La tutela y la curatela

Identity work provides demonstration of the interplay between nurse agency, structural and cultural influences and the ‘real’ world. The previous chapters have assisted in beginning to address the aim of this study by presenting an analysis of aspects influencing the context of the ‘practice world’ of rural nurses in providing primary health care.

Answering the research questions requires an approach that will support a study of the interplay between actors, primary agents, collective agents, structural and cultural influences, role positioning and collaborative practices between different

professions/institutions – that is, the interplay between agency and structure, in order to gain/increase an understanding of the causal powers generating PHC nurse

identity. A critical realist ontology supported an explanatory potential as part of the research strategy and offered a means of focusing on the contrasts, continuities and differences between ‘agency’ and ‘structure’ (Clark and Blundel 2007; Crinson 2007; Reed 2009). To explain this further it is necessary to outline how the world is viewed in a CR ontology.

A critical realist ‘world view’

Critical realism, as a structured ontology, perceives the social and natural world as consisting of three different (differentiated) domains. These are the real (or deep), the actual and the empirical (Bhaskar 1989; Ackroyd and Fleetwood 2000; Sayer 2000; Danermark, Ekstrom et al. 2002). These three domains will be briefly outlined, within the context of this study, providing an understanding of how mechanisms (causal powers), events and experiences are represented and overlap via these domains.

The real – is all that exists, whether we experience it or have knowledge of it or not (Bergin, Wells et al. 2008). It is the realm of objects, mechanisms, relations,

structures and powers that can produce events in the world. The structures in the real are connected and have their own causal powers, they are called generative

mechanisms and the real is constituted by the relations among these generative mechanisms (Bhaskar 1975; Bhaskar 1989; Archer 2000; Sayer 2000; Danermark, Ekstrom et al. 2002; Callinicos 2006). Generative mechanisms belong solely to the real and they are distinct from the events that their interactions produce. These events belong to the actual (Callinicos 2006:163). Rural nurses providing PHC services are real, the organisations they work in are real and the communities they work in are real. They all have causal powers. The interactions and the interplay between them all is the subject of this study.

The actual –Arising from the real world is the ‘actual’ and this encompasses all the behaviours, events and phenomena generated from the interactions with the ‘real’ (Callinicos 2006). This domain refers to what actually happens when the

mechanisms and powers of the real are activated and events and experiences are produced. The actual which is of interest in this study is the identity work that occurs in small rural communities at the interface between PHC nurses, health organisations and the community. As presented in the previous chapters, there can be many

proposed and interlinked causes for the behaviours of nurses, the positions taken by health organisations etc. The generative mechanisms of the real and the events that their interactions produce (actual) are also distinct from the experiences through which humans register the occurrence of some of the events (empirical).

The empirical – this domain comprises only what we experience, directly or indirectly. (Since not all events/phenomena are experienced or observed then the domain of the real is distinct from and greater than the domain of the empirical). The empirical domain is in a ‘contingent relation’ to the domains of the actual and the real. The Empirical consists of the subjective experiences and observations of the actual. The interviews with rural PHC nurses and the observations of their identity work along with the observations of PHC nurse identity work within the submissions to the NHHRC comprise the empirical domain for this study. Analysis of the

empirical informs an understanding of nurses’ identity work in PHC and PHC nurse agency within the current health care reforms.

Within CR ontology the world is both socially constructed and real which means there can be things that exist in the real which aren’t experienced empirically. As such, causal powers may exist which are not yet exercised. Danermark et al. (2002:39) state that there is an ontological gap between what we experience, understand and perceive as happening and the deep dimension where the

mechanisms are (the real domain) which produce the events. This ontological gap has the potential to allow us to understand how we could be from that which we currently are not (Sayer 2000).

It is in distinguishing these three domains that CR proposes a stratified ontology, that is the real world is greater than the actual (the results of activation of the structures and powers of objects) and the empirical (the observations and experiences which result from the application of a socially-influenced conceptual framework to the interpretation of sense-data). This allows for the understanding of emergence. Emergence results from a conjunction between two or more features of the actual or empirical domain giving rise to new phenomena. While a new phenomenon is dependant for its existence on the actual and/or empirical features, it has properties which are irreducible to the individual constituents of those domains. In this study the structure of PHC nurse identity may well be informed by nurse’s beliefs and interests and characteristic representations of PHC nursing evidenced as PHC nurse identity work, however PHC nurse identity is not reducible to these factors. This study uncovers some of the causal mechanisms of PHC nurse identity however, as a

necessarily ongoing process, the explanatory frameworks constitute part of a developing understanding PHC nurse identity.

The benefits of using a critical realist ontology

A CR ontology enables assessment of the interplay between nurse agency and social structures rather than favouring one or the other. The causal power of

structures/social forms is mediated through social agency and informed by the social, cultural and historical context (Bhaskar 1989). The introduction of a draft National PHC Strategy for Australia (Australian Government Department of Health and Ageing 2009a) necessitates concomitant changes in nurse’s work structures, roles and practices in providing PHC services and many different groups have an interest in how nurses will be positioned. As such, a research approach that can appraise the interplay between agency and structure within temporal and sociocultural contexts is required for this study.

Nursing practice depends on nurses’ agency and studying nurses’ opinions, interests and beliefs about their positioning as PHC providers incorporating how they

‘personify’ roles/ positions was required for this study (Archer 1995:187). However, while individual’s beliefs and opinions will provide some understanding of nurses’ agency and PHC nurse identity, it will be a subjective and incomplete understanding of the reality of PHC nurse identity as a social structure (Archer 1995). Archer (1995:11)describes the privileging of individual’s views, through intepretevist approaches, as upward conflation which ignores the influence of the emergent properties of society.

Moving towards an understanding of social structures, such as PHC nurse identity, requires more than just the individual’s account of their experiences. However, taking a constructionist or postmodern approach, which present human properties and powers (apart from biology) as derivative from society, will underplay the

influence of the individual in producing and reproducing PHC nursing identity within health services (Archer 1995; Ackroyd and Fleetwood 2000:12-13; Archer 2000:86). Viewing the social world as entirely socially constructed is described as downward conflation by Archer (2000:87). A CR ontology enables a depth of exploration and

explanation which goes beyond this ‘methodological cul-de-sac’ of having to choose between structural determinismand individualism (Bhaskar 1989; Archer 1995; Archer 2000; Sayer 2000; Crinson 2007).

Analytical dualism (Archer 1995:15-16) offers an approach within CR which not only recognises the interdependence of structure and agency, the ‘parts’ and the ‘people’, but also that they operate on different timescales. It is this morphogenetic approach to CR which provides the ability to explain ‘different performances of the same role’ (Archer 1995:186). The term morphogenesis acknowledges that society has no pre-set form (morpho) and that it is formed by agents (genesis) (Archer 1995:5). Nursing roles and PHC identity, as structures, exist prior to nurses taking them on, constraining and/or enabling nurses as agents. The way in which nurses interact with these pre-existing structures differs depending on their interests and their aggregate power and this interaction leads to ‘structural elaboration’, transforming or reproducing the initial structure/s. The resulting structures then provide the pre-existing context for future agents (Archer 1995:167-168).

The continuity of a structure such as PHC nurse identity (morphostasis) depends on the whether the combinations of events and experiences in the Actual and Empirical have the power to cause change (Elder-Vass 2004). Explaining structures like PHC identity as an emergence of the combinations of factors arising from the actual and empirical is supported by an understanding of morphogenesis and morphostasis (Archer 1995; Elder-Vass 2004). Whether, and how, a structure changes over a period of time is dependent on the aggregate power and structural continuity of the large number of causal influences informing the process. The previous chapters presented evidence of ongoing tension between different types of causal powers informing PHC nurse identity. Therefore, underpinning the conceptual framework of this study with a CR ontology allowed for an exploration of nurses’ agency to provide explanatory frameworks for the morphogenesis/morphostasis of PHC nurse identity as a structure.

Archer (1995:167) argues that even though structure and agency are interdependent it is possible to analyse structural/cultural powers and agents’ interactions separately. By isolating the structural/cultural factors which provide the context for nurses’

actions and exploring the subsequent interaction with these factors by nurses, it is possible to investigate how nurses’ interactions may result in redefining the roles/structures as well as reforming individual nurse’s beliefs/interests. This supports investigation of PHC nurse identity and recognises that it is not static. The morphogenetic approach allows ‘a tool for examining the dynamics by which the

“parts” and the “people” shape and reshape one another through their reciprocal interactions over time’ (Archer 1995:194).

Finally, a CR ontology allows for a connection between the empirical data gathered and an explanatory framework which is the aim of this study. Critical realism provides a methodological means of looking beyond the empirical (that is, the practices, observations, experiences and representations of PHC nursing and nurses) as real, to allow for the underlying causal mechanisms (powers) to be theorised (Sayer 2000; Danermark, Ekstrom et al. 2002). Identity work in this study is the outcome of mechanism interplay, which allowed for the development of explanatory frameworks about PHC nursing identity.

Despite the growing recognition of CR ontology within social science, there is an absence of guidance and advice regarding research design or specific types of analysis for approaching research questions (Ackroyd 2009). CR supports a wide range of research designs with the particular choice of methods determined by the nature of the object of the study including what one wants to learn about it (Sayer 2000:19). As such, the deliberate choice of research methods for this study supported analysis of empirical data in order to connect to an explanatory ability.

From the previous chapters, the conceptual framework for this thesis highlighted the importance of rural PHC nurse identity, agency and factors constraining and enabling (controlling) their PHC practices as the significant theoretical constructs of this study. The questions guiding this research process and supporting the studies aim were developed within this theoretical framework. Two data sources were each purposively chosen as having the potential to contribute to answering the research questions by revealing different aspects of these constructs (Neuman 2003:215). Interviews with rural nurses and publicly available submissions informing the

through thematic and content analysis evidenced PHC nurse identity work (the actual). This then provided the basis for further analysis which enabled examination of nurses’ agency within identity work and social and structural controls. The

emergence of causal mechanisms (the real) for nurses’ agency as PHC providers and the structural/cultural powers within rural health services were uncovered.

This qualitative research design fits within CR descriptions of an ‘intensive’ study (Sayer 2000; Danermark, Ekstrom et al. 2002; Reed 2009). As such, in identifying generative mechanisms and causal explanations for nurse’s agency as PHC providers in rural health services as a particular case, the explanatory framework is

generalizable as a theoretical conceptualisation however it is not representative or generalizable to rural nursing populations (Sayer 2000).

The diagrammatic representation on the following page (Figure 1) depicts the interrelationships between 1. The critical realist ontology of empirical/actual/real. 2. The research project’s conceptual framework of representations in texts/identity work/identity and agency with 3. The research strategies employed to answer the research questions - interviews and submission documents/content & thematic analysis/ data synthesis and an explanatory framework. This representation is informed by the works of Stirling (2007), Crinson (2007), Sayer (2000) and Lupele (2007).

Figure 1: Diagrammatic representation of interrelationships between critical realist ontology, the conceptual framework and research strategy employed by this study of

PHC nurse agency and identity

Figure 1: Informed by the works of Stirling (2007:113), Crinson (2007), Lupele (2007) and Sayer (2000:11-15).

Th

ACTUAL

The events generated by activation between powers of structures and objects of the REAL

The Critical Realist Ontology

REAL Objects, Structures, Powers, Generative/causal mechanisms generates experienced as EMPIRICAL Observations and experiences of the ACTUAL

Conceptual Framework of Thesis

PHC Nurses Identity Agency Rural health services Identity Work Negotiation Research Strategy generates experienced _as Representations Nurses’ experiences Patterns in texts Development of explanatory framework for PHC nurse identity and agency Analysis of Texts - content analysis - thematic analysis - retroductive analysis Interviews with nurses Public submissions to NHHRC followed by followed by