Inteligencia emocional: SEK Catalunya

9.1. Limitations

The first limitation is the passage of time. A research study of this type is always going to have a historical dimension. The experiences discussed by the participants cover on average, a ten-year period, up to the interviews in 2012. Change, which is one of the themes, may have occurred in the subsequent four years that make some of these experiences less relevant today. However, nothing further has been published and the rate of change previously discussed suggests that four years is not a long time. Therefore, the experiences of the participants are likely to be still relevant today.

Secondly, the participants were a homogeneous group situated in acute hospitals working with consultants. The experiences of the participants highlight a growing tension between primary care and secondary care in terms of service delivery and developing roles. It is therefore likely, there may be some differences between the experiences of ESP working with GPs and those working in hospitals with consultants. Thirdly, actions and institutional effects can be linked in various ways. Actors are likely to have their own ideas about who played which role in the processes of institutional change. “Success has many knights, but failure is usually someone else's fault” (Beunen and Patterson 2016 p3). Success might be over-claimed and influenced

by hindsight. The study is based on the experiences of the participants and cannot account for the experiences or perceptions of others. However, there may be parts of the participants experiences that have resonance with others. This phenomenological research study has attempted to express insight in such a way that it might evoke recognition and understanding in the reader and achieve the last feature of credibility by telling the reader something useful.

Institutional work was used as a conceptual framework to understand the participants` experiences and links the micro and macro processes. It identifies work that appears

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successful and other types of work that were not as well developed. The study did not set out with the intention of describing the ESPs experiences as institutional work and it may be that there are alternative explanations that can be applied. It is acknowledged that institutional change always takes places within a context, marked by a specific configuration of actors, institutions, and power-knowledge dynamics. Institutional work and its eventual outcomes cannot be isolated from this context (Beunen and Patterson 2016). Institutional work may be a means to understanding institutional change, but it is not a singular explanatory factor. There are many other drivers and dynamics shaping institutional and organizational change.

9.2. Reflection and Conclusion

To return to the aims and objectives of this study (p10-11). Parry (1995 p310) described physiotherapists as individuals “who function in the here and now to solve problems with an imperfect understanding of how they reached their current position.” The experiences of the

participants confirm the first part of the statement in that they were motivated and focused on problem solving. However, it is clear they were also forward looking in terms of their professional development. They were willing to take risks, compromise and deal with set- backs if they were developing new skills and enjoying the challenge the new roles brought. They knew how they reached their current position and the hoops they had gone through. They were reflexive in their experiences and actions.

This study therefore achieves its first objective. For the first time, the experiences of ESPs from different hospitals and specialities can be reviewed. Unlike previous studies (Dawson and Gharzi 2004) this study covered seven clinical specialities not just orthopaedics. It illustrated the participants` ambitions and motivation to create opportunities to extend their remits and roles. It highlighted the personal nature of this ambition and drive to be able to practise a greater range of skills in a clinical area they were passionate about. It confirmed Kirsteins et al (2007) assertions that change was led by the individuals in the workplace but it also captured the nuances of how this takes place. This study identified how the ESP set about

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change, negotiated with others, dealt with set- backs and planned future change. It identified how they responded to change in the organisation (in terms of service reviews) and the adaptive plans they considered. It showed purposeful actions when deciding to change or in not to change their roles. They were not “shrinking violets.” They arranged a framework of

practice, with others, with an insight into organisational change and impact on the physiotherapy profession. There was a vulnerability in the participants` experiences that illustrated the paradox of the ESPs shaping the institutional arrangements around them but equally the institutional constraints and threats to their roles because of cost pressures.

The impression from the interviews was of a group of physiotherapists proud of their achievements but missing some of the recognition for what they had achieved. Considering them as institutional entrepreneurs gave them this recognition. They were engaged in activity which brought personal satisfaction and the further development of a profession. This action was purposeful and the participants reflected on the changes that had occurred and probable future changes. They were engaged in institutional work.

Demonstrating that the experiences of the ESPs can be understood within a framework of institutional work meets the second objective and adds to the knowledge of the concept. The ESPs brought about institutional change in both the physiotherapy profession and the wider NHS by creating and maintaining their roles while disrupting the institutional arrangements relating to medicine. These roles were recognised by others within the hospital and by the CSP (CSP 2016). This study showed how the typology of institutional work can be applied but more importantly it provides an understanding of what is occurring. Working closely with the consultants and understanding their way of working can be viewed as the institutional work of mimicry. Through this work the participants became established and accepted and changed the perceptions of others. This study also illustrated that institutional work is a developing concept. The format initially described by Lawrence and Suddaby (2006) is too prescribed and does not reflected workplace reality. Institutional change does not involve the creation, maintenances and disruption of institutional arrangements in a cyclical pattern but occurs in

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response to environmental conditions and opportunity. The experiences of the participants demonstrated that creating and maintaining work can occur simultaneously and that different work streams can be at various stages but still bring about change.

The study met its third objective by demonstrating that institutional work can be applied to marginal actors and individuals to provide an insight into their experiences. It showed how marginal actors can bring about change in professional boundaries. It demonstrated that one of the key enablers is an ability to assimilate the different institutional logics within an organisation and articulate this in a form which gains support without being a threat to established actors.

Finally, the study met its fourth objective by demonstrating how the institutional work of the macro structure (the CSP) and the micro structure (the ESP) can be analysed and understood. In doing so areas of strength and development can be identified which can facilitate change in the physiotherapy profession and maintain its relevance and importance in meeting healthcare needs within evolving health and social care in the UK.

Future studies might investigate the creation and maintenance of Advanced Practice Practitioners using the institutional work framework. In doing so it would further the development of the concept and its application to professions and institutional change. It would provide further research to add to the evolving concept from the individual perspective and provide a link between the professional association and the individual within the professions.

To answer the research question and meet the aim (p10-11), posed at the beginning. These ESPs can be viewed as actors that “leverage(d) resources to create new institutions or to transform existing ones” (Maguire et al 2004 p657) using a variety of strategies (compromise,

negotiation, rhetoric and institutional work) to pursue their own interests against the rigidity and resistance of institutions. As such they are entrepreneurs. The purposeful activity, over several years, was institutional work and applying this to their career journey provided an

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understanding of their experiences which readers may wish to consider in relation to continuing development of healthcare professions in a changing NHS.

9.3. Recommendations

The development of the ESP roles highlighted common experiences which other Potential ESPs and the CSP might want to consider. The following recommendations based on the study are advocated.

For others considering such roles there is a need to understand the prevalent clinical and financial demands, the changes other professions propose in response to those demands and to have the ability to synthesis this into a professional clinical and business logic that will appeal to others. The publication of papers from this study will highlight the experiences of ESPs that have successfully manged this and provide insight for others in the role or considering such roles. In publishing the details of this study other clinical professions might be able to apply the understanding gained from physiotherapy to their own extend scope practitioners. It is recommended that further studies on clinical professions extending clinical roles, using an institutional work framework, might provide additional insight into the purposeful activity of practitioners engaged in change. This would add to the development of knowledge in the ways and means professions bring about change within their own practice and the wider institutional change within the NHS.

The experiences of the ESPs highlighted the need to create an educational framework that will support future roles and provide a licence to practise. Similar to the work in Australia (Harding et al 2015) this should be linked to a post-graduate degree programme and accreditation to practise the advanced skills. This would require the CSP and ESP to develop a curriculum with Higher Education and then jointly lobby Health Education England for funding to deliver these practitioner courses. It is recommended that the CSP work at the national level, with government and stakeholders, to advocate and gain acceptance of such roles to ensure advanced practice and consultant physiotherapists are embedded within the

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NHS. Linked to this is an additional recommendation that the current ESP and advanced practitioners work to create a robust “normative network” which would support individuals,

disseminate new practice, maintain quality and innovation but also lobby through the CSP for recognition and planned development of roles throughout the NHS.

Supporting the above recommendations is the need for the CSP to pursue recognition of advanced and consultant physiotherapists with these (and other new skills in the future) within healthcare. This would address the issue of identity and status within physiotherapy and provide an aspirational career pathway. It is recommended that the CSP robustly publicises these roles, with case examples, that highlights the positive impacts on health care and meeting clinical demand. The expected outcome is that these roles will have an identity with physiotherapy and become embedded in routine physiotherapy practice both at undergraduate and post-graduate level.

Finally, it is recommended that further studies within physiotherapy should look at continued advancement of the profession using the concept of institutional work. Physiotherapy is an evolving profession and using the concept of institutional work provides a common language and framework to investigate changes within a profession which would inform other professions and lead to the further development of a theory on Institutional Work linking the macro scale (CSP) and the micro scale (the individual).

The outcome of this study will result in several academic papers which will be published in peer reviewed physiotherapy journals as well as journal relating to organisational studies and management over the next 18 months. The thesis, as well as being housed at the University of Huddersfield, will be submitted to the CSP physiotherapy archives and made available to other physiotherapists in the UK and internationally. The impact of the study will add to the debate on the future role and development of physiotherapy as it continues to evolve through the endeavours of individual practitioners in a changing NHS and health care environment.