RECOMENDACIONES

The stratified nature of social reality may be said to be reflected in “ ...the dialectical complexity o f the social w orld where competing structures and mechanisms operate side-hy-side ” (Joseph:2002:34). Given this position, how are the variations that consequently exist within a social context or ‘restricted regions of time-space’, namely the practice of nursing within the contemporary NHS, to be analysed ?

The work of Tony Lawson (1997), discussed in detail above (in Section 3.2.2.3),

recognises that the underlying generative social mechanisms come to attention through their effects at the empirical level o f the contrasts that exist between two similar situations or between two similar social groups in the same situation. Something stands out, which enables ‘rough and ready generalities’ to be made about that situation. Such contrastive demi-regularities provide evidence for the occasional, but not universal, actualization of a generative mechanism.

Drawing on the outcomes of the ‘theorisation’ section of this process of data analysis, it is possible to identify a number of contrastive demi-regularities in relation to nursing work within the late modem system of health care. These exist in two forms: first, in terms of the contrasts in the nature o f nursing practice as it has changed in response to the organisational restructuring within the NHS in the 1990s as well as wider social processes o f change and transition (this is a period during which all the nurse participants in the focus group discussions were in practice); second, in terms of the contrasts that existed between the practices of the different groups of nurses at the time when the focus group discussions were conducted. Attempting to identify the underlying causes or mechanisms that could account for the differences or contrasts in each of the examples presented below means beginning the process of postulating an explanation for the phenomena in question - i.e. moving beyond the deductive to the causal-explanatory mode o f theorisation (Fleetwood:2002:65). Three contrastive demi-regularities that emerge from the discussion of the inductively-derived themes and deductive theorisations are discussed below.

(a) The contrastive demi-regulatory existing between form al nursing theory as expounded by the academic hierarchy o f nursing and the discourse o f nursing found in the everyday practice o f nurses within the NHS : The so-called ‘theory-

practice gap ’

Nurses’ own conceptualisations of their practice concerned with the delivery of care to patients, as articulated in the discourses emergent from the focus group discussions, appeared to be predicated on the basis of meeting clinical need (usually determined by the medical profession) as well as the organisational needs o f the hospital and of the health care system in general. It should be noted that the requirements of these two structures are not necessarily coterminous, which leads to inevitable tensions in the practice of the nurses. At the same time, the development o f a more openly philosophical approach to the practice of nursing (known generically as the ‘new nursing’) which arises out of the work of nurse academics (and North American theoreticians at that) stands outside the everyday demands of the health care system. This approach has consciously attempted to epistemologically demarcate nursing practice from biomedical and organisational priorities, in favour o f the holistic needs of patients. This represents an attempt to give nursing a ‘distinctive jurisdiction’ within the health care division of labour. However, such concerns, which are largely driven by a desire to achieve the ‘full’ professionalisation of nursing, do appear to be fairly low down on the priorities of practising nurses, as in this example taken from a focus group discussion:

R6 (A&E nurse) The pressures that we are under make it a lot harder than I thought it would be. I always thought that I would be the person that

communicated well, and, people would say ‘what a great nurse that A&E nurse was’, and ‘it’s a great hospital, and the A&E department is brilliant ’. But it does not always work out like that because there are so many pressures. Because there are never any beds, the immediacy of everything, people want things done now! That was one of the reasons I came into it, but on the other hand, after so many years working in A&E, I don’t think I actually fulfil my idea of myself as a nurse when I first came into the department.

There was only a minimal discussion by the nurses of the processes that would be necessary to apply nursing theory to practice in the NHS. This process is well recognised within the literature, where it is known as the ‘theory-practice split or gap’. This is a demi-regularity that has long existed in nursing practice but would appear to be much more marked in the 1990s, probably reflecting the shift of nurse education into the higher education sector in Britain and the subsequent development of a whole new layer of nurse academics, contrasted with ever greater demands from within the NHS for greater productivity and efficiency.

Material context is a crucial factor here, because these sets of idealisations and practical concerns associated with nurse academics and practising nurses exist within quite separate institutions, each with their own different sets o f organisational demands.

(b) The contrastive demi-regulatory existing between the differing perspectives o f groups o f nurses (generalist, specialist, community-based) regarding the key

constituents o f their practice

Contrasts also emerge in relation to the perception of the key constituents of the nursing role, with hospital-based nurses generally having a much more idealised view of the ‘basic role’ of nursing (although rarely defined) than community-based nurses. The ward-based nurses generally regretted the shift towards more ‘extended roles’, whilst the ‘specialist’ A&E nurses as well as the DNs welcomed the opportunities now offered to them as a result of the organisational changes within the NHS, which have sought to widen the roles of health care professionals in general (and have been resisted by the medical profession in particular).

In relation to the notion of holistic nursing practice, definitions varied widely between groups o f nurses, from seeing holism as simply a more elaborate form of patient assessment, through to the opportunities such an approach gave nurses to recognise and meet the emotional and social needs of patients. The community nurses as a group almost uniformly adopted the language if not the explicit philosophy of holism when describing the care they provided.

There were also contrasting perspectives concerning the contribution and commitment to the needs of the local community and the promotion of health by the different groups of nurses. Whilst for community nurses these areas of nursing work are central, hospital-based nurses tend to play down (occasionally with reflective regret) these aspects of nursing work in favour of clinical interventions and a concern with medical technology.This particularly applies in regard to nurses with specialist skills, such as A&E nurses; for example :

R8 (A&E nurse) I like working in a multidisciplinary team, I like the pace of the work. I like the fact that patients move on quite quickly so that you don’t have people to look after them for fifteen days, fifteen weeks, fifteen months. I enjoy the fact that there are always different things going on and things change very quickly, it made it more interesting to work in an area that was like that.

The causal factor that would appear to explain these contrasts between groups of nurses is the material and institutional context in which such nurses practice. This is certainly manifested in the relative distance (not just in physical but also in ideological terms) between the nurses in general and doctors when carrying out care. It may also be reflected in the on-going relationships that community-based nurses are able to establish with their patients, as against the brief interaction of a nurse with an attendee in the A&E department of a hospital.

(c) The contrastive demi-regulatory existing between the traditional relationship o f subordination within the medical division o f labour that pertained between nurses and the medical profession and that which now exists within a reorganised system o f

health care

In the NHS today, there would appear to be a greater willingness by nurses to question the clinical autonomy of doctors, although just how widespread this is in practice is difficult to ascertain. This is a development that possibly reflects a number of processes that have occurred within nursing itself. These would include the greater

willingness on the part of nurses themselves to take on a ‘patient advocate’ role, the acquisition of greater technical skills, and a wider academic knowledge-base for nursing practice itself.

The patient advocate role is in part a response by nursing to the ‘consumer-led’ organisational reforms within the NHS. It has now become more formalised within the new ‘clinical governance framework’ introduced as a central plank of the New Labour government’s ‘modernisation’ programme for the NHS. Nurses’ own discourse surrounding this patient advocacy role did appear to be all about asserting themselves as a relatively autonomous profession, rather than necessarily acting as a conduit for patient rights. This process is demonstrated in the following exchange between District nurses:

R1 We have become more o f an advocate for patients.

R15 Yes, we now have more responsibility. I can go in and say to the GP, ‘I’ve seen Mr X, he’s got a leg ulcer, query infection, we’ve swabbed it and he needs some anti-biotics, or could we try this dressing?’ And they now say, ‘Yeah, no problem, try it and come back to me’.

R13 Yes, we do have more responsibility. You have updated yourself, you have done your research. You are able to negotiate with the doctors.

What emerges from the focus group discussions is a manifest confidence amongst all the different groups of nurses to assert their knowledge and skills in clinical practice. This may also explain why there appears to be a greater willingness by doctors to acknowledge the contribution of nurses as colleagues (although not necessarily equal ones). However, the relative decline and diminution of the authority of the medical profession at the organisational level o f the NHS which was discussed in detail in the literature review (see Section 2.2 above) must also be a crucial factor in this contrastive demi-regularity.

4.3.2 The postulation of generative mechanisms underpinning nurses’