Discretion or discretions? Delineating professional discretion: The case of English medical practice

Navigating a maze: Midwives' identity response to the enactment of an abortion law in Chile

BACKGROUND

Chilean midwives have been identified as essential for successfully implementing an abortion law, a practice which could potentially be understood as contradicting their central mission. Nevertheless, to date, there has been no investigation into how Chilean midwives have incorporated induced abortion care provision into their professional identity.

OBJECTIVE

To elucidate how Chilean midwives understand and provide abortion care and how they have (re)defined their professional identity to include induced abortion care. This article reports the findings of the second part of this aim.

METHODS

This study was underpinned by a constructivist grounded theory methodology informed by a reproductive justice and feminist perspective. Midwives from Chile who have cared for women undergoing abortion were invited to participate in the study. After purposive and theoretical sampling, fifteen midwives were recruited.

FINDINGS

Midwives' identity is woman-centred, with high value placed on their role protecting life. These two aspects of midwives' identity are in contradiction when providing abortion care. Midwives' identity results from and informs midwives' practice. Midwifery regulation influences both practice and identity. The model 'Navigating a maze' explains the interaction of these three elements.

CONCLUSION

Midwives' identity response to the enactment of the Chilean abortion law is an example of how professional identity must navigate regulation and practice to make sense of its purpose. In light of this study's findings, the current tension experienced in midwives' identity should be carefully attended to prevent adverse outcomes for midwives and the Chilean population.

The Impact of Information and Communication Technology on Doctors' and Registered Nurses' Working Conditions and Clinical Work - A Cross-Sectional Study in a Norwegian Hospital

Purpose

Previous studies indicate that the introduction of information and communication technology (ICT) in health care organizations impairs health care professional’s working conditions and diminishes job discretion. Most of these studies, however, were designed to explore the influence of ICT exclusively on a single group of health care professionals and thereby did not consider the influence of the same technology on other groups of health care professionals. The aim of this article is to explore the influence of a fully integrated ICT system on both doctors and registered nurses within the same working environment: a high-tech hospital.

Methods

This is a cross-sectional study conducted in a high-tech Norwegian hospital. Data were collected in 2016. In total, 264 registered nurses and 172 doctors responded to a questionnaire on their working conditions and experiences with ICT in clinical work. Descriptive statistics, compare means, cross-tables, Chi-square and bivariate correlation analysis were used to analyze the data. Statistical significance was set at p < 0.05.

Results

The findings revealed differences in doctors' and registered nurses' working conditions. Registered nurses reported a statistically significant higher workload and better job content than doctors. There was no difference in job discretion between doctors and registered nurses. Both occupational groups experienced that the ICT system impairs patient contact and the quality of health services. We found statistically significant correlations between registered nurses’ and doctors’ experiences with ICT in clinical work and working conditions, whereof the strongest correlation was related to job discretion in clinical work.

Conclusion

This study concludes that the impact of ICT on doctors’ and registered nurses’ working conditions in a hospital depends on the experiences of ICT in clinical work. In consequence, it is recommended to involve doctors and registered nurses in the implementation of ICT in hospitals.

Off the record: The invisibility work of doctors in a patient-accessible electronic health record information service

In this article, we draw on Michael Lipsky's work on street-level bureaucrats and discretion to analyse a real case setting comprising an interview study of 30 Swedish doctors regarding their experiences of changes in clinical work following patients being given access to medical records information online. We introduce the notion of invisibility work to capture how doctors exercise discretion to preserve the invisibility of their work, in contrast to the well-established notion of invisible work, which denotes work made invisible by parties other than those performing it. We discuss three main forms of invisibility work in relation to records: omitting information, cryptic writing and parallel note writing. We argue that invisibility work is a way for doctors to resolve professional tensions arising from the political decision to provide patients with online access to record information. Although invisibility work is understood by doctors as a solution to government-initiated visibility, we highlight how it can create difficulties for doctors concerning accountability towards patients, peers and authorities.

Between diagnostic precision and rapid decision-making: Using institutional ethnography to explore diagnostic work in the context of Cancer Patient Pathways in Norway

Alongside other Nordic countries, the Norwegian government has introduced Cancer Patient Pathways (CPPs) for faster diagnostic assessment and timely treatment to improve the quality of cancer care. A key aspect of CPPs is the introduction of time limits for each phase of the diagnostic investigation. Occurring simultaneously are ongoing advances in medical technology, complicating the process of diagnosing and treating cancer. In this article, using institutional ethnography, we examine: how does the CPP policy influence physicians' experiences of diagnostic work? Data were collected from May 2018 to May 2019, through semi-structured interviews with physicians across five hospitals in Norway (N = 27). Our findings indicate that the implementation of various strategies aimed at enhancing quality in cancer care collide, compelling physicians to negotiate between diagnostic precision and rapid decision-making. We conclude that attention to interfaces between multiple guidelines and their implications for practice is crucial for understanding and developing quality of care.

A pay for performance scheme in primary care: Meta-synthesis of qualitative studies on the provider experiences of the quality and outcomes framework in the UK

BACKGROUND

The Quality and Outcomes Framework (QOF) is an incentive scheme for general practice, which was introduced across the UK in 2004. The Quality and Outcomes Framework is one of the biggest pay for performance (P4P) scheme in the world, worth £691 million in 2016/17. We now know that P4P is good at driving some kinds of improvement but not others. In some areas, it also generated moral controversy, which in turn created conflicts of interest for providers. We aimed to undertake a meta-synthesis of 18 qualitative studies of the QOF to identify themes on the impact of the QOF on individual practitioners and other staff.

METHODS

We searched 5 electronic databases, Medline, Embase, Healthstar, CINAHL and Web of Science, for qualitative studies of the QOF from the providers' perspective in primary care, published in UK between 2004 and 2018. Data was analysed using the Schwartz Value Theory as a theoretical framework to analyse the published papers through the conceptual lens of Professionalism. A line of argument synthesis was undertaken to express the synthesis.

RESULTS

We included 18 qualitative studies that where on the providers' perspective. Four themes were identified; 1) Loss of autonomy, control and ownership; 2) Incentivised conformity; 3) Continuity of care, holism and the caring role of practitioners' in primary care; and 4) Structural and organisational changes. Our synthesis found, the Values that were enhanced by the QOF were power, achievement, conformity, security, and tradition. The findings indicated that P4P schemes should aim to support Values such as benevolence, self-direction, stimulation, hedonism and universalism, which professionals ranked highly and have shown to have positive implications for Professionalism and efficiency of health systems.

CONCLUSIONS

Understanding how practitioners experience the complexities of P4P is crucial to designing and delivering schemes to enhance and not compromise the values of professionals. Future P4P schemes should aim to permit professionals with competing high priority values to be part of P4P or other quality improvement initiatives and for them to take on an 'influencer role' rather than being 'responsive agents'. Through understanding the underlying Values and not just explicit concerns of professionals, may ensure higher levels of acceptance and enduring success for P4P schemes.

The impacts of GP federations in England on practices and on health and social care interfaces: four case studies

Background

General practices have begun working collaboratively in general practitioner federations, which vary in scope, geographical reach and organisational form.

Objectives

The aim was to assess how federating affects practice processes, workforce, innovations in practices and the interface with health and social care stakeholders.

Design

This was a structured cross-sectional comparison of four case studies, using observation of meetings, interviews and analysis of documents. We combined inductive analysis with literature on ‘meta-organisations’ and networks to provide a theoretically informed analysis.

Results

All federations were ‘bottom-up’ voluntary membership organisations but with formal central authority structures. Practice processes were affected substantially in only one site. In this site, practices accepted the rules imposed by federation arrangements in a context of voluntary participation. Federating helped ease workforce pressures in two sites. Progress regarding innovations in practice and working with health and social care stakeholders was slower than federations anticipated. The approach of each federation central authority in terms of the extent to which it (1) sought to exercise control over member practices and (2) was engaged in ‘system proactivity’ (i.e. the degree of proactivity in working across a broader spatial and temporal context) was important in explaining variations in progress towards stated aims. We developed a typology to reflect the different approaches and found that an approach consisting of high levels of both top-down control and system proactivity was effective. One site adopted this ‘authoritative’ approach. In another site, rather than creating expectations of practices, the focus was on supporting them by attempting to solve the immediate problems they faced. This ‘indulgent’ approach was more effective than the approach used in the other two sites. These had a more distant ‘neglectful’ relationship with practices, characterised by low levels of both control over members and system proactivity. Other key factors explaining progress (or lack thereof) were competition between federations (if any), relationship with the Clinical Commissioning Group, money, history, leadership and management issues, size and geography; these interacted in a dynamic way. In the context of a tight deadline and fixed targets, federations were able to respond to the requirements to provide additional services as part of NHS Improving Access to General Practice policy in a way that would not have been possible in the absence of federations. However, this added to pressures faced by busy clinicians and managers.

Limitations

The focus was on only four sites; therefore, any federations that were more active than those federations in these four sites will have been excluded. In addition, although patients were interviewed, because most were unaware of federations, they generally had little to say on the subject.

Conclusions

General practices working collaboratively can produce benefits, but this takes time and effort. The approach of the federation central authority (authoritative, indulgent or neglectful) was hugely influential in affecting processes and outcomes. However, progress was generally slower than anticipated, and negligible in one case.

Future work

Future work would benefit from multimethod designs, which provide in-depth, longitudinal, qualitative and quantitative methods, to shed light on processes and impacts.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 11. See the NIHR Journals Library website for further project information.

Are we nearly there yet? A study of the English National Health Service as professional bureaucracies

Purpose The purpose of this paper is to explore issues of medical engagement in the management and leadership of health services in the English National Health Service (NHS). The literature suggests that this is an important component of high performing health systems, although the NHS has traditionally struggled to engage doctors and has been characterised as a professional bureaucracy. This study explored the ways in which health care organisations structure and operate medical leadership processes to assess the degree to which professional bureaucracies still exist in the English NHS. Design/methodology/approach Drawing on the qualitative component of a research into medical leadership in nine case study sites, this paper reports on findings from over 150 interviews with doctors, general managers and nurses. In doing so, the authors focus specifically on the operation of medical leadership in nine different NHS hospitals. Findings Concerted attention has been focussed on medical leadership and this has led to significant changes to organisational structures and the recruitment and training processes of doctors for leadership roles. There is a cadre of doctors that are substantially more engaged in the leadership of their organisations than previous research has found. Yet, this engagement has tended to only involve a small section of the overall medical workforce in practice, raising questions about the nature of medical engagement more broadly. Originality/value There are only a limited number of studies that have sought to explore issues of medical leadership on this scale in the English context. This represents the first significant study of this kind in over a decade.

New Game, Old Rules? Mechanisms and Consequences of Legitimation in Boundary Spanning Activities

Despite the increasing deployment of formalized boundary spanning roles and practices, the mechanisms and dynamics of their legitimation remain under-explored. Using the Bourdieusian lens, we theorize legitimation of boundary spanning as accumulation, mobilization and conversion of several forms of capital unfolding in a configuration of intersecting fields. Drawing on a qualitative longitudinal case study of a collaborative partnership between a university and healthcare organizations, we describe changes in the structure, sources and mutual convertibility of capital assets over time. We also analyse the implications of this evolution for the relationships between the intersecting fields and the social trajectory of boundary spanners. We argue that legitimation of boundary spanning roles and practices is a highly transformative, collective and political process that increases the capital endowments and authority of individual boundary spanning agents but may lead to the erosion of the very same roles and practices that were being legitimized.

Professional autonomy under pressure: towards a dialectical approach

PURPOSE

The purpose of this paper is to explore the process of evolution of medical autonomy as an analytic and historical aspect of the medical work organization in a public bureaucracy.

DESIGN/METHODOLOGY/APPROACH

The authors draw on the analytic concept of organizational contradictions (Heydebrand, 1977) to inform a dialectical approach in organizational analysis. Semi-structured interviews with 20 doctors of a Greek general public hospital were conducted and archival data were collected.

FINDINGS

The findings suggest that the historical development of two contradictions characterize the process of medical autonomy evolution. The first contradiction tends to develop between medical autonomy, as a self-control relation, and the established division of labour through which bureaucratic control is exercised over the allocation of resources and over the distribution of healthcare service. The second contradiction tends to develop between those reified aspects of the medical work organization and the ongoing organizing activity, i.e. activity towards extending, intensifying and centralizing organizational control over labour, resources and the distribution of healthcare services. These contradictions indicate a pressure towards constraining health professionals' power to self-define their relationship with patients and towards curtailing their discretionary domain over the use of resources.

ORIGINALITY/VALUE

This paper offers an empirical approach to materialist dialectics for organizational analysis towards conceptualizing change as a historical process.