The "professional becoming" of newly-qualified nurses in the English NHS

This thesis develops new empirical insights on the socialisation of English National Health Service (NHS) newly-qualified nurses as they enter the workplace. The NHS continues to face financial and human resource constraints on ensuring the quality and safety of patient care. Nurses are the largest professional group within the NHS, and their recruitment and retention has been problematic which has implications for the ability of organisations to deliver high quality care. Nursing has a turbulent history where changes to education and recent scandals have also raised questions about the quality and safety of care delivered by newly-qualified nurses. Within this context, Preceptorship has been introduced to improve retention and quality by supporting the transition from education into the workforce through several months of support and blended learning. This study focuses on the implementation and operationalisation of one NHS Trusts’ Preceptorship programme. Although professional socialisation has been studied extensively, there has been limited empirical research that mutually accounts for the post-qualification period and new membership of an organisation. Nursing Preceptorship is a useful case because it seeks to develop professionals’ skills and knowledge whilst aligning nurses to organisational expectations. In this thesis, socialisation is theorised as ‘professional becoming’, where knowledge, skills, customs and values acquired through education are enmeshed with those of the organisation as an everyday learning activity. This highlights the possibility for professional and organisational expectations to co-produce the professional identity and practice of newly-qualified nurses during Preceptorship. Taking a ‘practice perspective’ on learning, the study focuses on the experiences of newly-qualified nurses over an eight month period. First, the study shows how particular organisational and managerial imperatives influenced the design and operationalisation of the programme. Second, it shows how the newly-qualified nurses interacted within the programme in the classroom environment where these organisational expectations were articulated and promoted as part of the induction process. The study shows how managers had to ‘sell’ the scheme through constructing nurses as unsafe or inexperienced. Third, it shows how the nurses continued their professional socialisation in clinical settings through interacting with the Preceptors and other clinical peers to develop their learning and challenge the assumptions promoted by the organisation. The study depicts a period of post-qualification socialisation where the contemporary pressures of healthcare, via the Preceptorship programme, seeks to mould nurses to meet the expectations and needs of the organisation. At the same time, resource constraints make it equally difficult for Preceptorship to fulfil this aspiration, and nurses develop other strategies to develop their clinical knowledge and skills. The study also develops additional insights on the processes of post-qualification socialisation that centre on the interplay between emotion in everyday learning, positioning in the hierarchy and reflexive identity formation. Although appearing to be socialised into the organisation, the nurses retained fidelity to an aspirational, professional version of a nurse. This thesis thus develops a more holistic understanding into the ‘professional becoming’ of newly-qualified nurses during the Preceptorship period

Decentering health research networks: Framing collaboration in the context of narrative incompatibility and regional geo-politics

Research innovations and breakthroughs are increasingly realised through collaborative networks amongst state and non-state actors. This article investigates the utilisation of such networks in the field of applied health services research, where policy narratives repeatedly emphasise the importance of collaboration between university researchers, clinical and health service leaders, patient representatives and industry. The translation of policy into practice suggests that these networks are not always designed and managed in line with policy aspirations. Taking a decentred approach, the study reported in this article examines how local policy actors translate national policies for collaborative health research networks in the context of their own histories of applied research, including local narratives and priorities for health research. The study shows that local actors face key dilemmas and opportunities for situated agency, as they experience three competing policy narratives, first, for carrying out world-class research; second, for ensuring research meets local needs and third, for developing new understanding about the implementation of research into practice. Although these expectations might appear coherent to policy-makers, at the regional level, they provide the basis for disagreement and negotiation amongst local policy actors through which the local narrative of collaborative research is framed to regional stakeholders. The study shows how the tensions between elite and local narratives can be reconciled through re-framing activities, especially the articulation of ‘parallel frames’ within a ‘cascade framing’ process

Becoming active in the micro-politics of healthcare re-organisation:The identity work and political activation of doctors, nurses and managers

The changing organisation and governance of healthcare work represents a persistent focus of micro-politics. Whilst there is a developed literature describing the micro-politics struggles that occur amongst health occupations, there is little understanding about how actors become politically aware and active. Framed by research on political activation and the concept of identity work, the paper reports on a narrative interview study with 65 people, specifically doctors, nurses and managers, working in the English healthcare system. The narratives show that healthcare workers become increasingly aware of and engaged in micro-political activities through incremental stages based on their accumulating experiences. These stages are opportunities for identity work as actors make sense of their experiences of micro-politics, their occupational affiliations and their evolving sense of self. This identity work is shaped by actors changing views about the morality of playing politics, the emotional implications of their engagement, and the deepening political commitments. The study shows that political socialisation and activation can vary between occupations and rather than assuming political affiliations are given or acquired the papers highlights the reflective agency of healthcare actors

Implementing human factors in clinical practice

OBJECTIVES: To understand whether aviation-derived human factors training is acceptable and useful to healthcare professionals. To understand whether and how healthcare professionals have been able to implement human factors approaches to patient safety in their own area of clinical practice. METHODS: Qualitative, longitudinal study using semi-structured interviews and focus groups, of a multiprofessional group of UK NHS staff (from the emergency department and operating theatres) who have received aviation-derived human factors training. RESULTS: The human factors training was evaluated positively, and thought to be both acceptable and relevant to practice. However, the staff found it harder to implement what they had learned in their own clinical areas, and this was principally attributed to features of the informal organisational cultures. CONCLUSIONS: In order to successfully apply human factors approaches in hospital, careful consideration needs to be given to the local context and informal culture of clinical practice

The contingencies of medical restratification across inter-organisational care networks

Sociologists have long-debated how health and care reforms have transformed the social organisation of medical work, especially where managerial and market interventions appear to challenge the autonomy and power of doctors (Alford 1975; Harrison and Ahmad 2000; Ferlie et al. 2013; Light 1991; McKinlay and Stoeckle 1988; Waring and Currie 2009). With growing numbers of doctors taking up managerial and leadership positions within the organisation of care services, these debates increasingly focus on the implications of professional ‘restratification’ (McDonald 2012) and medical-managerial ‘hybridity’ (Bresnen et al. 2018). On the one hand, elites and hybrids are interpreted as organising professional work on behalf of management (Noordegraaf 2007); and on the other, they are shown as protecting professional interests in more managed work environments (McDonald 2012). Contemporary research problematises this control/resistance dichotomy, calling for a more nuanced understanding of the social organisation of medical work (Numerato et al. 2010), especially the way organising sensibilities are diffused throughout the professional workforce (Noordegraaf 2015)

Are we all on the same page? A qualitative study of the facilitation challenges associated with the implementation of deliberative priority-setting

Collaborative governance has given rise to decision-making methodologies promoting democracy, inclusivity and transparency. This is exemplified by deliberative priority-setting (DPS) that blends cost-effectiveness analysis with stakeholder deliberation. Little is known however, about the facilitation challenges when ‘technical’ and ‘social’ elements are combined in a methodology. This paper investigates the facilitation challenges of implementing a DPS project within the English National Health Service (NHS). Our study examines the relationship between facilitation and the effectiveness of DPS processes, highlighting the importance of knowledge management as facilitators seek to translate technical information, to enhance the deliberative experience and promote legitimate decisions

What can clinical leaders contribute to the governance of integrated care systems?

Background: Integrated care systems present enduring governance challenges associated with fostering interorganisational collaboration. Aim: To understand how clinical leaders can make a distinct contribution to the governance and system leadership of integrated care systems. Methods: A qualitative interview study carried out between 2018 and 2019 with 24 clinical leaders, and a further 47 non-clinical leaders, involved in the governance of three Sustainability and Transformation Partnership in the English National Health Service. Results: Clinical leaders were found to make four distinct contributions: (1) making analytical insights into integration strategies that ensured their relevance and quality to clinical communities; (2) representing the views of clinicians in system decision-making thereby enhancing the legitimacy of change; (3) translation and communication activities to articulate integration strategies in favourable ways and ensure clinical engagement; and (4) relational work in the form of brokering and building connections and mediating conflict between multiple stakeholders. These activities varied across the levels of system governance and at different stages in the processes of change. Conclusions: Clinical leaders can make a distinct contribution to the governance and leadership of integrated care systems based on their clinical expertise, membership professional networks, reputation and formal authority

Local Population Structure and Patterns of Western Hemisphere Dispersal for Coccidioides spp., the Fungal Cause of Valley Fever.

UnlabelledCoccidioidomycosis (or valley fever) is a fungal disease with high morbidity and mortality that affects tens of thousands of people each year. This infection is caused by two sibling species, Coccidioides immitis and C. posadasii, which are endemic to specific arid locales throughout the Western Hemisphere, particularly the desert southwest of the United States. Recent epidemiological and population genetic data suggest that the geographic range of coccidioidomycosis is expanding, as new endemic clusters have been identified in the state of Washington, well outside the established endemic range. The genetic mechanisms and epidemiological consequences of this expansion are unknown and require better understanding of the population structure and evolutionary history of these pathogens. Here we performed multiple phylogenetic inference and population genomics analyses of 68 new and 18 previously published genomes. The results provide evidence of substantial population structure in C. posadasii and demonstrate the presence of distinct geographic clades in central and southern Arizona as well as dispersed populations in Texas, Mexico, South America, and Central America. Although a smaller number of C. immitis strains were included in the analyses, some evidence of phylogeographic structure was also detected in this species, which has been historically limited to California and Baja, Mexico. Bayesian analyses indicated that C. posadasii is the more ancient of the two species and that Arizona contains the most diverse subpopulations. We propose a southern Arizona-northern Mexico origin for C. posadasii and describe a pathway for dispersal and distribution out of this region.ImportanceCoccidioidomycosis, or valley fever, is caused by the pathogenic fungi Coccidioides posadasii and C. immitis The fungal species and disease are primarily found in the American desert southwest, with spotted distribution throughout the Western Hemisphere. Initial molecular studies suggested a likely anthropogenic movement of C. posadasii from North America to South America. Here we comparatively analyze eighty-six genomes of the two Coccidioides species and establish local and species-wide population structures to not only clarify the earlier dispersal hypothesis but also provide evidence of likely ancestral populations and patterns of dispersal for the known subpopulations of C. posadasii