In this section I examine the impact of this tighter control on clinicians. I argue that tighter supervision of activity, combined with a lack of voice could result in psycho-social pathologies and these will be explored in the
nurse-participants’ accounts. I continue to examine Beryl’s account of her project work as she discusses the effect of fear on clinical judgement and look at Mandy’s conclusions. In both cases they reported that their trial work had shown change to be beneficial, but the work was not continued.
Beryl had provided an example of a fear of censure in her account of trying to move away from the rigid protocol of turning frail older patients every two hours at night. She described her frustration with colleagues: “not wanting to stick their necks out really,” stating: “I think people are very insecure and frightened to do anything different.” Here I focus more on this psycho–social aspect of colonisation. Beryl had found that when she handed over to senior nurses with a recommendation to leave a patient asleep for longer they carried through that action, but she had doubts that lower grade staff would take that responsibility. She argued they were concerned about their individual
accountability: “I have no evidence of that, but I think that is one of the negatives”. She continued: “There is always the chance that regardless of any assessment, if they had not followed what the trust had laid out….” This sentence was never finished, but the threat hung in the air as she pursed her lips and shook her head to indicate negative consequences. She added:
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“In all fairness, at the end of the day if the patients did develop any pressure damage and they were on the last shift, then I can stand and say well I will support you, but at the end of the day it is them responsible for that patient at night”
Listening to this final acknowledgement of the difficulties of bringing about change made me think she had accepted defeat.
The Royal had responded to the results of Beryl’s trial by suggesting a further assessment tool be introduced Beryl commented: “The trust has not changed their guidelines, but they have introduced the skin tolerance test.” This was supposed to offer another layer of risk assessment, to provide more evidence to support decision making and standardise practice, rather than delegating clinical judgement. However, there were already validated pressure area risk assessment tools in use in these clinical areas. For some, in this age of litigation, tools bring reassurance, but they could also be viewed as taking professionals further away from exercising clinical judgement.
From Habermas’s perspective, making small clinical changes appear simply practical (instrumental and rational) removes these decisions from any values-based (normative) debate (1984, p305). The issue of whether a professional has a right to make a particular decision on skin care (in this case) and whether this is actually of any benefit to the patient is side-stepped, as a standardised
approved tool is proudly produced. Habermas alludes to an ‘objectifying attitude’ that results from such strategic action, this process of ‘mediatisation’
or interference results in an ‘internal colonisation’ of the individual
practitioner’s sense of worth. The result is a further dependency on checklists and a loss of confidence in one’s own ability to make such judgements without these tools.
Beryl had rolled her eyes when she mentioned the new tool, suggesting some doubt as to the value of this new procedure. When asked how she felt about this further safety net, her voice went high pitched she said “yeah” in a choked gulp, suggesting some frustration with this approach. She went on to comment:
“It would be interesting to see how different things would be if people did put their necks out sometimes.” She added with a laugh she was not advocating
“anarchy” just a bit more initiative. However, she did acknowledge that her
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pilot had limitations: “It was only on a small scale it would have been nicer if I could have taken my stuff off and preached a bit further, but it is a big Trust, a big place you know.” Although she appeared disappointed she was prepared to accept that further work needed to be done.
The concern in this situation was that without a supportive procedural
document giving permission for clinical judgement to override protocol, nurses would not feel safe enough to go against the standard advice. Beryl felt
experienced and confident enough to take that responsibility, but realised it might be unfair to ask for that level of commitment from others, with less experience or a lesser sense of their own power. Beryl said she wondered nowadays if “nurses use their initiative or do they work solely by tools and assessment charts and things.” Beryl had resigned herself to just taking responsibility for her own actions and not asking others to take on this
responsibility: “At the end of the day I log it, I have a rationale for what I have done, and that is my justification if needed.”
Mandy had similarly shown through her trial that altering clinic times to suit different patient groups worked, but then went on to state that even though she had proven feasibility:- “I think I would have struggled to change it – on my own as a one man band.” Mandy’s isolation was disempowering, the barrier had been created by colleagues, but the organisation must take some
responsibility for allowing that block to go unchallenged, despite medical support and evidence demonstrating service improvement. A consequence of colonisation can be ‘restrictions on communication’ (Habermas, 1984, p.188) and the hierarchical separation of senior managers from clinical ground staff meant that individuals at a higher level were probably unaware of debates raised at unit level. The lack of a suitable communication channel left Mandy without influence.
Sumner, in her research into nursing, used a Habermasian framework to explore whether nurses could “flourish in an environment that emphasises a managerial, economic efficiency based on technical rationality” (2001, p.23)?
Her concern was that if the moral and relational work and dialogue about care
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were abandoned for scientific efficiency and technical tasks, the essence of nursing would be lost.
Having explored the concerns that were raised about threats to clinical judgement and questioned how local control can be maintained when such blocks exist I finish by remembering Beryl’s stance of deciding just to take responsibility for her own actions, that was her way of coping with the
restrictions. Paula commented that one of the reasons she was leaving hospital care was because she did not want to be “clone like,” she described herself as a
“creative” person, she continued: “I am not one to stay safe on the ward and there is nothing wrong with that. I want to use my brain I want to be a little bit challenged or scared at times.”
Conclusion
This chapter has looked at what could be considered intrusions of the system into the life-world and the pathological impact of these. Colonisation creates a range of challenges from changing organisational goals, limiting opportunities for individual decision making to undermining personal confidence. The interview accounts suggest that there was some evidence of colonisation and these compounded the traditional life-world barriers to change.
Carol had explored the new thinking and is the one whose ideas could be viewed as the most colonised in terms of the adoption of business principles.
Yet it could be argued that those who accept the political constraints on investment in public services and accept marketisation are making a political choice to accept business thinking. Most of the nurse-participants were learning about their life-world through their projects and confronting
challenges in terms of communication and influences that they had not come across before, but were still in the dark about political activity at higher levels of their organisation. In the next chapter I show what part WBL played in assisting individual nurse-participants to deal with the conflicts they came across, even though they did not become completely socially and politically aware.
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