they talked about placement and death that bothered me. I just thought would I be the person that needs the counselling if I do see death, so it just made me think about it like that (FG2–39-Alice).
92 In response to the knowledge that OH offer support services such as counselling, NS construct a confusing knowledge base around the true purpose of these services. For example, Claire indicates: For me, what I would like to know is that if I was having difficulties that I could go and find someone and that they would spend time with me and that maybe I could have an ongoing support mechanism (Claire-51).
However, she also states: Personally I wouldn't seek help because I don't have time. But I think some people are more open and need to talk and they will go and seek support and guidance. The ones that don't seek support and guidance are the ones who leave and that's my issue. They think I can’t cope what am I going to do, it's all getting on top of me, I've got other things going on and then they leave because they haven't took support because they don't know where to go and they don't want to feel stupid and they don't know how confidential it is (Claire-31).
This is an example of enthymeme in which OH is seen as important in offering support, whilst at the same time being a threat to the NS. Similarly, the use of time restraints on seeking help is opposed with the view that what is required within a supportive framework is more time. These confusing aims regarding the role and scope of OH practice and the suspicion regarding the aims of the referral process are also evident within the following: It’s one thing being supportive but then you have the other side of it where you know that they've got the ability to write you as unfit for work. So lots of people are wary of going (FG1-13- Nicola).
There was consensus at this point within focus group one with numerous affirmative responses: You are definitely wary of going because in one respect you want that support particularly if you're having a hard time but at the same time you don't want them to say well you can’t cope and you’re not fit to practise (FG1-13-Nicola).
This debate amongst NS came about because of the stories regarding one particular student who had been withdrawn from the course. Whilst most NS attributed their opinions to this one story, some outlined how numerous others have left their cohort. The former viewpoint is indicative of incomplete reasoning based on the probability of support leading to removal from the
93 programme. It is argued10 that the assumption underlying this incomplete reasoning is that healthism is seen by the NS as an appropriate form of governmentality to protect the public from unhealthy nurses. This is particularly true of how NS construct themselves in the practice environment. Foucault indicates how nation states within neoliberal societies have utilised mechanisms where individuals come to govern themselves within concepts such as healthism. By emphasising personal responsibility for health, and by educating students that they are role models for health and must utilise behaviours befitting the nursing profession, then the students must govern their own bodies and behaviours (Foucault, 1978). Within the next set of discourses Claire also evidences opposite thinking regarding stories of OH: There's only been one person really that we know about. You only hear their version that they were quite brutal in that she had to wait an awful long time to see OH and the university in general just tried to drag it out. She couldn't go into practice for a long time and she couldn’t do her retrieval. But I don't know who that was down to. I don't know who was particularly involved, which tutors were involved, and what OH input was, because you only hear her version and that’s second or third hand. So she's the only person I know (Claire-17).
This view is opposed to what was said by the same student regarding her views towards proactive support: It's quite shocking coming back after last year and seeing how many students have left and then to find out that, nobody finds out why these people have left. I really do think it's an outrageous waste of money (Claire-7).
Similarly, Karen indicates: You know that they are there for support. They're not there to be against you are they? You know you can go and address an issue with them just as much as you can a lecturer (Karen-41).
However, when specifically discussing mental health issues Karen indicates:
10 My analysis of this theme was influenced by the complete acceptance of the NS of the notion of healthism. I was surprised at how readily the students accepted this premise without any obvious forms of alternative reasoning. Whilst it was obvious that the students accepted notions of healthism, it was also obvious that for many this cognitive acceptance has not been translated into action. As stated in the preface, the mystery of health behaviours and my fascination with this subject has presumably prejudiced the decision to analyse this factor.
94 I think it's something that all of us would like to keep to ourselves or talk to other classmates about. I think I can speak for everybody, as mental health issues are something that we would keep to ourselves. That we would talk to other classmates about that, but you would try to stay away from staff as much as possible. Because you feel it gets escalated and then what you thought you were in control of then spirals out of control (Karen-43).
This student is indicating that in terms of MHI students become objects within a system which reduces their agency, and that this element is where notions of structure and agency are played out within games of power/knowledge. Here is evidence of resistance to forms of governmentality as the NS retain information for themselves (Rabinow, 1991). Similar stories, which position NS as subjects to be examined and categorised according to OH standards, show that the holding of opposing views of OH, such as it is both a supporting and threatening mechanism, creates in the students an incomplete logic. This is in line with Giddens’ notion of the dialectic of control, which outlines how students play out the tension between autonomy and dependence through their stories of OH (Giddens, 2005). For example, self-help is better than expert medical help: So you are aware that it is there [referral to OH] but you try to avoid it at all costs (FG1-18-Ann). Why is that? (AM). You hear stories about OH. For example, if I had stress I would never go to OH, that would be my last option. I would rather just be stressed at home than take it to someone in the university (FG1-21-Ann). A further example of enthymeme is evidenced by the following discussion surrounding access to GPs, where the doctor’s approachability is seen as more important than their effectiveness: When I went to them after my operation they were far more welcoming than my GP. Even the doctor in OH was better than my own GP. In asking me if I wanted to go back, he was really thorough because he went through everything and he was adamant in checking if I was okay to go back to work (FG1-29- Ann).
Here it is argued that the thoroughness of the OH doctor is seen as welcoming, rather than as a threat to the student in terms of not being able to go back to placement.
95 I argue that the assumption on which this inconsistent logic is based surrounds the status of medicine as a scientific instrument, which can exert control over the students’ bodies and decide upon their suitability11. This form of dividing practice has elements of governmentality as the threat of surveillance of the body creates docile bodies to the benefit of the university and the state (Foucault, 1974). Students accept that ill-health creates a risk and that risk needs to be adhered to: They decide if you can go back into practice or not? You just see them as the superior ones really! (FG1-15-Ann).
Their acceptance of their power status is evidenced by quotes such as: You feel like you’re being judged. You feel like you’re going to be questioned, you feel like somebody is going to be questioning your physical and mental health, and you don't think that's a positive thing, you feel a bit scared. Nobody wants to feel judged and it's part of the role. You know that as a student you can be judged, you know you can be tested and you know your health has to be good (FG1-43-Jane).
In a discussion on whether other university students have OH screening, this student reflects the views of this group regarding limited power: Yes I do think the other students would question it more but because we're nurses we just say okay… [General laughter and agreement]… We need it so we'll have it (FG2-50-Wendy).
The use of medicine as a scientific instrument of governance creates within the NS a notion of learned helplessness. NS become objects of the referral process. NS are evidencing the effect of referral to OH as they construct themselves as inferior and with limited power. Similarly, NS are evidencing notions of difference and of differing social expectations of behaviour due to their status. Foucault indicates that these mechanisms indicate how awareness of power/knowledge shapes their educational experience and constructs them as different and unworthy of support (Rabinow, 1991).
11 In analysing this extract, I have indicated that the acceptance of medicine as a form of scientific practice constructs the student as docile in the scrutiny of her own body. This interpretation is based on Foucault’s notion of professional deference towards those within the scientific community. However, as this is an example of inconsistent logic, the reader should be aware that there could be multiple interpretations of this data.
96 I think we talked more about the bad experiences, but I think that's what you do with everything. If you have a bad experience, you want to tell everyone. Whereas if you've gone and they've been nice, you don’t necessarily talk about that. That's just a fact of life as I know from experience (Richard-17).
So you automatically assume that when you get called to them that you are in trouble (Richard-21).
Because there are no good stories to tell, I don't think that's down to the OH role or their abilities… There's not been anything positive because there's nothing positive to say really (Claire-19).
We can see from the above that the lack of knowledge NS have regarding the role and function of OH manifests itself in terms of anxiety. NS are aware that they are only assessed after mandatory referral for screening and vaccinations, and that contact with OH is the beginning of a bad story for them as individuals within the referral process.12 Within notions of stories of OH we can see how the process of examination of the body introduced by the Sadler Report has embedded a loss of agency for those surveyed. Similarly, the use of surveillance as a form of dividing practice and the effects this process has is made clear. Stories of OH are utilised by the NS to vent their feelings of anxiety created by reduction in their agency. 4.4 Referral to OH Within their responses to questions regarding referral to OH, the NS indicate that the referral process is an object created to ensure compliance with legislation. NS evidence awareness that legislation controls entry into nursing employment and is needed to control the risks faced in the clinical environments. This legislation creates NS as subjects to be surveyed, categorised and controlled via pseudo-scientific criteria contained in the HSWA 1974 and in particular via the risk agenda. They also evidence awareness that the role of OH which they express is concerned with controlling and surveying the health of those in work or those wishing to enter
12 This conclusion may have been based on my own assumptions regarding the knowledge students should have of my chosen profession. That ‘bad stories’ are associated with OH is clearly disquieting for me as I have an innate wish for OH to be a positive story. However, when combined with the acceptance of healthism and an ignorance of mechanisms to improve health, it could be argued that students’ own regulatory subjugation means that they can view OH only as a form of anxiety.
97 employment. The practice of surveillance and control is enacted via compulsory referral for health screening, and via mandatory vaccinations against known communicable disease. Students position the referral process within a three tiered classification system. This system, outlined by the NS, indicates their acceptance of the referral process and their awareness of the degree of intrusion and choice evident in each tier. Their acceptance is based on the assumption that they need to be protected from inherent risks and that their ill-health is a risk to patients. In rationalising their understanding of how the practice of compulsory referral influences their ability to enter employment as a nurse, the expressions mandatory, self-referral and referral are utilised consistently to outline students’ perceptions. Also of interest in this form of discursive positioning is the use of language to indicate notions of power and control. Some respondents use phrases such as referral whilst others use the phrase get referred. Consistently throughout the data collection process, the term self-referral is used to indicate where the students felt they had control over the structure, process and outcome of contact with OH. Where knowledge of control over any of these elements was absent, then the phrases get referred or more often being sent to OH were utilised. Within this form of naturally occurring language, we can infer that referral is viewed as a participatory process only when students instigate it. 4.4.1 Mandatory referral Within this category, NS position themselves as a homogenous group requiring protection from the risks contained within the practice environment, particularly physical risk or communicable diseases. Although the term mandatory referral is used, students privilege themselves as having the power to make a choice within this construction of the referral process. The choice offered is to accept mandatory referral or to avoid it by not becoming a nurse: I think it's better for organisations if they have a blanket statement and do the same for everyone and that's just the way it is. Then there is no argument. That's what you are signing up for. There are certain things that you have to comply with otherwise don't sign up for nursing (Claire-47).
This student continues by indicating initial contact with OH:
98 I thought it was to make sure that you would be able to go to the course, because I had to go and see them about my leg and then for immunisations so it was all about preparing you and making sure you were safe from work (Claire-47).
Within this context, mandatory referral to OH is seen as acceptable. This fact was particularly evident around discussions of vaccinations: I wasn't bothered about it being mandatory (FG1-51-Julie).
Yes that was fine because you think that's mandatory (FG1-45- Jane).
My understanding was that I needed the Hepatitis B vaccination and that wasn't a choice for me. It's for my own safety, so they say it’s mandatory (FG2-15-Wendy).
Within this form of discourse the students are accepting the natural social order that mandatory referral outlines. Given its judicial status, the students accept this form of scrutiny without question. Within the above quotes, students are indicating that they are knowledgeable about the referral system, but that they are passive recipients within a system designed around risk in which the possibility for change is absent. We can see an accepted regime of truth which has historical organisation and resonance, and is taken for granted (Rabinow, 1991). The effect of this taken-for-granted process is that students accept without question that they will be excluded if they do not meet the needs of the classification system (Foucault, 1979). However, they do not view this as problematic, rationalising compulsory referral for factors such as physical risk and vaccinations as being of benefit to themselves, their families and the public. There are clear utilitarian benefits surrounding exclusion of individuals with physical and communicable diseases, and therefore students see these processes as natural. This form of pastoral power exercised by the university allows the state to shape the students’ behaviour, and to impose techniques and rationalities which appear humanistic (Bastalich, 2009). According to Gutting (2005), Foucault indicated that the use of humanism reduces the agency of individuals by ensuring that pastoral power increases the need for disciplinary control. I don't think it's just being safe, I think for me personally it means I'm not going to take anything home to my family and to
99 my children and to spread things to other patients (FG1-57- Jane).
I think it's good in your normal life as well. Most people would find it useful. Most people of our age at university haven't had their Hepatitis B vaccinations so I think that I'm lucky to have got that (FG1-59-Claire).
Claire describes her perception of mandatory referral in this way: There are certain things that you have to comply with otherwise don't sign up for nursing (Claire-47).
This quote, first utilised on page 83, deserves further analysis here. This dual interpretation is made due to awareness that Claire is initially indicating acceptance of referral, but also indicating how this acceptance shapes her perceptions of her own agency. Here she is indicating that in constructing her body as a device of labour, it is acceptable to vaccinate her against known risk. The threat of exclusion from practice for refusal of mandatory referral means that the student’s body is created as docile to risk. Her individual notions of health and of her health behaviours become confined within the dominant discourse of risk, and via the assumption that risk is the best form of protection to and from the body (Rabinow, 1991). Giddens (2009) notes that the risk agenda has developed as a system of social control in which scientific advances, which outline risk create visions of a threatening or uncertain future. We can see from the above quotes that factors which ameliorate this uncertain future are seen as beneficial. Giddens continues that neoliberal principles and, in particular, increased individualism utilise risk to transfer responsibility from organisations, which have the legal responsibility for addressing risk as part of employment, via technologies of the self to individuals through notions of choice and control (Giddens, 2009). In classifying people as fit or unfit for practice, the referral process creates NS as a subject within the risk agenda. Compliance with technologies of the self and mechanisms of governmentality to address known risk, which allows students to enter employment, is seen as acceptable even though the students are aware that within this process they appear powerless (Giddens, 2009).
100 Subjectification is also evident in the structure of the educational process. Foucault termed this form of subjectification a dividing practice (Foucault, 1977). The educational structure requires exposure to professional education and is matched by exposure to the practice environment. This element is utilised to address the theory-practice gap. Having professional courses with a practice element utilising two separate spaces, in the form of the university and NHS placements, is a system which creates the students as subjects. Firstly, by the threat of exclusion from placement. Secondly, reflection is used as a mode of thinking within nursing practice which focuses attention on personal and micro-political factors, to understand how nurses can address the incongruence between the theory of nursing as taught in universities and the reality of nursing in clinical settings (Hannigan, 2001). By focusing on personal and micro-political factors, the students are structured to consider technologies of the self before other modes of thinking, which reduces choice and disempowers nursing as a profession (Hannigan, 2001). Richard and Kirsty in discussing choice indicate: Everyone has a choice I suppose, in a way I didn't have to go but if I didn't go then I would have had to face the consequences of potentially not being able to continue on practice (Richard-25).
It’s like a requirement of the university. If I don't go and see them then I can't go back to practice. So I just see it as part of your course, it's like, part of your, I don't know, it’s part of your requirement (Kirsty-31).
The simple fact that students’ behaviours are structured by adherence to medical and educational practices which are overseen by OH creates a normalising system, in which the students are passive actors with no opportunities for negotiation. Students evidenced their passivity by describing their initial contact with OH: I think it's just a tick box exercise (FG2-92-Susan).
In the first year that it was like a tick to say that this is okay and this is okay. I felt very confident, I felt positive that they are taking their time to look at the things that were very, very important to all of us SNs before we go into practice (FG1-84- Julie).
101 However, this passivity was coupled with anxiety over the outcome of contact with OH: Yes I felt very worried and scared. I found it difficult to find evidence of my vaccinations and I was worried that they would not accept me (FG1-53-Julie).
Here students are created as a product to be shaped and moulded to comply with judicial requirements. The organisation in utilising mandatory referral is able to assure NS that it is acting in line with the law and therefore in their best interest. Whose interest OH operates in is a recurring theme in all the classifications of referral. Within mandatory referral, the assumption of risk as a utilitarian form of social governance is accepted: If we catch something and we pass it on to people who are already poorly we just kind of understand that we should keep ourselves well to do what we do (FG2-51-Alice).
Similarly, Claire indicates that mandatory referral is seen as a supporting system, which safeguards the individual from themselves and others from risk: Well it was for my immunisations and well that's okay, because I need to go for my immunisations. I think it's good that they are monitoring you and they know that you are due for your second or third immunisations. So they send for you and I think that's fair enough and I'm pleased with that (Claire-21).
According to Rabinow (1991), divisive practices construct the students as victims of the referral process because via the medicalisation of their behaviours any attempts to rebel against this form of practice lead to stigmatisation. However, students indicate awareness that they can resist mechanisms of classification. In being classified as fit or unfit students did not view themselves as docile. Rather they indicate that choice is an option open to them: Well you do have a choice; you can choose not to go. Then you can't go on placement and then you can't do the course. If you want to do the course then you have to go and have the immunisation because you are not only putting yourself at risk but you put other people at risk. So you've always got a choice. (FG2-18-Elizabeth). Is that a choice? (AM).
102 Well that's it isn't it, you either take the injections or you don't. That's your choice because if you want to be a nurse then you have the injections… Because… for your own safety and other people's. (FG2-19-Elizabeth). 4.4.2 Self-referral One interesting feature of the interviews is the way students construct notions of choice within the referral process. Within a juridical framework such as risk assessments, students indicate a take-it-or-leave-it choice to mandatory referral. This theme develops into notions of empowerment when students discuss the process of self-referral. Here students indicate that they feel empowered by the ability to make a choice to see OH. Here Melanie is discussing self-referral following diagnosis with a chronic condition: I referred myself and I suppose you are empowering yourself because you have made that choice to refer yourself because you are not well. It is something I chose to do. If somebody makes that choice for me and tells me that I have to attend, then that's not empowering… but if I have made that choice to go from my free will, then free will is empowering. I could choose what I wanted to say. It is my word, my voice that I would be expressing… what I would want to share (Melanie- 32).
Melanie continues: It's very different when it's you that's making a choice. Rather, than somebody else making a choice for you, which I think can seem like a bit of an attack (Melanie-36).
Likewise, Richard: A few months later I referred myself to OH. I just rang up and made an appointment, so in that instance I was in total control. In the first instance, I didn't have any control over it whatsoever. I didn't have a choice. It was go or face the consequences, those were my two options (Richard-33).
Here Richard is outlining his feelings on the difference between mandatory referral and self-referral. With self-referral, students position themselves as powerful and knowledgeable. They indicate that through active engagement they can set the parameters of the discourse and that they are acting in their own best interests. Within this discourse, Richard is indicating that because he has control over the relationship he is able to have knowledge of the predicted trajectory of the referral process. According to Foucault (1979), power/knowledge is exercised by the student to ensure
103 personal objectives become the strategic purpose of the relationship between OH and the respondent. Here contact with OH is not oppressive, for Foucault indicates that awareness of our own power/knowledge allows development of resistance towards the initially conceived oppressive system. Power therefore becomes productive for these students and allows a clearer insight into their social position as a student. The use of resistance is also evident within the next quote, where OH via self–referral is seen as a buffer from the criticisms students felt they suffered when unwell during practice placements: If you say you’re ill then they [practice mentors] could just say, just get on with it. You’ve got a cold or something, but if you went to OH and they confirmed that you were ill, it's more credible. If you went and said look I'm not well… It stands better for you to say, well I was feeling unwell and went to OH and OH and myself agree that maybe I should have a couple of days off. It's more credible than going in and saying I'm not coming in (FG1-137-Jane).
Emerging from this discourse is the notion of trust and the relationship students have or have had with their practice mentors. The discourse of relationships emerges in several of the themes debated. Within this particular theme, I wish to focus on the notions of trust between students and OH and not on the relationship between students and practice mentors.13 In the above excerpts, Melanie and Richard are indicating that within the discourse of choice comes the concept of choices with career and emotional consequences. Melanie, in utilising the phrase what I would want to share, indicates one of the fundamental problems of referral to OH by the students within the power/knowledge continuum. In their opinion, whilst self-referral does create a trajectory of support they are aware that referral of any kind usually does not have their best interest at heart, which leads to feelings of
13 Given that the focus of this thesis is on the referral process then this statement seems obvious. However, it should be noted that a section of the oral events was taken up with discussion of a hierarchy of nursing support in which OH and the practice mentors featured. Whilst this concept is touched upon in subsequent debates within this study, the reader should be aware that OH nurses were constructed within a value system that outlined how qualified nurses did not care for student nurses. The attitude of qualified nurses towards student nurses was seen as a separate area of research. However, the negativity students had towards qualified staff could be considered influential. On reflection, the decision not to include this element as a theme could have been influenced by the fact that I am a qualified nurse and that I saw this theme as a threat to my professional standing. The subjectification of nurse professionals as professionally defensive should be considered.
104 resentment, suspicion and anxiety. This construction of the self as disempowered individuals is most striking within discussions of referral. 4.4.3 Referral Referral occurs when a member of staff involved in the students’ education feels that they need to be referred to OH to assess their health. Students are not permitted to return to the practice environment until OH staffs have seen them. However, in most cases they can continue to attend university lectures. Sometimes you feel like being sent to them is the last resort. So I felt like this is the university's way of saying right we’re on to you (Richard-12).
Depending on how strong the organisation is, sometimes I do think it is a bit of a police role that OH has (Karen-6).
Compulsory referral positions the NS as a homogeneous group whose health needs are secondary to the needs of the organisation. Within the above quotes, NS position OH as a mechanism utilised by the organisation to protect itself and the public from NS within the risk agenda. Here NS become the focus of the lens of risk. We can see from the language utilised such as we’re on to you and police role that NS perceive that OH undertakes a surveillance role on behalf of the organisation. NS indicate that this perception means that they question the motive for this service: People can go to OH to unload their problems and it worries me that it can be used as a stick with which to beat you later on. People go through capability… If you mention in an unguarded moment when they're looking for support something that later could be used against you (Karen-6).
Is there an ulterior motive type thing? Because obviously, although they are looking out for the students, they are also looking out for the public and you… well sort of the risks of you being out in practice, they are looking at that as well. You know if you're saying something open and honestly that you are worried about, you would hate for that to be taken out of context and for that to be fired against you (Melanie-24).
This student continues: I feel like it's quite problem orientated. I think it's… I don't feel like it would be support focused. I think that it’s problem orientated (Melanie-30).
105 The outcome of this distrust evidenced by the NS into the role of OH is that NS are anxious over a loss of control. Their bodies have become objects, which allow their bodies to be scrutinised and regulated. Foucault indicates that this form of governmentality allows organisations to introduce notions of the economy over other ethical and political considerations (Rabinow, 1991), a point that is not lost on some of the students: So you never know if you are speaking to them in confidence or whether it's a general conversation that goes on your record… So I would like to think that on a superficial level that they would offer some support. Whether I would be able to do something with it, I don't know. I sound like I don’t like them but that's not fair, it just seems that it's a business transaction, that we need to get this done and now we've done it. We need to get you checked out… job done, move on (Karen-52).
At a corporate level they've got to be seen to be getting people back into work to reduce the payments and they want to be seen that they are supporting their staff; that they are doing the best for their staff. I'm just flabbergasted that that's the case (Claire-65).
Claire continues: I think when you get to that level it becomes all about money really. No matter what the organisation is be it a school or hospital when you're at that level it’s just about money (Claire- 67).
The distrust of OH in terms of confidentiality is most often expressed when discussing MHI, and stress in particular. Here Claire is discussing one of her friends who was referred to OH: You know they are not coping with stress and they go to OH and is it that they are going to get back to the university. Within their role are they the students’ confidant. If I was on antidepressants for example, would they be able to prescribe them and if they did prescribe them, would it be their duty to inform the university that this person is on antidepressants. Their whole role is a problem! Is it confidential? There is that ambiguity (Claire-35). Well as you know nurses must enter into a confidentiality clause. (AM). Do they? (Claire-37). Why do you say that? (AM). Well I still have to reveal that some people are ill on a need-to- know basis. Is it the university’s need to know? (Claire-39). Other students indicate their views on MHI as follows:
106 I think I can speak for everybody, as mental health issues are something that we would keep to ourselves. That we would talk to other classmates about that, but you would try and stay away from staff as much as possible. Because you feel it gets escalated and then what you thought you were in control of then spirals out of control (Kirsty-1).
Nobody wants to feel judged and it's part of the role. You know that as a student nurse you can be judged. You know you can be tested and you know your health has to be good, but it's this questioning of your mental health more specifically than your physical health. That makes you worry (FG1-47-Jane).
I would be worried that if anything came up later on that they would say that she wasn't coping well on placement and that might be enough to tip a decision against me (Kirsty-50).
Here it is argued that this discourse is indicating that these students have turned themselves into subjects to be tested and classified. This process of self-formation creates anxiety in the students, and the struggle for power/knowledge is indicated by their anxiety over factors which appear scientifically subjective such as MHI. Similarly, their preferred method of exercising power is to internalise their problems and to avoid knowing about threats to mental health. Perhaps14 this is due to the assumption that MHI and in particular stress is seen as a form of weakness leading to stigmatisation, which creates a barrier between OH and the students. Schirato, et al. (2012) indicate that this form of care of the self is required as the students gain insight into the social contexts they inhabit. It is evident that students are aware that disclosure of worries regarding MHI creates a regime of power which seeks to exclude them from the practice space. The mechanism described by the students above is indicative of stage two of Foucault’s four-stage process for the development of technologies of the self. It appears that the students are ashamed of their inability to be a good nurse and are internalising their problems to avoid exclusion. The knowledge they have of OH and the processes it utilises is constructing them in complex ways. Within the statutory reports analysed we can observe the creation of
14 In reaching this conclusion, I was affected by the strength of feeling students had towards stress and mental health conditions. Given that many of these students are training to be mental health nurses, then I must consider that their desire to turn away from mental health support may have influenced this analysis. My optimism that health care services provide care and support may blind me towards the subjectivity of mental health care.
107 divisive practices. Within the classification system outlined by the students, we can see the effects of the referral process in shaping their behaviours both in the university and practice space. The students have created a power/knowledge continuum, which makes real the reduction in agency enacted upon them by referral and surveillance. The outcome of this is that the students seek greater pastoral support. This leads to increased self and disciplinary control mechanisms (Foucault, 1979). 4.5 Knowledge of the role of OH Within the students’ outline of the referral process, they identify a dual purpose for contact with OH. On the one hand, OH acts as an empowering force in which students have notions of agency to improve their health; this is countered by notions of OH as a process which disempowers students through the removal of autonomy. Within this process, the student adopts a social role which dominates their personal role, leaving them as objects to be manipulated via the threat of exclusion from occupation (Foucault, 1979). Within these dual interpretations, a recurring theme was a perceived lack of knowledge regarding the role of OH practice. NS consistently sought greater clarification of the role of OH, and expressed a desire to understand in detail how OH might be utilised as an aid to progress through university into occupation. According to Foucault (1973a), the knowledge students have of OH can be analysed on two levels to ascertain its influence on their role as an agent. Firstly, OH knowledge which is objective and visible. Secondly, OH knowledge, which is subjective and hidden, but which can be inferred. These classifications are useful as they aid discovery of how the institution of OH propagates ideas and knowledge of OH: how the conditions in which OH can be known or observed emerge; how OH affects students’ thoughts, feelings and behaviours; and how the dominant ideology of the institution creates docile beings (Foucault, 1973b). According to Wodak and Meyer (2009), analysis of the students’ knowledge base will help to identify the struggle for understanding into how power is encoded, and the search by individuals for increased awareness of relationships of domination held by social structures over individuals (and vice versa). Differing discourses and notions of
108 structure and agency are utilised to allow contextualisation of power in social spaces. Within the oral events, NS position themselves as lacking knowledge of the institution of OH. However, analysis of their discourses contradicts this position as the students evidence a good awareness of the role of OH as a practice. In analysing the oral events in terms of the objective and subjective meanings attributed to OH, three forms of discursive construction emerge. These are factual knowledge about the role and function of OH; knowledge of students’ emotional response to the services provided; and finally, OH as a mechanism of surveillance. 4.5.1 Factual knowledge about the role and function of OH Factually, students construct OH in terms of measures of assessment, and as a safeguard between the university and the risks posed in the practice environment. For example, they are aware that all nurses are referred to OH for screening to ensure fitness to enter the practice environment and to ensure their vaccinations comply with statutory standards: I've heard that they are here to make sure that we are fit and well and are able to practise. That's my perception of them, and when you get referred to them that's probably because somebody else wants to make sure you're fit and well (FG1-3- Claire).
They're here to deal with your injections as well aren't they? (FG1-4-Dawn).
Knowledge of OH as a form of divisive practice is evident within students’ understandings: You know that they've got the ability to write you as unfit for work (FG1-13-Jane).15
Within these viewpoints are objective constructions of NS as a homogenous group worthy of assessment and at risk from exclusion: It’s available for all nurses on campus. I don't know about any of the other courses? (FG1-1-Ann).
They [other students] are not as likely to be messing with bodily fluids (FG1-65-Jane).
15 Please note that this quote was first utilised on page 77 as an example of enthymeme. It is used again here to emphasise the effect of enthymeme in constructing understanding of OH as a form of practice.
109 Here notions that nurses are at an increased risk within the practice environment become obvious. This has the effect of constructing NS as docile bodies to be examined and quantified (Foucault, 1979). Similarly, risk becomes associated with the practice environment, and NS become docile bodies to be surveyed for evidence of the adverse effects of practice on health or of ill-health on practice (Foucault, 1979). In line with Giddens’ (2009) description of its use as a method of governmentality, the risk agenda creates a vision of an intimidating future and RAs become both protector and threat. Knowledge that the practice environment is a threat to physical and mental health creates a need for protection from risk and for on-going support. OH appears to fulfil this need for a benevolent provider of support. Assumptions that support the beneficial input of OH to assist in managing one’s own life are created. However, the threat of assessment hangs over the students, as they are aware that contact with OH can lead to stigma or exclusion. Within this objective understanding of OH, we can observe that the objective discourses students have regarding OH and its institutional function regulate the students, as the relationship within the two parties is biased towards the needs of OH. This discourse for the need for support to address risk creates a power relationship, as OH has the knowledge of the impact and management of identified risks. The scientific notions of risk as a threat disadvantages the student, and ensures power/knowledge is utilised to construct the student as less valuable and knowledgeable than the professionals involved (Foucault, 1973a). Students construct their sense of self around this knowledge, and are produced as a homogenous group who are passive recipients of support (Foucault, 1973a). The dialectic of control produces students with decreased levels of agency and decreased notions of social worth, which creates within the students an affective response (Giddens, 2009). 4.5.2 Knowledge of the emotional response to the OH services provided The assumption that students require support and that the support offered may be a risk to the self creates in students an affective response, which manifests itself in discussions of the vagueness of role, issues of trust and of the need-to-know criteria:
110 It seems to me a little vague as to why people get referred there and also what the outcomes can be, it seems to be vague. It seems difficult to predict what will happen at the end (FG1-2-Elizabeth).
I think the overall reason for OH being in the workplace is to reduce the sick pay (Claire-63).
The outcome for students within this process is that it creates anxiety, which leads to psychological barriers towards OH. The use of simplistic terms such as fit and unfit construct the student into differing forms of classification system. Classification within these terms constructs notions of normality for the students, and some of the systems are a threat to the students’ programme of education. This dividing practice (Foucault, 1979) has the effect of creating the need for support whilst constructing affective responses within students, which turn them away from this support mechanism as OH is the arbiter of the classification system. Students move from a homogenous group to be assessed to a singular entity, forced to internalise their problems due to the fear of abnormal classification (Foucault, 1979). Subjectively, students understand that contact with OH can be interpreted as a need for support and consequently as a form of weakness, and so to avoid the root cause of their anxiety they reject OH as a supporting service. The following extracts indicate that the effect of this discourse is that students are produced who believe that they do not require support and that to seek support is inappropriate within the nursing profession: I think because we are trying to be caring, that we are internalising these issues and we should be able to internalise our problems without needing to go for help… I just sometimes think that we try and seem not to be weak. We try and seem to be able to do everything. We're supposed to be superhuman. We're supposed to be nurses. We're not supposed to be able… we're not supposed to have problems (Melanie-54).
I do think that they internalise their problems. Personally, I do because you just keep going on the treadmill, don't you? Until things eventually resolve themselves one way or the other (Claire-55).
The relationship between the OH staff and the student is the next area that students consider when talking about OH in subjective terms. Within the
111 assessment process, the competence of OH staff is viewed as good which indicates awareness of compliance with notions of quality and professionalism. The concept of the student becoming a professional also acts as a dividing practice, which has influence on the students’ self-worth. According to Foucault, administrative mechanisms such as notions of professionalism ensure ‘obligatory comportment,’ which can have painful consequences (Foucault, 1979, p.215). The notion of professionalism creates assumptions that professionals have the best interests of the students at heart. Objectively, qualified OH staffs are constructed as a mechanism of support due to them attaining this status, which the student can trust: It’s good to have that reliable service as part of the university (FG2-3-Susan).
OH as a competent practice is considered by the students as ‘superior’ (FG1- 15-Ann). Consequently, the institution of OH gains superiority over the students. Within a university environment where students are commencing a three- year programme of education to attain the professional status of those delivering the service to them, then this form of relationship is understandable. However, even at this early stage of the educational process, the students evidence an incongruence between what they are being informed are the actions of a professional and the practice of OH. This incongruence, which has affective consequences, is best evidenced within notions of holistic care: Well they're not supporting me from the viewpoint of a person. They’re supporting me from the viewpoint of the employing trust. The trust are paying me my salary for six months, you see people who go off and have this miraculous recovery just before the six months is up and so if you can get people back before then, then fine because you're costing a lot of money. Yes, they want to get you better, but they are not employed to get me better for my wellbeing. They are employed by the trust to get me better because I am costing the trust a lot of money (Claire-61).
Students evidence awareness that OH are not viewing them as holistic clients and are not attempting to meet their holistic needs. By focusing purely on the assessment of physical and mental health, students subjectively know
112 that OH is not predominantly interested in their holistic welfare. Students are aware that OH screens them to ascertain the risks they pose to people in practice, and that OH has to consider the needs of other interested parties such as the employing organisation. They are aware that OH seeks to protect them from the risks others or the environment might pose and, finally, they are aware that OH seeks to prepare them psychologically from the threats that practice may bring: I’m sure that OH visits us in our first week here and I always remember them saying that they offered counselling and support. That put a big fear in me. Because I thought am I going to need help, am I going to be the person who needs counselling? I thought what am I letting myself in for at first. I found that quite a big fear for me within the first week (FG2-34- Oliver).
Here, OH can be analysed as employing the administrative apparatus of the induction process to construct the practice environment as a threat to the students’ health, and in particular their mental health (Foucault, 1979). Students emerge as potential victims of practice, and students are again constructed as dependent on OH and the university for support. Once again, the risk agenda is utilised to construct NS as requiring the pastoral support of OH and the university due to the threat of an uncertain future. Risk is once again utilised to reduce the autonomy of the students by increasing the need for OH to be the arbiter of risk. Subjectively, the practice environment disempowers the student and creates a relationship of dominance (Foucault, 1979). Two separate social spaces are created and students are aware that the support services are different for each space. Whilst support in the university space is seen as generally good, support from the Practice Education Facilitators (PEFs) and mentors within the practice space is generally seen as poor: We don't feel supported by them [PEFs]. They care more about the placement and themselves. If you have a problem with the placement, they are more likely to side with the placement and you are completely on your own (FG1-88-Richard).
It's like the moment you voice something I wouldn't say negative but I would say concerned, straightaway they turn you into a negative and they say you're not doing this and you're
113 not doing that and you're not doing well and it's your fault (FG1- 88-Ann).
Within the practice environment, students are constructed as secondary to the needs of the NHS, and students subjectively accept the dominant role of that institution. They realise that the support offered is focused towards the needs of the institution and the PEFs, and within this realisation the student is situated as a disempowered individual. Students subjectively become aware that OH is not a holistic service, as they have no input into the practice environment which is the one area OH highlight as a risk. It is a space where OH services are most needed, but where OH is conspicuously absent. Within the university space, it is argued that OH creates a dependency culture through its supportive nature. However, they then abandon the students to the practice environment, which they themselves have described as psychologically damaging. Subjectively, students become aware of the limited role of support services, and that within the practice environment they move from a homogenous group worthy of support to individuals who are threatened from the inherent risks of the practice space. The reduction from a homogenous group to a singular body is compounded by removal of other traditional forms of support which the students see as important. For example, as individual students are placed into the practice environment they lose the support of their fellow students, their friends and peers, and of the personal academic tutors. We can observe that the isolation between the differing spaces of the university and practice is now complete. I contend16 that the result of this dividing practice is that students become aware of the need to develop technologies of the self in order to comply with the cultural requirements of the practice space (Foucault, 1979). They have no option but to conform to the scrutiny of OH,
16 It seems simplistic to say that when an individual has no outside mechanism of support that they look inward. However, I have taken the view in line with Foucault’s technologies of the self that the university, and by extension OH, creates relationships of domination which alter inner resilience. On reflection, this decision was reached due to the learned helplessness evident in the oral events, and to the emotional response the students portrayed when asked to construct the ideal support services for both the university and practice spaces. Students predominantly expressed mechanisms in line with technologies of the self. However, the reader should consider if I have represented the students faithfully or if I have found a self-fulfilling prophecy. In seeking to represent the students as accurately as I could, then factors such as member checking and probing questions were utilised.
114 but also to the scrutiny of the self to become potential professionals who do not require support. In an affective sense, the development of technologies of the self creates in students an awareness of the motives for the supporting relationships they have encountered: I think all of the university is approachable. I think all of the lecturers are approachable. You can even go to the reception staff and you can tell them all your personal problems [laughter] (FG1-113-Claire).
I think you do feel more vulnerable in practice because when we are all sat here together we can sort of air your upsets to the rest of your cohort and that's really good. But I think when you're on placement you are a bit more isolated. So I think it is harder to deal with things. You do need support more on placement. However, you are isolated from your peers and you get less support (FG1-97-Barbera).
Claire outlines, in an analogy about a school she has recently attended, how students come to feel aggrieved about minimal input from support services within the practice space. The conversation commences with a discussion regarding the role of OH. She states: I just think there's a lot more that they could be doing and I don’t know why they don't do more. Perhaps they are happy doing little. The other side of that is that people say well nobody bothers about us anyway we are not important so you have the flipside of that, don't you? (Claire-24). Could you clarify for me what you mean by the phrase people think; do you mean the students or the OH staff’? (AM). For example I was in the school yesterday, which was a very badly run school. I was with a group of students who have had their third session of the day. They were in the bottom set and no one cares about them. I just don't… you know they're not bothered about them and at the end of the day those kids were sick of doing games. I don't want to be doing games all day and that's what it is. At first it’s okay that no one bothers us, we will just be getting on with it. Then it turns, people will think why aren’t we getting any help, why does no one bother with us, and I think that maybe it’s an attitude that becomes a resentment. We are not important and they don’t care about us and it becomes a barrier (Claire-29). Here, the assumption that support is a positive element of university life is made real and becomes a normalising judgement. The effect of not feeling supported in practice is the development of feelings of resentment and
115 isolation. It also ensures that technologies of the self are utilised to structure the students as docile bodies to be shaped by the differing social spaces. The realisation that OH is not a holistic service reinforces notions of OH as a disciplinary technique (Foucault, 1979). 4.5.3 OH as a mechanism of surveillance Due to its pseudo-scientific status, the assessment process compounds the feelings of isolation and inferiority evidenced by the students. It also implies that OH has the ability to conduct surveillance of students and to judge them in ways the university sees fit. Judgement of the students is permitted due to the use of the risk process within the wider context of the application of the scientific method and biomedicine (Foucault, 1975). This judgement commences with the practice of providing evidence of vaccination status. So we had to go back and call our parents to get the list of the immunisations that we have had because we needed to present evidence to OH (FG1-36-Julie).
This judgement and testing is extended through health screening and mandatory referral. Here, notions of surveillance of the body emerge and students understand that OH becomes a system of the university and of the local NHS trusts directed towards them, and not a service of the university provided for them. According to Vaz and Bruno (2003), the use of surveillance has changed historical notions of health. The risk agenda has led to development of technologies of the self, which mean that traditional notions of sickness have been replaced by acceptance of surveillance and risk. Rather than act towards our health, by changing behaviours and attitudes when we are confronted by symptoms of disease as was the traditional mechanism of coping with illness, the risk agenda means that we now alter our attitudes and behaviours when confronted with risk. Traditional classification systems of well and unwell have been replaced by classifications of at risk, or of at greater risk (ibid.). The students readily accept surveillance as a form of disciplinary technique in order not to be excluded based on the regime of truth: that they are a risk. The effect of this increased surveillance within these new classification systems is a reduction of individual freedom due to the need to reduce risk (Peterson & Bunton, 1997).
116 You feel like you are going to be judged. You feel like you going to be questioned and you feel like somebody is going to be questioning your physical and mental health (FG1-43-Jane).
On a subjective level, the use of the word screening within the OH process creates awareness of a deeper problem for students. In contemporary society and, in particular, in organisational terms screening is associated with questions of truth-telling (Vaz & Bruno, 2003). In being screened by OH, the use of the term judged includes notions such as truth- telling and honesty. Foucault described the concept of truth-telling as the hermeneutics of oneself, and indicated that it allows us to transform or displace ourselves in order to become ourselves within culturally accepted ways (Foucault, 1988). We can see from the above quotes that students feel, within certain situations, obliged to tell the truth despite awareness that it places them at risk of exclusion. Students see health as a social construct and as a mechanism of disciplinary control, indicating that through differing notions of health their status as individuals who tell the truth is challenged both by administrative practices and by the culture evident in the practice space towards them as students: Even when you're actually genuinely ill and you phone up, you feel like you're lying. You feel guilty don't you and you feel that people think that you're lying (FG2-57-Alice).
This quote indicates that students are aware that their behaviours are being monitored and questioned. It also indicates awareness that to be unwell is a form of dividing practice as the students become aware that they need to come to work to be viewed as a ‘good student’, irrespective of their own subjective notions of ill-health. A normalising judgement is created which indicates that good students don’t get sick. The notion of truth-telling is evident in a range of administrative practices because as well as being screened for their health status, students are also screened for factors such as criminal records status or their previous employment details, and are asked yearly to self-declare their good health and good character. These organisational structures constrain the students via regulatory mechanisms aimed at protecting the public. Here notions of the
117 student as a risk are accepted, and regulatory mechanisms are considered normal and in some cases desirable. Within notions of truth-telling we can see that the desire to be judged positively is a technology of the self in which the students are seeking credit for being ‘good students’ (Foucault, 1988). This group of students acknowledge the desirability of being judged, indicating acceptance of the scientific assessment of the body, and as viewing this development as positive. Words such as safe emerge to indicate assumptions of the outcome of compliance with the risk agenda that being judged represents: You are safe (FG1-56-Julie).
It's for my own safety (FG2-15-Wendy).
Similarly, students welcome the fact that the university supports them in dealing with the stresses and strains of university life: Yes I think the university is very good at supporting you (FG1- 86-Richard).
The desire for effective support also arises through notions of difference. The notion of being a NS, and of being different from other students because of the practice element of their educational programme, heightens the desire for further support. The NS signal their discomfort with their situation by seeking greater input from OH by demands for greater proactive services. The students’ conflicting understanding of the value of support from OH, which they both welcome and resent, constructs the students as disempowered individuals. Stigma is utilised as a disciplinary mechanism to ensure compliance (Foucault, 1979): I would like to have seen them talk about extra support and time management and relaxation techniques. I would have liked to have seen a preventative role for people who have reached the point where they can't cope. Maybe we could have been introduced to stress reducing techniques (FG2-33- Elizabeth).
I think a talking group would be useful. You can go to them if you have any area of concern. Even if it's not just health as well. You can come if you want to, as there are some people who don't want to talk to other people or they feel talking to other people or relating to them… because it might lead to something, because it increases your stress level to go to
118 them. So maybe if we talked to them… so maybe talking therapy session would be a good thing (FG1-140-Julie).
These conflicting outlines of the need for support are indicative of the behavioural responses caused by the anxiety of OH’s dual role. In response to a direct question from me into what support the university could offer that would make a significant difference to the students’ anxieties, answers such as ‘Child care’ (FG1-133-Jane) were expressed. Here students are giving voice to the notion that, via its focus on biomedical investigation of the body, OH is failing to pay attention to sociological and psychological assessment of the individual. The bio-psycho-social triad is the cornerstone of nursing practice, and it is obvious to students that social aspects of assessment are absent within all forms of support offered by OH. Within their programme of study, NS will have been educated into the negative elements of a solely biomedical approach, which dehumanises the caring relationship between caregiver and client. Biomedicine constructs the human body as a series of separate systems, which can be isolated, measured and fixed without regard to the effect on other biological systems or on the sociological or psychological influences on the body. Here nurse education reflects Foucault’s (1979) notion of the struggle against disciplinary technologies. Nurse education is seeking to challenge medical education technologies, which make the human self-calculating, manageable and governable within a set of fixed parameters. Rather, NS are schooled within the concept of humanism via the bio-psycho- social triad, and humanism is translated as meaning concern for the human within all spheres of human environments and being (Henderson, 1964). However, Foucault (1994) indicates that the problem with this conception of humanism is that it does not take into account how human agency is structured within power/knowledge. The disconnect between the theory taught to the students and the reality of OH practice based on disciplinary technologies gives rise to awareness of a system utilised towards the students: one based on a pseudo-scientific rationale which only partly constructs the students’ story. The subjective awareness that OH does not provide a holistic service to meet their needs, but is predominantly utilised as a university system,
119 manifests itself again in discussions regarding MHI and stress. Stress caused by the educational process is perceived as a substantial threat to the successful completion of the students’ programme. However, comments such as: If I had stress I would never go to OH, that would be my last option (FG1-21-Ann)17 indicate that investigation by OH into this area of wellbeing carries the potential to have a detrimental effect on student progress. Similarly, student’s voice concern that OH, rather than being a holistic service designed to meet the needs of the students, is a system operated by the university as a gatekeeper to employment. The notion that OH after mandatory input only sees students if something is going wrong or if there is a problem is articulated as follows: I do know that if there's a problem with your attendance or with the work that they will send for you (FG2-73-Elizabeth).
It's not a supportive role is it? It's more a… what we can do about it type role (Kirsty-14).
Kirsty continues: So I think that was quite a business-like approach. This is what the university needs to get you on your course, rather than it being the other way around, these are the things that you need to keep you safe (Kirsty-20).
I feel like it's quite problem orientated. I think it is… I don't feel like it would be support focused, I think that it’s problem orientated. A problem in itself is not an empowering word (Melanie-30).
Melanie articulates the difficulties experienced by many students in relation to the disempowering nature of a problem based system. They don't like to see themselves as having any problems (Melanie-34).
Here, this student is giving voice to the idea that the word problem is a subjective concept. The following extract commences with a discussion about
17 Please note that this quote was first utilised on page 79. It is used again here to indicate how the knowledge of referral evident on page 77 is subjectively interpreted and subjectification becomes clear to the student.
120 empowerment and self-referral, and goes on to indicate the issue of subjectivity: How do you know if someone has your best interests at heart? If you did not know that you have been referred I would find that… I would be annoyed if somebody had referred me and I did not know why. By the way, I have just referred you to OH, you would be like why? Why have you done that without getting my consent to do that? Because what somebody else sees as a problem, you might not see as a problem. Because we are all different people, we all manage things differently. What I might see as a problem, someone else might not. What I might not see as a problem someone else might see as a problem for themselves. So for someone else to assess your situation from their point of view or to make a referral I would not find empowering (Melanie-32).
Assessment is predominantly a biomedical process which seeks to measure normality. The concerns students have of the assessment of stress and mental health emerge as a threat due to the limitations of measuring this element of health effectively. The psychological response from students to this anomaly is to seek out meaningful supportive relationships in the differing spaces. The notion of truth-telling returns within these discourses as it appears the students – whilst willing to tell the truth regarding physical issues – are reluctant to engage with health professionals when they may have to discuss their mental health. Here students requiring the greatest support utilise technologies of the self to avoid contact with OH. Notions of Cartesian duality exist within students as surveillance of the body is accepted whilst surveillance of the mind is not. I contend that students, rather than utilise holistic theories to address the way their health is constructed, utilise reductionism to protect themselves from the affective responses they have to OH and from OH’s threat to their role as a social provider of resources through employment. As such, the incongruence between the theory of nursing as taught within the university space and the practice of nursing as evident within the university and clinical space becomes manageable. It is evident within these discussions that the duty of care criteria implemented within all of the statutory reports analysed has led to a reduction in agency, due to the acceptance of the neoliberal need to manage individuals for the
121 continued economic prosperity of the state; the outcome of this is that the students accept the risk agenda and the concept of deference to it. This concludes the FDA chapters. The next chapter will utilise Foucault’s 1997 notion of the dispositif to synthesise the analysis undertaken of the policy development of referral to OH and the students’ perceptions of the referral process. This chapter will also include an outline of the implications of this study and will conclude with a reflection of the research process.
122 Chapter 5: Dispositif; synthesis and recommendations
In commencing the process of drawing together and discussing what this study has identified, Foucault’s notion of the dispositif will be utilised. This is a process of discursive alignment where the various discourses can combine to form a structure which preserves the existence of a social process, such as referral to OH (Veyne, 2010). To commence this process I shall revisit the original aims of this study in light of the FDA undertaken. The primary aim of this study was to explore, via FDA, students’ perceptions of the referral process. The specific questions set were: 1. What are the trends for structuring referral to OH within health policy? 2. What functions does the referral process have in constituting subjects? 3. What can be considered as valid knowledge at this time within one HEI in respect of being referred to OH? 4. How does knowledge surrounding contact with OH emerge and how is it passed on? Within the FDA, it became clear that within the referral process NS were subjected to historical and contemporary technologies of power/knowledge, which constructed the students as a homogenous group requiring pseudo- scientific rules and judicial forms of surveillance and control (Foucault, 1988). The NS, within notions of self-identity, accepted forms of governmentality with limited consideration of its effect. Within modes of governmentality, the NS evidenced development of technologies of the self to structure their self- identity, and to evidence the self as a good student and a good nurse. 5.1 The dispositif Given this point, the dominant finding from this study is that modes of governmentality have been and continue to be utilised by the state to shape OH as a form of practice by which the state controls its citizens and maintains social order. I feel it would be useful to structure this dispositif around Foucault’s notion of the rules of governmentality, to identify if they exist and the effect of their existence or otherwise on the research aims. Foucault (1979) indicates that forms of governmentality experienced by the NS occurred due to the need to exert control over the means of production during the industrial revolution. Reform commenced with the
123 intention of making power work better. Here the idea was that by restraining the power to punish, which was becoming increasingly disliked by the public and seen as an increasingly dangerous practice for the state, reformers could turn away from the spectacle of punishment and utilise power in more sophisticated ways. Reformers could utilise humanitarian ideals as a mechanism to measure punishment against man. The right to punish moved from a process of vengeance to a process that protected society by creating techniques where crime was prevented. Foucault (1979, p.94) characterises the new technique of discipline according to the six rules introduced on page 33 of this thesis. I feel it would be useful to revisit these rules to identify their existence and effect. Foucault (1979) indicates that a humanitarian approach to punishment creates a clear distinction between first offender and recidivist, and allows a shift away from the punishment of the body to a punishment of the mind where representation of the self is central. Consequently, the body becomes politicised and is central in the use of power. A human in becoming the benchmark of acceptable conduct restructures notions of conformity with rules within the workplace, and expands judgements on behaviour. Foucault continues that many of the reformers were from the upper and middle classes who were hostile to the behaviour and morals of the lower social classes. This observation is evident within the policies analysed, as each policy can be viewed as utilising a judgement on the health and morals of the working classes and thus seeking to control development of the mind and body. 5.1.1 What are the trends for structuring referral to OH within health policy? Within this FDA, the rule of minimal quantity is evident in the use of health certificates. This process commences within the Sadler Report and is expanded in the Black Report as it shifts from the confines of the factory to include those of working age. Here we can see an expansion of the need to protect the productivity of the state, which is threatened by the current economic crisis and by predicted rising levels of ill-health in society. The phrase referral to OH has signifying power and acts as a form of governmentality within society, as the threat of being divided from the means
124 of economic security through work or state benefits exerts significant control. Referral to OH and the use of health certificates by OH, which act as scientific mechanisms of control, together with the increasing use of surveillance within the risk management agenda, are evident in all the policies analysed. The rule of sufficient ideality is evident in the use of referral to OH as a dividing practice. Most striking is how OH apparently utilises health surveillance and the certification of age to create docile bodies. In addition, the use of dividing practices allows the state to construct society to maintain traditional social stratification, via dominance of the mind and body and by governing the flow and nature of individuals entering the world of work. This trend of the state utilising health in the workplace in response to perceived or actual threats is evident across all the policies analysed. To achieve the aim of creating model citizens who were healthy and of good morals, the state sought to alter mentalities towards child labour through mechanisms such as health certificates, compulsory education and health surveillance, with the intention of changing horizons of possibilities for the working classes and the industrialists. The resulting threat of limited access to the world of work created a need for NS to conform to accepted regimes of truth about what being healthy means. 5.1.2 What functions does the referral process have in constituting subjects? The rule of optimal specification is evident with health certificates and surveillance. Deformity and non-compliance with subjective interpretations of health are utilised to constitute and classify health in and out of the workplace. Traditional measures of health, which generated a culture of apathy toward health and a dependency culture within medicine and risk management, were created within the Sadler Report and challenged in the subsequent reports once the effect of constituting subjects in this way became apparent. However, within all of the reports the referral process acts as a form of governmentality, which disempowers individuals due to its association with the risk agenda. The NS discourse awareness of their subjectification within the referral process and have tacit knowledge of its implications. However, the apathy created by the use of compulsory
125 certificates for health means that NS are constituted to accept the reduction in their autonomy without question. Knowledge of the potential consequences of referral to OH constructs NS to develop a hierarchy of support in which OH is afforded little value. Mistrust of OH is evident within the students’ construction of support. Paradoxically, OH as a form of care is constructed as a risk to the NS, as OH is the gatekeeper to the world of work. Within the risk agenda, OH threatens the students’ ability to become good nurses committed to performing their roles as productive workers. Students also evidence understanding that the HEI utilises OH within a reductionist approach and has little interest in their holistic wellbeing. Here the construction of OH as a dividing practice is most evident to the NS as they discourse feelings of abandonment when placed in the practice setting. NS evidenced increased notions of division at this point, as they not only have to construct themselves as good nurses, but also as good students. 5.1.3 What can be considered as valid knowledge at this time within one HEI in respect of being referred to OH? Within their discussions, NS evidence knowledge of OH as the gatekeeper to the world of work and of its function in constructing them as good nurses and students. Here the rule of common truth becomes evident as the NS conform to notions of OH discussed via stories of, and personal accounts about, referral to OH. Similarly, NS discuss what is known about OH from the organisational signs of and about OH. The NS evidence acceptances of the discourse of OH as a form of governmentality via its association with the risk agenda. The notion of risk allows OH to construct a regime of truth about its role and scope of practice, which is accepted almost without challenge by the NS. 5.1.4 How does knowledge surrounding contact with OH emerge and how is it passed on? By discoursing their ability to act as agents toward their own health, the NS construct a hierarchy of effect of the process of referral on their autonomy. Within this element, the rule of lateral effects becomes evident, as the outcome of various forms of referral is apparent in students’ constructions of avoidance of contact with OH. This is best illustrated within students’ constructions of the impact of scrutiny for MHI. Notions of Cartesian duality
126 are evident, which allow the students to play out ideas of resistance to power/knowledge by evidencing acceptance of surveillance of the physical body, whilst surveillance of mental health is opposed. Resistance to power/knowledge is utilised to protect notions of self-identity. Students evidenced resistance to the regime of truth encapsulated in stigmatisation caused by surveillance: they indicated that the subjectivity of mental health classification meant that those evidencing ‘stress or anxiety’ would likely be excluded automatically due to a perceived inability to cope, which stigmatises them as a threat. 5.2 Contradictory discourses Within the reports analysed we can see a trajectory of mechanisms of governmentality across time. However, also evident are discontinuities of thought into the long-term implications of the structure of OH provision and towards the use of technologies of the self towards health. For example, the duty of care held by people towards each other has shifted based on the needs of the state to protect itself from predominantly external threats. The lack of cohesion into the role and scope of OH practice evidenced in the reports analysed has led to a regime of truth in which the true purpose of referral to OH remains largely hidden. Similarly, contradictions and incomplete logic are evident in the students’ discourse of referral to OH and its implications for them. For example, the outcome of referral to OH is discoursed in a precise manner when discussing awareness of OH as a surveillance service, but is then discoursed as an ethereal concept when discussing power/knowledge of the role and scope of OH practice. Therefore, a key finding of this study is that knowledge of the role of OH as a process to support good health is conceptually fragmented, which has clear implications for practice. 5.3 Recommendations for future practice and research The finding that referral to OH and the use of health certificates by OH, to create a regime of truth about what being healthy means, has implications for future practice and research. The corollary implication is that the dominance of OH as a form of professional practice which is structured on meeting the needs of the state will continue. As stated, the use of surveillance by OH practitioners has expanded outside the factory walls. Within the regulatory
127 framework created by the policies analysed, a partnership approach, which places the needs of the service user at the centre of the provision of health in and out of the workplace, is a misnomer. The rationale for this statement lies in the identification that within Cartesian notions of to-know-thy-self, individuals construct knowledge of communal responsibility within risk management systems. This limits aspiration and explains why individuals accept surveillance without question. Research into the development of policies based on a partnership approach to health provision is required to address this anomaly. The link between OH and the risk agenda serves to construct passive recipients of care and, as stated in the RR, whilst apathy towards health within the workplace is evident a preventative culture cannot emerge. Robens’ solution of a tri-partite agreement based on shared decision-making has never been fully enacted within the UK. Instead, safety measures are dealt with due to their legislative status whilst actual improvements in health have not materialised. Given that the structure identified by Robens has been effectively implemented in other countries, I argue that Robens’ recommendations for OH should be revisited and the structures he identified duly implemented. There needs to be a clear demarcation between the risk agenda and the wellbeing approach to health so that empowerment of individuals can occur. This element will require further research. At the practical level, however, OH practitioners need to rebalance the role and scope of their work to incorporate wellness initiatives. In constituting scrutiny of health via a compulsory format which places the needs of others before the needs of the individual, the referral process has created OH as a dividing practice, with clear implications for a proactive service. From its inception as a mechanism of governmentality, both employers and employees have viewed OH with some mistrust. Similarly, across the policy texts analysed, OH as a constitutive practice has been constructed within tightly controlled criteria, which are located in the risk agenda and have a predominantly preventative function. OH, as a form of practice, is thus subjugated within the risk agenda and so holistic public health practice becomes difficult due to the focus of compliance with a protectionist discourse. The protectionist discourse encapsulated within the
128 risk agenda reduces opportunities for partnership working and for the empowerment of individuals to control their own health. Rather, healthism arises out of the risk agenda, which disempowers individuals due to healthism’s association with forms of stigma and exclusion (Galvin, 2002). Accordingly, research is required into the use and value of systems thinking as evidenced by the settings agenda into the provision of OH. Support systems offered by OH need expansion and OH as a practice needs to clarify its role and scope of provision for all parties. Collaborative provision by OH needs to occur within the differing settings which students inhabit. Referral to OH for mental health issues also requires further research. Students feel admission of not coping brings them to the attention of OH, as they are classified as a risk to the public. The students indicated that they had no control over this element and that the outcome is preordained as this form of surveillance is a bad story. The dominant implication of this finding is that there is scope for OH practitioners to create therapeutic relationships with the NS, due to the desire of the students to seek out support networks which offer mental health resilience techniques and allow the NS to seek support without fear of being judged. This potentially reduces the mistrust of OH and opens the door for holistic practice. However, it will require increased funding, training and expertise in salutogenic initiatives and a reduction in risk-based activities, which may be difficult, in the short-term at least, to realise in practice. 5.4 Reflection of the research process At the outset of this study, it was not my intention to discover a conclusive account of the perception of NS towards the process of referral to OH. Rather, the objective was to illuminate how the discourses in the reports and interviews do not signify a singular definitive perspective, but instead create a complex, plural reality. Thus, FDA does not look for a fixed understanding of reality but looks for a dynamic understanding of its structure, aiming to make explicit the ongoing struggle of interpretative processes. It is to this tradition that this study belongs. In seeking to make clear the decisions made within the interpretative struggle, I feel it would be useful to reflect upon some of the significant milestones within my research journey. This will allow me to evidence how
129 the research journey has shaped my horizons of possibility; to highlight how this journey has developed my interpretation of factors such as social justice, structure and agency, politics and ethics, gender and power; and to make clear how this thesis will impact on my own personal practice. Within the preface and introduction I indicated that students within HEIs exist in a public health vacuum and that this needed to be addressed for ethical reasons. This and the desire to understand in greater detail the implementation of government policy – the application of increasingly liberal principles towards health, and the effect of these principles on individual and collective agency – were stated as the driving forces behind this thesis. The above evidences a drive for social justice and the need for informed ethical practice. On a personal level, this thesis and the process of research have been transformative. In particular, I have come to a much deeper understanding of how politics and the use of political ethics are used to shape practice. Politics in this sense is defined as the ‘exercise of influence’ (Walzer, 1973). Despite the knowledge that health surveillance, commenced by Sadler and which continues to expand in current policies, has led to significant improvements in the health status of individuals in the workplace, I remain troubled by the influence of politics on social justice and in particular by two recurring thoughts. Firstly, as a health professional was my naivety toward politics a personal issue or is it evidence of a professional regime of truth enacted upon the nursing profession? Secondly, is the political use of governmentality and technologies of control justified from an ethical perspective? In seeking to begin to answer these questions I sought to revisit the work of Hannigan (2001) who indicates that, due to the incongruence between traditional humanistic ethics evidenced in predominantly female professions such as nursing and the use of political ethics in the traditionally masculine professions, nurses have been ineffective in influencing policy makers. Hannigan implies that for too long nurses have lacked a clear vision of what nursing is and have focused too much attention on establishing nursing as a recognised profession. The outcome of these developments is the lack of a unified discourse which could influence policy makers. In addition, the domination of men in positions of political power has meant that the
130 discourses of female professions have been largely ignored. Daly, Speedy and Jackson (2015) concur and add that female professions are disadvantaged due to the traditional division of masculine and feminine roles, which deprives women of an adequate political education, undermines their motivation to become politically active, and encourages them to devalue both themselves and other women. It is evident within my own professional socialisation that political education is given scant attention. Rather, as Daly, Speedy and Jackson indicate, nurse education has a narrow focus on clinical issues. Hannigan (2001) indicates that rather than looking outwards, the nursing profession has adopted a contemplative approach, which is compounded by the use of reflective thinking. Schön (1983), in his pivotal work on how reflection on action can overcome many of the problems faced by the emerging professions based outside the sciences, offers nursing a pathway to acceptance, which the nursing profession has been quick to seize upon. However, the use of reflective thinking as a mechanism to ensure its status as a profession is problematic for nursing, the difficulty being that reflective thinking encourages introspection and self-doubt (Hannigan, 2001). Reflective thinking has done little to help overcome both the socialisation issue facing women entering the nursing profession and the lack of political awareness within this profession of factors such as structure and agency and social justice. In reflecting upon the concept of social justice it now seems very naïve to say that at the start of this thesis I considered that most health policies were based on ethical considerations and evidence of effectiveness. This research journey has indicated to me that what I consider to be the two main resources for health – the equitable provision of healthcare and education – are mechanisms of social inequality and have been deliberately created for this purpose. This revelation is disquieting and has implications for the way that I practise in the future, as it is clear that I need to become much more of a political advocate for those whom I educate. Similarly, notions of structure and agency have altered significantly due to the identification of Foucault’s technologies of government.
131 The choice to research within the critical paradigm was based on a desire to uncover the historical forces which shaped the development of OH across time. I believe that this was the correct choice given my innate desire to ‘improve practice’. I do believe that this thesis has the potential to develop the debate about OH as a practice. I also believe that this thesis allows OH the opportunity for expansion and growth once the conditions of domination have been made explicit to others in this field. I cannot foresee how this development could have occurred outside the critical paradigm. In utilising Foucault’s methods as the theoretical basis for this work I was conscious that many critics have argued that these result in teleology (Cavalieri & de Lima, 2013). To avoid this development I feel the decision to analyse the oral events has ensured that the students’ perceptions of referral to OH have taken prominence in the thematic analysis. Within the Foucauldian tradition of genealogy the identification of differing discourses is important, as it allows the researcher to challenge taken-for-granted assumptions and to challenge dominant discourses. Within this analysis I have sought to compare the rhetoric of government policies with the reality of practice as lived by the service users. I do feel that this was an appropriate mechanism as it allowed for greater insight into the effects of competing discourses within the current practice arena for OH. In respect of how this thesis has influenced my own personal practice, then two lessons must be enacted. In reflecting upon Foucault’s premise that power is not absolute, rather it is how power is exercised which is important, then as an educationalist and a health professional I clearly believe in the concept that knowledge is power. I am now duty bound to ensure that the knowledge I have acquired by undertaking this thesis is opened up for debate and scrutiny within the OH field. To this end I intend to access prominent publications in the field of OH, to place discussion points within OH blogs and electronic media, and to forward my findings to Dame Carol Black, who at this time is writing a second report into the development of OH. Within my everyday role as an educationalist I have to seek to raise notions of politics and effective OH practice as important starting points for effective public health.
132 In seeking to identify rich data from the perspective of service users into referral to OH, I feel that I have achieved this aim. Whilst a limitation of this study is its focus on one university setting with one cohort of student nurses, with its own unique set of cultural constraints, I would argue that the research has resonance with other HE institutions and OH practice in general. This statement is based on the knowledge that the subjugating processes seen within policy development influence professional practice irrespective of the setting in which practice takes place. Similarly, the students’ development of technologies of the self has resonance with wider sociological responses to the risk management agenda. The research questions set have been addressed and have led to some evocative insights into OH.
133 References
Abrams, H. K. (2001). A short history of occupational health. Journal of Public Health Policy, 22(1), 34-80. Antonovsky, A. (1979). Health, stress, and coping. Baker, P., & Ellece, S. (2011). Key terms in discourse analysis. London, United Kingdom: Continuum Books. Barr, M. (2009). Manet and the object of painting. Retrieved from http://www.scribd.com/doc/130351081/Michel-Foucault-Manet-and-the- Object-of-Painting-2011#scribd Bastalich, W. (2009). Reading Foucault: Genealogy and social science research methodology and ethics. Sociological Research Online, 14(2), 3. Retrieved from http://www.socresonline.org.uk/14/2/3.html. Berg, L. D. (2009). Discourse analysis. Retrieved from http://www.academia.edu/2044710/Discourse_Analysis Black, C. (2008). Working for a healthier tomorrow: Dame Carol Black’s review of the health of Britain’s working age population. [The Black Report]. London, United Kingdom: HMSO. Black, C., & Frost, D. (2011). An independent review of sickness absence. London, United Kingdom: HMSO. Blackburn, S. (2008). In Oxford Dictionary of Philosophy, second edition revised. Oxford: Oxford University Press. Boorman, S. (2009). NHS health and wellbeing. London, United Kingdom: NHS. Bourdieu, P. (1977). Outline of a theory of practice. Cambridge, United Kingdom: Cambridge University Press. Bourdieu, P. (1989). Social space and symbolic power. Sociological Theory, 7(1) (Spring, 1989), 14-25. Retrieved from http://www.soc.ucsb.edu/ct/pages/JWM/Syllabi/Bourdieu/SocSpaceSPowr .pdf Browne, R. C. (1973). Safety and health at work: The Robens report. British Journal of Industrial Medicine, 30, 87-94. Bryman, A. (2012). Social research methods. (4th ed.). Oxford, United
134 Kingdom: Oxford Books. Cavalieri, M. A. R., & de Lima, I. V. (2013). A Foucauldian view of Veblen's institutionalism: Non-teleology and the interdiscursivity between economics and biology. Economia, 14(3), 199-213. Daly, J., Speedy, S., & Jackson, D. (2015). Leadership and Nursing: Contemporary Perspectives. Elsevier Health Sciences. Data Protection Act. (1998). Office of Public Sector Information. Retrieved from http://www.legislation.gov.uk/ukpga/1998. De Gialdino, V. (2009). Ontological and epistemological foundations of qualitative research. Forum: Qualitative Social Research, 10(2), art. 30. Denzin, N. K., & Lincoln, Y. S. (2005). The SAGE handbook of qualitative research. (3rd Ed.). London, United Kingdom: Sage. Department of Health. (2007). Tackling obesities: ‘Future choices’ Foresight project. Retrieved from http://webarchive.nationalarchives.gov.uk/ +/www.dh.gov.uk/en/Publichealth/Healthimprovement/Obesity/DH_07971 3. Dooris, M. (2009). Holistic and sustainable health improvements: The contribution of the settings based approach to health promotion. Perspectives in Public Health, 129, 29-36. Dryzek, J. S. (2005). The politics of the earth: Environmental discourses. (2nd ed.). Oxford, United Kingdom/New York, NY: Oxford University Press. Eaves, D. (2014). Two steps forward, one step back: A brief history of the origins, development and implementation of health and safety law in the United Kingdom, 1802–2014. Retrieved from http://www.historyofosh.org.uk/brief/index.html#chapter10 Egerton, M., & Savage, M. (2000). Age stratification and class formation: A longitudinal study of the social mobility of young men and women, 1971– 1991. Work, Employment and Society, 14(1), 23-50. Ennis, C. (2012). Qualitative research methods: Methodical literature review, critical discourse analysis. Retrieved from http://www.academia.edu/3446413/Qualitative_Research_Methods_A_Cri tical_Review_of_Critical_Discourse_Analysis. Equality Act. (2010). London, United Kingdom: HMSO. Feldman, M. S., Skoldberg, K., Brown, R. N., & Horner, D. (2004). Making
135 sense of stories: A rhetorical approach to narrative analysis. Journal of Public Administration Research and Theory, 14(2), 147-170. Foucault, M. (1966). The order of things: An archaeology of the human sciences. London, United Kingdom: Tavistock. Foucault, M. (1969). The archaeology of knowledge. London, United Kingdom: Tavistock. Foucault, M. (1970). The order of discourse (M. McLeod, Trans.). In: R. Young (Ed.), (1981). Untidying the text: A poststructuralist reader. Boston, MA: Routledge. Foucault, M. (1971). L'ordre du discours. In: B. C. Stahl (Ed.), (2004, August). Whose discourse? A comparison of the Foucauldian and Habermasian concepts in critical IS research. Proceedings of the Tenth Americas Conference on Information Systems, New York, NY. Foucault, M. (1973a). The birth of the clinic. London, United Kingdom: Tavistock. Foucault, M. (1973b). The order of things: An archaeology of the human sciences. New York, NY: Vintage. Foucault, M. (1975). The birth of the clinic: An archaeology of medical perception. New York, NY: Vintage. Foucault, M. (1976). Histoire de la sexualité I: La volonté de savoir. In: B. C. Stahl (Ed.), (2004, August). Whose discourse? A comparison of the Foucauldian and Habermasian concepts in critical IS research. Proceedings of the Tenth Americas Conference on Information Systems, New York: Hersey. Foucault, M. (1978). The history of sexuality: Volume 1 An introduction (R. Hurley, Trans.). In: R. Young (Ed.), (1981). Untidying the text: A poststructuralist reader. Boston, MA: Routledge. Foucault, M. (1979). Discipline and punish: The birth of the prison. Harmondsworth, United Kingdom: Penguin. Foucault, M. (1982). The subject and power. Critical Enquiry. 8(4), 777-795. Foucault, M. (1984). What is enlightenment? In: P. Rabinow (Ed.), The Foucault reader, pp. 32-50. New York: Pantheon Books. Foucault, M. (1988). Practising criticism (A. Sheridan, trans.), In: L. D. Kratzman (Ed.), Politics, philosophy, culture: Interviews and
136 other writings, 1977–1984, pp. 152-158. New York, NY: Routledge. Foucault, M. (1994). Two lectures (07/01/76 & 14/01/76). In: M. Kelly (Ed.), (1994) Critique and power: Recasting the Foucault/Habermas debate. Cambridge, MA/London, United Kingdom: MIT Press. Foucault, M. (1997). Utopias and heterotopias. In: N. Leach (Ed.), Rethinking architecture: A reader in cultural theory. London, United Kingdom: Routledge. Foucault, M. (1997). What is critique? (L. Hochroth, Trans.). In: S. Lotringer & L. Hochroch (Eds), The politics of truth: Michel Foucault, pp. 23-82. New York, NY: Semiotext. Foucault, M. (2008). The birth of biopolitics. Lectures at the Collège de France 1978–1979. (G. Burchell, Trans.). In: M. Snellart, F. Ewald, A. Fontana, & A. I. Davidson (Eds.). Basingstoke, United Kingdom: Palgrave. Foucault, M. (Oct–Nov 1983). Discourse and truth: The problematization of parrhesia (six lectures). The University of California at Berkeley. Retrieved via http://foucault.info/system/files/pdf/DiscourseAndTruth_MichelFoucault_1 983_0.pdf Galvin, R. (2002). Disturbing notions of chronic illness and individual responsibility: Towards a genealogy of morals. Health: An Interdisciplinary Journal of the Social Study of Health, Illness and Medicine, 6(2), 107-137. Gibbs, A. (1997). Focus groups. Retrieved from http://sru.soc.surrey.ac.uk/SRU19.html Giddens, A. (2005). The nation state and violence. Cambridge, United Kingdom: Polity Press. Giddens, A. (2009). Sociology. (7th ed.). Cambridge, United Kingdom: Polity Press. Giddens, A., & Sutton, P. W. (2013). Sociology (7th ed.). Cambridge, United Kingdom: Polity Press. Gochfeld, M. (2005) Chronological history of occupational medicine. Journal of Occupational & Environmental Medicine, 47(2), 96-114. Great Britain (1832). Report of select committee on factory children’s labour
137 [known as the Sadler Committee]. Published in Parliamentary Papers, 1833, Hansard: London. Great Britain (1972). Safety and health at work: Report of the Committee, 1970-72. Chairman: Lord Robens. London, United Kingdom: H.M.S.O. Green, A. (1990). Education and state formation: The rise of education systems in England, France and the USA. Basingstoke, United Kingdom: Macmillan Press. Gutting, G. (Ed.). (2005). The Cambridge companion to Foucault. (2nd ed.). Cambridge, United Kingdom: Cambridge University Press. Guzik, A. (2013). Essentials of occupational health. Chichester, United Kingdom: John Wiley & Sons. Hannigan, B. (2001). A discussion on the strengths and weaknesses of reflection in nursing practice and education. Journal of Clinical Nursing, 10, 278-283. Health and Safety at Work Act. (1974). Commencement No.1. Order 1974, 1974/1439, art. 2(a)/ sch.1. Henderson, V. (1964). The nature of nursing. American Journal of Nursing, 64(8): 62-67. Heyes, D. (2008). Well notes rather than sick notes aim to cure long-term sick leave. Retrieved from http://www.communitycare.co.uk/2008/05/07/well-notes-rather-than-sick- notes-aim-to-cure-long-term-sick-leave. Higginbotham, P. (2014). Introduction to the workhouse. Retrieved from http://www.workhouses.org.uk/intro. Hutchins, B. L., & Harrison, A. (1911). A history of factory legislation. London, United Kingdom: P.S. King & Son. Hutt, W. H. (1925). The factory system of the early 19th century. London, United Kingdom: Wiley. International Labour Organisation/World Health Organization (1950). Joint ILO/WHO committee definition of occupational health. Geneva, Switzerland: WHO. Jacobson, M. (1971). Qualitative data as a potential source of theory in nursing. Journal of Nursing Scholarship, Volume 4, Issue 1, 4(1), 10-14. Jenkins, R. (2013). Pierre Bourdieu. London, United Kingdom: Routledge.
138 Jordan, S., Messner, M., & Becker, A. (2009). Reflection and mindfulness in organizations: Rationales and possibilities for integration. Management Learning, 40(4), 465-473. Kirshenbaum, H., & Henderson, V. l. (Eds.). (1989). The Carl Rogers reader. New York, NY: Houghton-Mifflin. Kloss, D. (2010). Occupational health law. (5th ed.). London, United Kingdom: Wiley- Blackwell. Lim, W. K. (2011). Understanding risk governance: Introducing sociological neoinstitutionalism and Foucauldian governmentality for further theorizing. International Journal of Disaster Risk Science, 2(3), 11-20. Lupton, D. (1997). Foucault and the medialisation technique. In: A. Peterson & A. Bunton (Eds.). Foucault, health and medicine. Abingdon, United Kingdom: Routledge. Lupton, D. (Ed.). (1999). Risk and sociocultural theory: New directions and perspectives. Cambridge, United Kingdom: Cambridge University Press. Marmot, M., & Bell, R. (2010). Challenging health inequalities: Implications for the workplace. Occupational Medicine, 60, 162–166. Miller, P., & Rose, N. (1993). Governing economic life. Foucault's new domains, 19(1), 75. Mortishead, R. J. P. (1946). The world parliament of labour. A study of the I.L.O. Essex: Oast Park Books. Nancy, J. L. (1991). The inoperative community (Vol. 76). Minnesota, MN: University of Minnesota Press. Nardinelli, C. (1980). Child labour and the Factory Acts. Journal of Economic History, 40(4), 739-755. Nursing and Midwifery Council. (2015). The code for nurses and midwives. Retrieved from http://www.nmc.org.uk/standards/code/ Peterson, A., & Bunton, A. (1997). Foucault, health, and medicine. Abingdon, United Kingdom: Routledge. Pillow, W. (2003). Confession, catharsis, or cure? Rethinking the uses of reflexivity as methodological power in qualitative research. International Journal of Qualitative Studies in Education, 16(2), 175-196. Plummer, G. (2000). The failing working-class girl. Stoke-on-Trent, United Kingdom: Trentham Books.
139 Puwar, N. (2001). The racialised somatic norm and the senior civil service, Sociology, 35(3), 651-670. Rabinow, P. (Ed) (1991). The Foucault reader: An introduction to Foucault’s thought. London, United Kingdom: Penguin. Reay, D. (2001). Finding or losing yourself? Working-class relationships to education. Journal of Education Policy, 16(4), 333-346. Reay, D., Davies, M. E., & Ball, D. S. (2005). Degrees of choice: Social class, race and gender in higher education. Stoke on Trent, United Kingdom: Trentham Books. Robens, Lord. (1972). Safety and health at work: Report of the committee, 1970–72, Cmnd 5034, London, United Kingdom: HMSO. Rogers, B. (2002). Occupational and environmental health nursing. New York, NY: Mosby. Rose, M., & Millar, P. (2010). Political power beyond the state: Problematics of government. The British Journal of Sociology, 61 (supplement one), 271-303. Schirato, T., Danaher, G., & Webb, J. (2012). Understanding Foucault: A critical introduction. (2nd ed.). London, United Kingdom: Sage. Schön, D. A. (1983). The reflective practitioner: How professionals think in action (Vol. 5126). Basic Books. Schultz, C. M. (1976). The complete Peanuts, vol. 13: 1975–76. Seattle: Fantagraphic Books. Scriven, A., & Hodgins, M. (2012). Health promotion settings. London, United Kingdom: Sage. Shah, V., & Bandi, R. K. (2003). Capability development in knowledge intensive IT enabled services. European Journal of Work and Organisational Psychology, 12(4), 418-427. Shenton, A., K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22, 63-75. Smith, T. (1997). Robens revisited: An examination of health and safety law 25 years after the Robens Report with particular emphasis on the explosives industry. Retrieved from http://www.eig.org.uk/eig2002/documents/robens.pdf Stahl, B. C. (2004, August). Whose discourse? A comparison of the
140 Foucauldian and Habermasian concepts in critical IS research. Proceedings of the Tenth Americas Conference on Information System, New York, NY: Hersey. Stevenson, C. (2004). Theoretical and methodological approaches in discourse analysis. Nurse Researcher, 12(2), 14. Stozier, R. M. (2002). Foucault, subjectivity, and identity: Historical constructions of subject and self. Detroit, MI: Wayne State University Press. Taket, A., Crisp, B. R., Nevill, A., Lamaro, G., Graham, M., & Barter-Godfrey, S. (2009). Theorising social exclusion. Oxon, United Kingdom: Routledge. Taylor, P. C., & Medina, M. D. N. (2013). Educational research paradigms: From positivism to multiparadigmatic. The Journal of Meaning-Centered Education, vol. 1, art 2. Retrieved from https://www.academia.edu/2635980/Educational_research_paradigms_Fr om_positivism_to_multiparadigmatic. Thomas, M. W. (1948). The early factory legislation: A study in legislative and administrative evolution. London, United Kingdom: Thames Bank. Tones, K., & Green, J. (2010). Health promotion: Planning and strategies. London, United Kingdom: SAGE. Vaz, P., & Bruno, F. (2003). Types of self-surveillance: From abnormality to individuals at risk. Surveillance & Society, 1(3), 272-291. Veyne, P. (2010). Foucault: His thought, his character. Cambridge, United Kingdom: Polity Press. Waddell, G., & Bunton, K. (2006). Is work good for health and wellbeing? London, United Kingdom: HMSO. Walzer, M. (1973). Political action: The problem of dirty hands. Philosophy & Public Affairs, 160-180. Weindling, P. (1983). The social history of occupational health. London, United Kingdom: Croom Helm. Welch, R., & Wright, J. (2011). Tracing discourses of health and the body: Exploring pre-service primary teachers' constructions of ‘healthy’ bodies. Asia-Pacific Journal of Teacher Education, 39(3), 199-210. Wells, J., Barlow, J., & Stewart-Brown, S. (2003). A systematic review of universal approaches to mental health promotion in schools. Health
141 Education, 103(4), 197-220. Wickham, G., & Kendall, G. (1999). Using Foucault’s methods. London, United Kingdom: Sage. Willig, C. (2012). Qualitative interpretation and analysis in psychology. Buckingham, United Kingdom: Open University Press. Wilson, H. V. (2001). Power and partnership: A critical analysis of the surveillance discourses of child health nurses. Journal of Advanced Nursing, 36(2), 294-301. Wodak, R., & Meyer, M. (Eds.). (2009). Methods of critical discourse analysis. London, United Kingdom: Sage. World Health Organization [WHO]. (1986). The Ottawa charter for health promotion. Geneva, Switzerland: WHO. World Health Organization [WHO]. (2002). Good practice in occupational health services: A contribution to workplace health. Copenhagen, Denmark: WHO Regional Office for Europe. Wrbouschek, M. (2009). Discourse analysis and social critique. Psychology & Society, 2(1), 36-44.
142 Appendixes
Participant information sheet Invitation letter Consent form
143 Appendix 1: Participant information sheet
Participant Information Sheet
Compulsory contact with occupational health: a critical analysis of the referral discourses of pre-registration nursing students.
You are invited to participate in a research study. Before you decide, it is important for you to understand why the research is being conducted and what it will involve. Please take time to read the following information carefully and discuss it with your friends if you wish. Please ask the researcher if there is anything that is not clear or if you would like more information. Take time to decide whether or not you wish to participate. Thank you for reading this.
What is the purpose of the study? The purpose of this study is to analyse the perceptions of Undergraduate Students into the referral process to occupational health and what impact this may have on your educational experience. The study will explore what knowledge you have of referral to occupational health in terms of why referral to occupational health is necessary and where this knowledge originated; how you felt within the referral process and what part you played in this process; finally your views will be sought on how referral to occupational health influenced your educational experience. Why have I been chosen to participate? The researcher is interested in the perceptions of Undergraduate Students into the effectiveness of and/or the barriers to occupational health services that enhance the student experience. You will be a representative of the type of student required to provide insight into these characteristics. Do I have to participate? No – you are not obliged to participate in the study. You do not have to give any reason or explanation for your decision to decline participation.
144 What will be expected of me if I participate? You will be asked to attend a focus group, which will explore your views on the referral process. You will then be asked to take part in an interview around the referral process to occupational health on two separate occasions. Approximately two months apart for one hour at a time. The interview will be conducted in a mutually agreed room in the university setting. The interviews will be conducted at a mutually agreed time and the responses will be tape-recorded. What are possible disadvantages and risks for participating? There are no likely disadvantages or anticipated risks involved in your participation. In the event of you becoming anxious or distressed during the conversations due to the sensitive topic of health and professional health support, the conversation will be stopped immediately and a debriefing session will be conducted by the researcher if necessary. What are the benefits of participating? You will be contributing to the existing body of knowledge relevant to the provision of effective occupational health services to Undergraduate Students, as this study is about your experiences following referral to occupational health. The research will also highlight issues of ease of access to proactive occupational health services and will allow for the development of enhanced health care for students. Will my participation in this study be confidential? Yes. Interviews will be recorded, coded and transcribed verbatim with your consent. Your responses during the interview may be read by you and checked if you so wish. The research study will be available for you to read once completed. The consent forms which you sign will be kept in a locked, secure facility in the care of the researcher and will be destroyed at the end of the research project. All data collected from the conversations will be processed on a password protected laptop, which only the researcher will have access to. All data collected during the study will be stored for 5 years and then shredded and disposed of in the university’s confidential waste system.
145 What will happen to the findings of the research study once completed? The information gathered will be analysed and presented in the format of a thesis being undertaken for a Professional Doctorate in Education and will disseminated through journal publication and conference presentation. Your quotes from the interviews will remain anonymous, be coded and transcribed with your consent. Confidentiality will be maintained throughout the study. The findings will reported back to the participants and the unit staff. Who is organising and funding the research? The researcher (Alan Massey). Who may I contact for further information? Alan Massey Email: [email protected]; Tel: 01925 534226 Thank you for your interest in this research project
146 Appendix 2: Invitation letter
Invitation letter Title of Research Project: Compulsory contact with occupational health: a critical analysis of the referral discourses of pre-registration nursing students. Date: ……….. Dear You are invited to participate in a research study conducted by myself, Alan Massey, a Professional Doctorate student in Health and Social Care at the University of Chester. The research enquiry will explore and offer insight into the factors, which influence the use of Occupational Health services within the Higher Education sector. The focus will be on students undertaking educational courses leading to a professional award and their perceptions of occupational health. The research method which will be used for the study will be that of a critical discourse analysis. This will involve the use of a focus group, which will be followed on two separate occasions by one-to-one interviews. These interviews will span over time and will fit in with you and your wishes. The interviews will be about your experiences of the referral process to occupational health and will last one hour. With your permission I hope to tape-record the interviews so that I have an accurate and precise record of the discussion. I will be the only person who knows whom has been involved in the study and will ensure that your name will not be linked with any data that appears in any reporting of the research. In other words, privacy and concealment of your name and details will be secured and maintained. Your decision to participate in the research is yours and should you agree and then later change your mind that is your right and I will respect your wishes. If you wish to participate I will contact you to arrange an agreed date and suitable time for the discussion. The tape recordings of the discussion will be coded and stored separately from any list that links your name or details. They will be stored in a locked filing cabinet in my office at the University of Chester where I work. The tapes will be destroyed after the study has been completed and you can have your own copy. I would be happy to discuss the study with you at any time and thank you for your time and support. Kind regards Alan Massey Tel: 01925 534226 Email: [email protected]
147 Appendix 3: Consent form for interview
Faculty of Health and Social Care University of Chester Exton Park Chester, Cheshire CH1 4AR Consent Form for Interview Title of Research Project: Compulsory contact with occupational health: a critical analysis of the referral discourses of pre-registration nursing students. Name of Researcher: Alan Massey
Please initial box 1. I confirm that I have read and understand the information sheet dated 1/4/2014 for the above study. I have had the opportunity to consider the information, ask questions and have had these answered satisfactorily
2. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason or legal rights being affected.
3. I understand that relevant sections of any data collected during the study, may be viewed by the researcher’s supervisors from University of Chester, where it is relevant to my taking part in this research. I give my permission for these individuals to have access to the data. 4. I agree to take part in the above mentioned research study.
5. I agree for the interview to be audio taped.
6. I agree for anonymised direct quotations to be used for publication.
------Name of Participant Date Signature
------Name of Researcher Date Signature
(When completed: 1 copy for participant; 1 copy for researcher)
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