Métodos para la determinación de la estabilidad

Lawrence and Suddaby (2006) argue that education is more than the acquisition of skills and knowledge; it provides the template and structure that others can follow. All the participants had completed post-graduate university courses in their area of specialism. However, the initial development of the ESP role depended on either in-house training or the practical component of academic courses had to be delivered and assessed by a consultant. For example, participants with injection skills completed a post-graduate university course in the theory of practice and pharmacology but the qualification depended on the practical component in the workplace supervised by a consultant who was responsible for certifying competence. Post graduate courses for extending roles, delivered and assessed by physiotherapists for physiotherapists and recognised by hospitals and the NHS appear not to

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be readily available. This is not unique to physiotherapy. Nursing has had advanced practitioners in many countries for more than thirty years but education and its link to practice within the organisation can still be problematic.

Carlisle (2003) argued that for the full potential of the nurse practitioner role to be achieved, changes were required in traditional organisational structures for nurse-led services to be feasible and acceptable to all stakeholders. This would require strategic planning for the education of practitioners but also a framework and commitment within the organisation to enable the practitioners to apply this new knowledge and skills. In this way, new nursing roles, such as the nurse practitioner, are more likely to be truly advanced and not simply developed by taking on of a new skill previously the province of another health care professional. Heale and Buckley (2015), in a recent review of advanced nursing from an international perspective, found that, even with recognised qualifications in advanced practice, barriers and opposition to the roles came from physicians, medical organisations, pharmacists and administrators within organisations. Ryley and Middleton (2016), from a UK perspective, found a lack of clarity around the educational preparation required to work safely and effectively at a level above that of initial nurse registration and concluded that this has caused confusion for the public and debate among health professionals about the scope and competence required by advanced practitioners.

Jones et al (2015) argue, for advanced nursing roles to flourish there is the need for development opportunities, support and integrated working needed between professional representatives, managers, commissioners and educators to deliver sustainable service delivery. The same sentiment applies to physiotherapy. Skinner et al (2015), examining physiotherapy post graduate education, argue for the need for formalised, widely recognised training to support these roles, and found significant challenges to the delivery of such training. Many of these roles function in the absence of specially defined standards of clinical practice

and it is unclear where the responsibility for training provision lies. Therefore, dependence on in-house training in the UK for ESPs will remain (Mir et al 2016).

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However, in the Australian state of Victoria, a competency based educational programme for ESPs has been developed. Harding et al (2015) describe the essential programme as a Masters qualification and argue that any in-house education should focus on the gaps not addressed in the Masters course. In-house training should not be considered as a replacement for post graduate university qualifications. This is consistent with the nurse practitioners in Australia and New Zealand (Heale and Buckley 2015). All the key components required for implementing a competency-based training and assessment program have been developed to provide clarity and transparency for the physiotherapists and stakeholders. In addition, the

physiotherapists in the project used the evidence of successful competency attainment to support transferability of their roles between health services, thus increasing workforce capability and sustainability. There is a time delay in innovative clinical practice and the provision of clinical study programmes especially when there is no strategic direction for where physiotherapy practice is destined.

The experience of the participants highlights the individual nature of their role creation but also the lack of an engagement with a professional network to support and maintain change. A professional network of ESPs exists but membership is voluntary. None of the participants referred to this professional network. Lawrence and Suddaby (2006; 221) outline a requirement to construct a normative network which they describe as “inter-organisational

connections through which practices become normatively sanctioned and which form the relative peer group with respect to compliance, monitoring and evaluation.” Or as Hwang and Powell (2005 p188) describe, entrepreneurs need to juggle the “dual roles of creation and enforcer”. This can be seen in the individual experiences of the participants in the robust ways

they policed themselves through audit and published data within their hospitals but sustainability and maintenance of such roles needs to move from the individual to the collective.

Labelle and Rouleau (2016) showed how individual hospital risk managers in Canada enhanced their professional profile through creating a voluntary real and virtual network.

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Networking with colleagues included formal and informal gatherings quality, performance, and risk management practices were debated. This networking was an important way of integrating newcomers. Labelle and Rouleau (2016) argue that pro-actively setting the agenda, the collective of risk managers within the region shared their everyday experience and built a common professional discourse. Increasing the density of their network, risk managers reinforced the institutionalization of risk management at the local level and their strength as a professional collective seeking recognition. By identifying best practices, discussing the best ways to implement them or sharing innovative practices with other risk managers could

generate, diffuse, and apply knowledge within their own workplace. The whole, or collective group, became greater than the individuals and in doing so they began to address the shape of their professional identity through social interactions with peers. However, despite this there was no agreement on the future orientation of the profession. The risk managers blamed this on a lack of political will to provide an official description of their role and duties, along with professional jurisdiction. Rather than letting this stifle change, Labelle and Rouleau (2016) found that the risk managers in individual hospitals took advantage of the ambiguities to experiment with what a future role might look like. Like the ESPs, there was a degree of freedom to engage in an evolutionary process.

Ibarra (1999 p765) describes a phenomenon of creating ‘provisional selves’ as “temporary

solutions people use to bridge the gap between their current capacities and self-conceptions and the representations they hold about what attitudes and behaviour expected in the new role.” In other words, creating a role that is somewhere between what an individual was and

where they want to ultimately become. The same can apply to collectives and professions as they develop. In institutional terms, Lawrence et al (2002) argue that one step in creating an institution is to develop a proto-institution. In other words, creating a recognizable entity which embraces a collection of individuals engaged in the same or similar practices. In doing so, these new practices, rules or technologies can be explored within a recognizable framework. If successful there may be a diffusion of these changes and an acceptance of the outcome as

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the solution to a problem. Di Maggio (1988 p14) in his seminal paper stated that “new

institutions arise when organized actors with sufficient resources see in them an opportunity to realize interests that they value highly.” Elaborating on this Marti and Mair (2010) contend

that there are stages in this process, or provisional institutions, that serve the actors interests for a period of time and will either develop and flourish or whither and decline over a period of time based on the agency of the actors and the context in which they operate.

These proto-institution can then take on the mantle of an institution but Battilana and D’Aunno

(2009) argue the actors must engage in work aimed at imagining and theorizing the future role. This has links to the institutional work of identity and theorizing. From the experiences of the participants this is work in progress which could be addressed by a more robust professional network and greater support from the CSP.

Lawrence and Suddaby (2006 pg221) define the institutional work of creating an identity as “defining the relationship between an actor and the field in which the actor operates”. For most

of the participants being an ESP was secondary to their identity of being a physiotherapist. However, for a small minority there was uncertainty about their professional identity. This is important because professional identity plays a central role in making sense of the working environment and careers (Weick, 1995).

Pratt, Rockmann and Kaufman (2006), argue that identity work is a nuanced and dynamic process of social construction that requires individuals to navigate competing institutional pressures. It involves experimenting and adapting provisional identities until a collective view and agreement is accepted. This could provide an explanation of the experience of participants who felt confused about their role. Working almost exclusively in a medically orientated environment and practising outside of conventional physiotherapy they adopted a provisional identity of “other”. In that, they were not medical practitioners but felt different to

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Everitt (2012, 2013) points to sense-making and identity as key elements of understanding how individuals subjectively interpret, enact and creatively reproduce institutions. Blomgren and Waks (2015) observed that to make sense of institutional complexity, individual professionals confronted with multiple logics may become ‘hybrid professionals’ as a way of

subjectively coping with oppositional logics. Suddaby et al (2015) extended the concept of hybrid professionalism by showing how actors’ sense-making and identity work can

successfully integrate organizational values into one’s professional identity thereby successfully integrating both managerialism and professionalism into a coherent sense of self.

It could be argued that the ESPs incorporated the CSP`s professional project of extending the roles of physiotherapists, meeting the clinical demands of the organization and achieving their own personal goals. The sacrifice for some was the temporary ambiguity about the professional roles they were undertaking.

Drawing on the literature on advanced nursing roles allows the development of the ESP role to be seen in context. Lowe et al (2012) in a review of international arrangements of Advanced Nurse Practitioners (ANPs) found that in Singapore, there is no Nurse Practitioner (NP) regulation, but there is an advanced practice accreditation. In Australia and New Zealand, there is no advanced practice accreditation, but there is NP accreditation. In the UK, the title of NP or ANP is not protected, or under any regulatory governance, unlike the role in other countries such as Australia, Canada, Ireland and the US. This lack of organizational understanding of an advanced practice nursing role led to wide variations in practice, lack of role clarity, inconsistent expectations, restrictive employer job descriptions, and variable stakeholder acceptance (Llyod-Jones et al 2005; Altersved et al 2011; Lowe et al 2012; Heale and Buckley 2015). Physiotherapy has mirrored some of these frustrations but recent changes in CSP policy have produced a new framework for careers and roles with the advocacy of advanced practice physiotherapy (APP) and Consultant physiotherapist roles (CSP 2016). These are discussed in the next section (p150), when considering the work of the CSP. The creation of these defined job titles goes some way to addressing the issues of identity and

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career progression within the physiotherapy profession. More importantly it highlights the need for integration of institutional work between the individual, the profession and the wider institutional arrangements of the NHS. Change, lack of direction and overarching structure created a sense of professional confusion in some of the participants.

This ambiguity in identity is linked to a weakness in the institutional work of theorizing which is part of the process of maintaining institutional change. Lawrence and Suddaby (2006) argue that an important aspect of theorizing is the naming of new concepts and practices so that they are recognized as part of a field. It has been argued earlier that the participants changed the normative associations of the physiotherapists` role within the hospital by their practical abilities to perform the role usually associated with consultants. However, Greenwood, Suddaby and Hinings (2002) contend that constructing normative associations is not theorization by which existing arrangements and practices are disassociated from their moral foundation and by which situated improvisations are justified. Theorizing refers to the creation of abstract categories to diffuse new practices that can support new institutions.

To put it simply, the participants were accepted in the role they performed and this changed the relationship and normative associations about who could perform the tasks usually associated with a consultant within that hospital or department. However, the bigger step of having the role, skills and responsibilities associated with the physiotherapy profession had not been completed. The participants explained that if they left the posts may not be filled and there was no assumption that the posts would be filled by a physiotherapist. The link between the role and physiotherapy was not firmly established.

Localized experimentation can become a base for theorizing through the transition from individual practices to an organizational and institutional level construct. It involves the definition of the situation requiring intervention, as well as specification of the intervention and its rationale (Greenwood et al 2002). It is in the process of theorization that local deviations are abstracted, modified and generalized solutions proposed. Theorization enables the diffusion of the newly proposed initiative beyond its initial context (Szkudlarek and Romani

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2016). In other words, the work of the participants must be used as evidence of best practice on the national scale and advocated by the CSP as a role for physiotherapists and, more importantly, a role that is incorporated within the physiotherapy profession. Defining the role within physiotherapy and accumulating the experiences of practitioners enables more standardized arrangements to come into focus. The concept of the role moves beyond the organisation and into the wider domain of health care and the institutional arrangements of the NHS. At this point the construct of what the ESP in the NHS can be defined independent to the hospital, or organisational arrangements, and becomes available to other hospitals and clinics.

Hardy & Maguire, (2008) suggest that practice-driven changes can become embedded without the loud appeal or use of rhetoric by disaffected actors seeking to mobilize support for change. As Abbot (1988) suggests, the pressure of getting work done means that professional boundaries cannot be strictly maintained. The inter-professional division of labour becomes an intra organisational one which is established through negotiation and agreement within the workplace. In other words, the demand to meet clinical demand means that professions come to agreements about sharing the work load and this means that professional boundaries become blurred. This happens incrementally over time without a strategic end-point. It occurs with the aim of solving workplace problems, in most cases meeting clinical demand with existing resources. Once seen to be effective in solving the problem it becomes accepted within that clinic or organisation as normal practice sometimes to the point that it is not view as an innovation.

The implication, paradoxically, is that the highly localized, pragmatic improvisations of practice driven change may be harder to resist than the more visible actions of identifiable institutional entrepreneurs, especially those that involve rule-based changes such as new laws. This is because the workplace solutions avoid the attention of regulators and potential resistors until they have become relatively pervasive well established and proved to be effective and safe (Lawrence et al., 2002).

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The experiences of the participants describe practice-driven improvisations occurring under the regulatory radar, developing in a loosely coordinated manner without attracting attention. This, low visibility and unobtrusiveness embedding at the field level creates favourable conditions for further improvisations. Positive feedback from consultants, managers and patients amplified small improvisations and reinforced their legitimation. These sets of practices and symbolic constructions create a logic (Helfon and Sydow 2013) which was then used by the CSP to create a social movement and theory relating to the efficiencies and effectiveness of having ESPs.

This theoretical component if linked with education could form a template to provide the profession, organisations and their members with a vocabulary, values, beliefs, rules and a sense of identity. The work and experiences of the individuals could be used to develop a profession wide change through institutional work of the CSP. This is discussed later when considering the interface between the macro and micro nature of institutional work but it is an opportunity to integrate the different institutional work-streams of the individual and profession.

Another form of institutional work linked with maintaining new institutions is valorising and demonising. Lawrence and Suddaby (2006) describe the former as work that reinforces the positive aspects and benefits of the institution, which could include how safe it is, how effective it is and what it has contributed to society. The latter, in contrast, is work that focuses negative attention on other parties who threaten or challenge the institution by pointing out their weaknesses or inefficiencies. The two strands together are used to create uncertainty and concern in an alternative institution while emphasising all the positive qualities in the current or new arrangements. The participants were keen and able to point out the successes of the roles in terms of clinical outcomes, safety and cost effectiveness. In conversation with hospital managers and commissioners they emphasised their effectiveness but more importantly the cost efficiencies of their role when compared with consultants. However, they realised that the work of demonizing would be counter- productive. They needed the support of consultants and other professions to continue their developments.

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Although there is no evidence that consultants used the risk to patient safety as an argument against creating ESP posts, the participants were aware that this could happen. They were also aware of consultants negotiating for more medical hours to meet demand (as in the case of Participant J in rheumatology and Participant F in paediatrics). More concerning for the participants was the workforce plans being discussed within the hospitals. Nurses would be competing for their roles. They were on a lower pay band in the hospitals and could use the same argument of being equally effective and more cost efficient than ESPs. Therefore, much of the maintenance work involved negotiated settlements with other actors within the field,

highlighting ESP effectiveness but avoiding demonising others to avoid conflict. As discussed