Allan PhD thesis 2014 Nursing

384 Pages·2015·3.73 MB·English

OpenAIR@RGU

The Open Access Institutional Repository
at Robert Gordon University

http://openair.rgu.ac.uk

Citation Details

Citation for the version of the work held in ‘OpenAIR@RGU’:

ALLAN, E., 2014. “Nursing by the long stretch of the arm”: an
exploration of community nursing middle managers’ experiences
of role enactment within Community Health Partnerships in three
regions of Scotland. Available from OpenAIR@RGU. [online].
Available from: http://openair.rgu.ac.uk

Copyright
Items in ‘OpenAIR@RGU’, Robert Gordon University Open Access Institutional Repository,
are protected by copyright and intellectual property law. If you believe that any material
held in ‘OpenAIR@RGU’ infringes copyright, please contact [email protected] with
details. The item will be removed from the repository while the claim is investigated.
“Nursing by the Long Stretch of the Arm”: an exploration of
community nursing middle managers’ experiences of role
enactment within Community Health Partnerships
in three regions of Scotland.

A thesis submitted in partial fulfilment of the requirements of
Robert Gordon University for the degree of Doctor of Philosophy

Elaine Allan

December 2014

1
To open my thesis I searched for a meaningful quote from a person I could relate to.
Instead it found me via the gift of a beautiful Victorian postcard.

“Where There’s A Will There’s A Way”
“Should you see, afar off, that worth winning
Set on the journey with trust;
And ne’er heed if your path at the beginning
Should be among brambles or dust –
Though it is by footsteps ye do it,
And hardships may hinder and stay;
Walk with faith and be sure you’ll get through it;
For where there’s a will there’s a way”.
Eliza Cook (Miles 2011)

2
Acknowledgements

The individuals and institutions referred to in my acknowledgements have
contributed greatly in making this investigative study a reality.

I would like to express my appreciation to NHS Scotland and The Queen’s Nursing
Institute Scotland for their contribution in partially funding this investigation.

Most importantly I am very grateful to the community nursing middle managers who
generously gave of their time, shared their work world and trusted in my
interpretation of their experiences.

I am indebted to my Principal Supervisor Dr Colin Macduff whose patience and
constructive guidance throughout has been invaluable and has greatly contributed to
my intellectual development during the course of the PhD. Dr Bernice West and Dr
Sue Barnard added to my PhD experience with their productive feedback.

I am grateful to my family and friends far and wide for their collective belief in me.

I have been touched by Barry’s steadfast encouragement and have delighted in his
gigs and musical adventures which provided the ultimate antidote to the pressures of
study.

Words cannot express how grateful I am to Robbie for being my rock, tolerating “the
cuckoo in the nest” and giving me the space I needed to focus on my academic
work.

This thesis is dedicated to the memory of my beloved Mum and Dad.

3
TABLE OF CONTENTS
Page

“Where There’s A Will There’s A Way” – Eliza Cook 2
Acknowledgements 3
Table of Contents 4
List of Appendices 10
List of Figures 10
List of Tables 11
Abbreviations, definitions and acronyms, & glossary of terms 12
Abstract 13

CHAPTER 1: INCEPTION OF THE THESIS – INTRODUCTION & 15
BACKGROUND

1.1 Overview of chapter 15
1.2 Personal and professional motivation for the research 16
1.3 Initial search of the literature in 2007/2008 17
1.4 The research need and aim 19
1.5 The structure, main content and format of the thesis 21

CHAPTER 2: CRITICAL REVIEW OF RELEVANT LITERATURE 25

2.1 Overview of literature review in the thesis 25
2.2 Structure of the foundational review 26
2.3 Literature search approach 28
2.3.1 Foundational literature searching 28
2.3.2 Ongoing literature search and review 29
2.4 Overview of key cross cutting concepts 33
2.4.1 Change 33
2.4.2 Management 34
2.4.3 Leadership 35
2.4.4 Role 37
2.5 Overview of key structural contexts and focal concepts 39
2.5.1 UK healthcare structures, culture and community nursing 39
2.5.2 Scottish Government health and social care policy, NHS Scotland and 42
community nursing
2.5.3 Health Boards, Local Healthcare Co-operatives and CHPs 44
2.5.4 Local nursing teams in CHPs 49
2.5.5 Community Nurse Middle Managers (CNMMs) 50
2.6 Identification of research questions 53

4
CHAPTER 3: STUDY DESIGN: FOUNDATIONS AND METHODOLOGY 54

3.1 Overview of chapter 54
3.2 Qualitative inquiry 55
3.3 Epistemology and ontology 56
3.4 The researcher’s position: the emic and etic 58
3.5 Reflexivity 60
3.6 Methodology 61
3.7 Phenomenology 62
3.8 The interpretivist phenomenology of Heidegger 64
3.9 Interpretative Phenomenological Analysis (IPA) 65
3.10 Design principles and practice 71
3.10.1 Ongoing literature reviewing 71
3.10.2 Interviewing 71
3.10.3 Sampling 73
3.10.4 Preparation 75
3.10.5 Expansion 76
3.11 Overview of the study design 77
3.12 Consideration of quality criteria 79

CHAPTER 4: DEVELOPMENT AND APPLICATION OF METHODS 80

4.1 Overview of chapter 80
4.2 Reflexivity: foundation and application 81
4.2.1 Reflexive interview: purpose and structure 81
4.2.2 Reflexive interview: feelings and findings 83
4.2.3 Reflections on the reflexive interview 86
4.2.4 Outcomes of the reflexive interview and implications for next stages 89
4.3 The preliminary interviews phase 91
4.3.1 Rationale 91
4.3.2 Testing recruitment 92
4.3.3 Planning, organising and enacting interviews 93
4.3.4 Design and methodology reflections 97
4.4 The foundational interview phase 99
4.4.1 Objectives 99
4.4.2 Recruitment 99
4.4.3 Revised interview schedule 100
4.4.4 Conducting the interviews 100
4.5 The recursive and expansive interview phases 102
4.5.1 Objectives 102
4.5.2 Recruitment to the recursive phase 102
4.5.3 Revised interview schedule for the recursive phase 103
5
4.5.4 Conducting the recursive interviews 103
4.5.5 Sampling and recruitment to the expansive phase 104
4.5.6 Revised interview schedule for the expansive phase 104
4.5.7 Conducting the expansive interviews 105
4.6 Analysis processes 106
4.6.1 Reading of the case 108
4.6.2 Initial appraisal and developing intra-case themes 108
4.6.3 Developing inter-case themes 109
4.6.4 Triangulation and development of analyses 110
4.6.5 Presenting the findings 111
4.7 Ethical considerations 113
4.7.1 Professional ethics 113
4.7.2 Statutory codes and processes 113
4.7.3 Legislative frameworks 114
4.7.4 Conducting research in the researcher’s employment context – challenges 115
and advantages
4.7.5 Protecting participants from harm: informed consent 116
4.7.6 Protecting participants from harm: sensitivity during the interviews 117
4.7.7 Maintaining anonymity and confidentiality 117

CHAPTER 5: FOUNDATIONAL PHASE FINDINGS 119

5.1 Overview of chapter 119
5.2 Role type in foundational, recursive and expansive phases. 120
5.2.1 Participant profile information 121
5.2.2 Description of sites, regions and CHP characteristics 122
5.3 Presentation of transcript quote codes 124
5.4 Foundational phase findings: Superordinate Themes and Theme Clusters 125
5.5 What is the role? 128
5.5.1 Nature and scope of role 128
5.5.2 Lack of review/evaluation 129
5.6 Strategies for managing change 132
5.6.1 Championing change 132
5.6.2 Inclusion to facilitate change 132
5.6.3 Change through persuasion 133
5.6.4 Change through leadership 134
5.7 Contingent conditions and tensions (professional/personal) 136
5.7.1 Partnership working 136
5.7.2 Managing competing/conflicting priorities 137
5.7.3 Integrating nursing values 137
5.8 Professional & personal consequences 139
5.8.1 Role fatigue 139
6
5.8.2 Feeling undervalued 139
5.8.3 Disengagement/alienation 140
5.8.4 Positive adjustment strategies 140
5.9 Reflections and projections 142
5.9.1 Learning from the past 142
5.9.2 What the future holds 142
5.10 Foundational phase: synthesis of findings with initial reference to literature 144
5.11 Foundational phase: conclusion 147

CHAPTER 6: RECURSIVE INTERVIEW FINDINGS 148

6.1 Overview of chapter 148
6.2 Recursive phase aim & objectives 149
6.3 Recursive phase: Superordinate Themes and Theme Clusters 150
6.4 Changing context and consequences 152
6.4.1 Role complexity 153
6.4.2 Role fluidity 153
6.4.3 Widening span of control 154
6.5 Role enactment strategies for managing change 157
6.5.1 Enacting engaging leadership 157
6.5.2 Exhibiting strong professional nursing identity 158
6.5.3 Acting as service user advocates 159
6.6 Contingent conditions and tensions 161
6.6.1 Politicisation of the NHS 161
6.6.2 CHP identity and partnership working 162
6.6.3 Middle position and semi-autonomous role 163
6.6.4 Financial constraints and cutbacks 166
6.6.5 Role dissonance 166
6.7 Professional and personal consequences 168
6.7.1 Managing conflicting priorities 168
6.7.2 Reactive management 169
6.7.3 Eroding support mechanisms 169
6.7.4 Lack of review and evaluation of CNMM role 170
6.7.5 Role and change fatigue 170
6.7.6 Reduced job satisfaction 171
6.7.7 Loneliness of the CNMM role 173
6.8 Positive adjustment strategies 174
6.8.1 Managing work/life balance 174
6.8.2 Mobilising asset building 174
6.9 Reflection and projections 175
6.9.1 Learning from the past 175
6.9.2 What the future holds for CNMMs 177
7
6.10 Recursive phase : synthesis of findings with initial reference to literature 180
6.11 Recursive phase findings – conclusion 183

CHAPTER 7: EXPANSIVE PHASE FINDINGS 184

7.1 Overview of chapter 184
7.2 Expansive phase: Superordinate Themes and Theme Clusters 185
7.3 The CNMM role within the CHP setting in the expansive phase 187
7.4 Role complexity 190
7.4.1 Role fluidity 190
7.4.2 Widening span of control 191
7.5 Role enactment strategies for managing change 192
7.5.1 Enacting engaging leadership 192
7.5.2 Exhibiting strong professional nursing identity 192
7.5.3 Acting as service user advocates 193
7.6 Contingent conditions and tensions 195
7.6.1 CHP identity and partnership working 195
7.6.2 Middle position & semi-autonomous role 196
7.6.3 Financial constraints and cutbacks 198
7.6.4 Role dissonance 199
7.7 Professional and personal consequences 200
7.7.1 Managing conflicting priorities 200
7.7.2 Reactive management 201
7.7.3 Lack of review and evaluation of CNMM role 201
7.7.4 Loneliness of the CNMM role 202
7.8 Positive adjustment strategies 203
7.8.1 Mobilising asset building 203
7.8.2 Strategic leadership and support 203
7.9 Reflection and projections 206
7.9.1 Learning from the past 206
7.9.2 What the future holds for CNMMs 207
7.10 Expansive phase: synthesis of findings with initial reference to literature 209
7.11 Conclusion of expansive phase findings 213
7.12 Summary of commonalities and variances found between all phases of the 214
investigation
7.12.1 Commonalities 214
7.12.2 Differences in patterns 215

8
CHAPTER 8: ACQUAINTANCE WITH PARTICULARS: TWO CONTRASTNG 217
EXPERIENCES

8.1 Overview of chapter 217
8.2 Overview of exemplars 218
8.3 Exemplar one – Mary 219
8.3.1 Foundational interview 219
8.3.2 Recursive interview 222
8.4 Exemplar two – Laura expansive interview 227
8.5 Discussion exemplar one – Mary 234
8.6 Discussion exemplar two – Laura 236
8.7 Cross-exemplar analysis 237

CHAPTER 9: DISCUSSION 239

9.1 Overview of chapter 239
9.2 Reflection on the purpose and nature of the study 240
9.3 Contemporary context as a lens 242
9.3.1 Outer context: primary care in the UK 246
9.3.2 Outer context: primary care in Scotland 247
9.3.3 Outer context: policy influencing community nursing in Scotland 248
9.3.4 Inner context: recent empirical research relating to Community Nursing 250
and CNMM role enactment
9.4 How CNMMs experienced their role 253
9.4.1 Role content: shifting ground 254
9.4.2 Role set: the view from the middle position 259
9.4.3 Role form: how CNMMs navigated change through professional identity 266
9.5 Analysis of leadership and management 271
9.5.1 Enacting engaging leadership 271
9.5.2 Reactive management 273
9.5.3 Taking stock 274
9.6 Learning from diversity: how can the CNMM role best thrive? 278
9.7 Coda 292

CHAPTER 10: CONCLUSION AND RECOMMENDATIONS 295

10.1 Conclusion 295
10.2 Value of the investigation 297
10.3 Acknowledgement of limitations of the research 299
10.4 Recommendations 300
10.4.1 Policy, education and research 300
10.4.2 Practice 301
9