Constituting Modern Matron: Exploring Role, Identity and Action in an English NHS Trust Liz Matykiewicz PhD The University of York Management April 2011 ABSTRACT The English National Health Service (NHS) is a contested organisational terrain where what it means to be ‗professional‘ is under threat from a dominant ‗new managerialism‘ discourse. Sustained organisational change and reform during the past thirty years has impacted on the nature of professional work and role relationships between health care practitioners, managers, patients and the public. Identity is a useful analytic frame for exploring professional role dynamics and has pertinence for studies of health care professionals as they negotiate these changes. This study considers professional identity as constructed through the enactment of a nursing role, Modern Matron, in an English NHS Trust. The role has been introduced into the nursing hierarchy in response to public and political demand for an authoritative clinical leader to take responsibility for managing standards of care within nursing; it is a hybrid management role, performed across professional and managerial boundaries, and across different organisational levels. The research has been conducted within an interpretive paradigm of social constructivism; qualitative data from semi-structured interviews is the primary source from which findings are drawn. The findings illustrate the contradictory nature of the Modern Matron role as performed across occupational and organisational boundaries and within competing discourses of professionalism, managerialism and holistic patient-centred care. The empirical contribution of this research is to suggest that the Modern Matron role is constituted of multiple and different identities which are mediated through ‗syncretic action‘ whereby individuals act singularly and collectively upon elements of competing discourses to create uniqueness in role and identity reflective of the specific structural, socio-political and historical circumstances in which Modern Matron is performed; this is epitomised in the collective presentation of Corporate Matron. The concept of syncretic action offers an alternative perspective through which to consider and understand the processes of identification in organisational role reconfiguration within health care; the concept has broader application to identity studies in general. 2 TABLE OF CONTENTS ABSTRACT ...................................................................................................................... 2 TABLE OF CONTENTS .................................................................................................. 3 TABLE OF FIGURES ...................................................................................................... 9 LIST OF TABLES ............................................................................................................ 9 ACKNOWLEDGEMENTS ............................................................................................ 10 AUTHOR‘S DECLARATION ....................................................................................... 11 1 INTRODUCTION ................................................................................................... 12 1.1 The Research Question ..................................................................................... 13 1.2 The Organisational Context .............................................................................. 14 1.2.1 The English National Health Service (NHS) ............................................ 14 1.2.2 NHS Reform .............................................................................................. 15 1.2.3 Essence of Care Benchmarking ................................................................. 17 1.2.4 Modern Matrons and Essence of Care ...................................................... 18 1.2.5 Mediating Boundaries: reconciling tensions ............................................. 19 1.3 Significance of this Research ............................................................................ 20 1.4 Contribution to Knowledge .............................................................................. 20 1.5 Thesis Overview ............................................................................................... 21 2 IDENTITY AND RELATED CONCEPTS ............................................................ 24 2.1 Defining Identity and related concepts ............................................................. 24 2.2 Theoretical Stances ........................................................................................... 25 2.3 Identity at the level of the individual: a sense of self ....................................... 27 2.4 Identity: a relational, social process .................................................................. 29 2.5 Developing Identity: the social self .................................................................. 35 2.6 A Critical Perspective on Identity ..................................................................... 39 3 2.7 Discourse: a device for constructing and analyzing identity in organisations .. 44 2.8 Concluding Thoughts........................................................................................ 47 3 PROFESSIONAL IDENTITY ................................................................................ 49 3.1 Defining professional identity .......................................................................... 49 3.2 Professionalism and Management within Public Services ............................... 52 3.3 Professionalism and Management in Health Care ............................................ 54 3.3.1 Medicine and Management ....................................................................... 55 3.3.2 Nursing as a Vocational Occupation ......................................................... 56 3.3.3 Nursing as a Professional Project .............................................................. 57 3.3.4 ‗Problems‘ of Professionalisation ............................................................. 59 3.3.5 Reconfiguring Professional Nursing Identity ............................................ 61 3.4 Matron: past, present and modern .................................................................... 62 3.4.1 Reform Policy: ―Bring Back Matron‖ ....................................................... 63 3.5 Concluding Thoughts........................................................................................ 68 4 METHODOLOGY .................................................................................................. 70 4.1 The Research Area ............................................................................................ 70 4.2 Doing Qualitative Research .............................................................................. 72 4.3 Methodological Considerations for this Research ............................................ 73 4.3.1 Qualitative Research in Health Care ......................................................... 73 4.3.2 Research Strategies .................................................................................... 74 4.3.3 Research Methods ..................................................................................... 77 4.4 Analysing Qualitative Data ............................................................................... 80 4.4.1 Discourse Analysis as Method .................................................................. 81 4.4.2 Understanding Grounded Theory .............................................................. 82 4.4.3 Alternative Approaches to Data Analysis ................................................. 84 4 4.5 My Chosen Methodology ................................................................................. 85 4.5.1 Approach and Methods ............................................................................. 85 4.5.2 Data Analysis ............................................................................................ 86 4.5.3 Self Reflection ........................................................................................... 87 4.5.4 ―Starting Where You Are‖ ........................................................................ 88 4.5.5 My (un)reflective Self ............................................................................... 89 4.6 Concluding Thoughts........................................................................................ 90 5 CONDUCTING THE RESEARCH: THE CASE ORGANISATION .................... 91 5.1 Organisational Structure ................................................................................... 91 5.2 Organisational Complexity ............................................................................... 95 5.3 Getting Started with PhD Research .................................................................. 97 5.3.1 Being Known to the Research Site ............................................................ 98 5.3.2 Gaining Access: Ethical Approval .......................................................... 100 5.3.3 Data Collection: Points of Contact with the Case Organisation ............. 100 5.4 Transcriptions and Initial Coding ................................................................... 104 5.4.1 Initial Coding ........................................................................................... 105 5.5 Reframing the Research .................................................................................. 106