Management Changes in the National Health Service: nursing and organisational theory in relation to the development of a new unit of health care. by Susan Margaret Read A thesis submitted to the University of Sheffield for the Degree of Doctor of Philosophy in Management School of Management and Economic Studies University of Sheffield June 1989 MANAGEMENT CHANGES IN THE NATIONAL HEALTH SERVICE; NURSING AND ORGANISATIONAL THEORY IN RELATION TO THE DEVELOPMENT OF A NEW UNIT OF HEALTH CARE. SUSAN MARGARET READ SUMMARY This thesis gives an account of research into management changes in the English NHS following the implementation of the Griffiths' Report (1983). The research had three aims: 1. To describe and consider the effects of new management philosophies plans and practices by conducting a case study of one particular unit of health care. 2. To study theories of nursing and health care organisation. 3. To assess the relationship, if any, between experience and theory, suggesting ways to bring theory and practice closer together. The academic perspective is multidisciplinary, drawing on literature from nursing, organisational 'theory and behaviour, health service management, social science, philosophy, history, economics and policy studies. The thesis commences with a discussion of research methodology, arguing the appropriateness of an interpretive stance. An account of the development of the NHS and nursing's place within it is followed by a detailed case study of one unit, which lasted nine months and involved more than a hundred interviews. Particular characteristics of the case study are:- Data analysis utilising grounded theory methodology Inclusion of members of the organisational context A system for participants to validate data pertaining to themselves. The style is naturalistic, qualitative and processual. Presentation of the results recognises the existence of multiple interpretations of organisational reality; a metaphor likens the development of the Unit to the weaving of a tapestry, where the backing is the structure of the unit, and the pattern the perceptions, values and aspirations of its staff, patients and context members. Emerging themes in the thesis are:- the complexity of the NHS professional philosophies and their relationship to management organising as a process growth of a distinctive unit culture. A deliberate choice is made to expose the conflicts and difficulties of naturalistic inquiry, by reflecting on research method throughout the thesis, which is written in the first person. DEDICATION "Whatever you do, work at it with all your heart, as working for the Lord not for men.". St. Paul's Letter To The Colossians, chapter 3, Verse 23. 1 CONTENTS PAGE List of Tables 11 List of Figures 11 Acknowledgements 14 List of Abbreviations Used In The Thesis 16 CHAPTER ONE: INTRODUCTION: THE SUBJECT, STYLE AND 18 PERSPECTIVE OF THE THESIS. 1.0 Introduction. 18 1.1 The Subject Of The Thesis. 18 1.2 The Style Of The Thesis. 19 1.3 The Perspective Of The Thesis. 20 1.4 The Structure Of The Thesis. 22 TWO: THE RESEARCH PROCESS - IN THEORY. 25 2.0 Introduction. 25 2.1 Similarities Between Researching Accounting 25 And Researching Nursing. 2.1.1 Developments In The Philosophy Of Science. 27 2.1.2 Lack Of Organisational Research By Nurses. 28 2.2 Four Paradigms Of Social Research. 30 2.2.1 Definitions Of Philosophical Terms. 32 2.2.2 Key Variables In Social Science Theory. 34 2.2.3 Characteristics Of The Four Paradigms. 35 2.2.4 Most Nursing Research Is Functionalist. 36 2.3 Choice In Research Methodology. 37 2.3.1 Stating My Own Position. 38 2.4 Other Ways Of Looking At Research 43 Methodology. 2 PAGE 2.4.1 The Importance Of Seeing An Organisation In 44 Its Context. 2.5 From Methodology To Research Design. 45 2.5.1 Choice Of Case Study Method. 46 2.5.2 The Research Proposal. 47 2.5.3 Case Study Method. 48 2.5.4 The Influence Of Research Education And 50 Experience. 2.5.5 Can Research Be Value-Free? 52 2.5.6 Naturalistic Inquiry. 55 2.6 Grounded Theory. 58 2.7 The Contrast Between Positivist And 64 Naturalistic Viewpoints. 2.8 Criteria For Trustworthiness In 66 Naturalistic Research. 2.8.1 Credibility. 67 2.8.2 Transferability. 70 2.8.3 Dependability And Confirmability. 71 2.9 Conclusion. 73 THREE: THE BACKGROUND - THE NHS AND THE PLACE 74 OF NURSING WITHIN IT. 3.0 Introduction. 74 3.0.1 Literature Searching As An Aspect Of 74 Naturalistic Inquiry. 3.0.2 The Importance Of The Research Context. 75 3.1 The History of Health Care And Nursing 76 In England Up to 1948. 3.2 The Formative Years Of The NHS. 82 3.2.1 The Birth Of The NHS. 82 3.2.2 Nursing - Before And After The 86 Coming Of The NHS. 3.2.3 The 1960's - Managerialism. 89 1 3 PAGE 3.2.4 Preparations For Change In The NHS. 92 3.3 Nursing - Another Opportunity For Change. 93 3.3.1 Higher Education And The growth Of 95 Nursing Research. 3.4 The 1974 Reorganisation And Its Aftermath. 97 3.4.1 Problems Following The 1974 Reorganisation. 100 3.4.2 The Effect Of Economic Pressure On The NHS. 102 3.4.3 The Royal Commission On The NHS. 104 3.4.4 The Royal Commission's Views On Nursing. 105 3.5 Accelerated Change In The NHS. 107 3.5.1 The 1982 Reorganisation Of The NHS. 110 3.6 Organisation Theory And The NHS - 112 An Overview. 3.6.1 Characteristics Of The NHS. 114 3.6.2 Domain Theory And Its Implications 116 For The NHS. 3.7 Recent Nursing Developments - An Overview. 119 3.7.1 The Role And Function Of The Nurse. 120 3.7.2 Nursing Values. 123 3.7.3 Accountability In Nursing. 125 3.7.4 The Nursing Process. 127 3.7.5 Nursing Models And Theories. 131 3.7.5.1 Criticisms Of Theories And Models. 133 3.7.5.2 Benefits Of Theory Based Nursing. 134 3.7.5.3 Classifications Of Theories And Models. 136 3.7.6 The Concept Of Profession In Nursing. 139 3.7.7 Nurses And Politics. 141 3.8 Is There Any Benefit In Considering Nursing 143 And Organisation Theory Side By Side? 3.9 Conclusion. 144 4 PAGE FOUR: THE FOREGROUND - THE QUICKENING PACE OF 145 CHANGE IN THE NHS FROM 1983 ONWARDS. 4.0 Introduction. 145 4.1 The Griffiths Report (1983). 145 4.2 Initial Responses To The Griffiths Report. 151 4.3 The Implementation of Griffiths - 154 1984 onwards. 4.4 Other Management Initiatives. 157 4.4.1 Management Budgeting And Resource Management. 161 4.5 Issues Raised By The Implementation Of The 162 Griffiths Report. 4.5.1 The Position Of Nurse Management 163 After Griffiths. 4.5.2 The Possibility Of Political Pressure. 168 4.5.2.1 The Constitutional Position Of 169 The Secretary Of State. 4.5.2.2 DHSS Involvement In Day-To-Day 170 Management. 4.6 A Longer Term View Of Griffiths'. 172 Implementation. 4.6.1 General Management And Leadership. 173 4.6.2 General Managers As Mediators. 174 4.6.3 General Management As A Symbol Of Pluralism 176 In The Welfare State. 4.6.4 General Management As A Challenge To Medical 179 Dominance. 4.6.5 General Management As A Balance Between 181 Individual And Community Needs. 4.6.6 General Management As A Balance Between Many 182 Other Conflicting Interests. 4.7 Conclusion. 186 FIVE: THE RESEARCH PROCESS - IN PRACTICE. 187 5.0 Introduction. 187 5 PAGE 5.1 From General Ideas To Research Desi gn - 187 Choices And Constraints. 191 5.1.1 Gaining Access To A Research Site. 5.1.2 The Research Design. 191 5.2 From Acceptance To Beginning The Research. 194 5.2.1 Problems With Tape-Recording. 195 5.2.2 Delays In Beginning The Research. 196 5.3 Doing The Case-Study. 198 5.3.1 The Interview Process. 199 5.3.2 Writing-Up Interviews And Seeking 200 Validation. 5.3.3 Keeping The Data-Base Intact. 201 5.3.4 Interviewing Nurses And Other Unit Staff. 201 5.3.5 Interviews In The Unit's Context. 204 5.3.6 Other Data Sources. 205 5.3.7 Summary Of Interview And Observation 206 Scripts. 5.3.8 Documentary Data. 208 5.3.9 Data Not Available. 208 5.4 Data Analysis. 209 5.4.1 Preparing Data Summary Cards. 209 5.4.2 Comparative Analysis. 210 5.4.3 Discerning Patterns In The Data. 211 5.4.4 Including Nurse Managers' Responses 212 With Their Staff's Responses, Not Making Them A Separate Group. 5.5 The Unit Report. 215 5.6 Further Data Analysis. 216 5.6.1 Using Metaphor In Organisational Analysis. 217 5.6.2 Using The Metaphor Of A Tapestry In This 218 Analysis. 6 PAGE 5.6.3 Defective Memo-Writing Recognised As A 220 Problem. 5.7 Conclusion 221 SIX: THE CASE STUDY - LOOKING AT THE PROCESS OF 223 UNIT FORMATION. 6.0 Introduction. 223 6.1 Stoneyshire District, Up To 1985. 224 6.1.1 Implementation Of Change In 226 The District in 1985. 6.2 The Creation Of Western Unit. 230 6.2.1 Western Unit's Health Care Facilities. 230 6.2.2 The Unit's Geography. 231 6.2.3 The Unit's Management History. 232 6.2.4 Western Planning Group. 233 6.2.5 Transferability - Key Characteristics 235 Of The Unit. 6.3 The Process Of Unit Formation. 240 6.3.1 Western Unit - Gestation, Birth 242 and Early Life.