Medicine, management, and modernisation: a "danse macabre"?

Degeling, Pieter; Maxwell, S; Kennedy, John; Coyle, Barbara

doi:10.1136/bmj.326.7390.649

Cited by 172 publications

(174 citation statements)

References 10 publications

(9 reference statements)

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“…However, since the 1970s such idealised conceptions of professionalism and professional autonomy have been tempered and critiqued (Atkinson, Reid, & Sheldrake, 1977;Kennedy, 1981;Larson, 1977). The medical profession has been the subject of renewed attention since the 1990s when governments in many developed Manuscript Click here to view linked References 2 countries, notably the United Kingdom and United States, attempted to strengthen managerial and bureaucratic control over doctors within state and insurance funded health systems (Alaszewski, 1995;Degeling, Maxwell, Kennedy, & Coyle, 2003;Harrison & Ahmad, 2000;Harrison & Pollitt, 1994). Further challenges to doctors' professional autonomy followed in wake of the rising evidence based medicine movement that targeted the mystique and privacy of medical decisionmaking (Greenhalgh, 1996;Horton, 1995;Smith, 1991), and new formalised systems of patient management, such as care pathways, provided an increased clinical impetus for interprofessional collaboration (Pinder, Petchey, Shaw, & Carter, 2005).…”

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Professional autonomy in 21st century healthcare: Nurses’ accounts of clinical decision-making

Traynor

Boland

Buus

2010

Social Science & Medicine

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Autonomy in decision-making has traditionally been described as a feature of professional work, however the work of healthcare professionals has been seen as steadily encroached upon by State and managerialist forces. Nursing has faced particular problems in establishing itself as a credible profession for reasons including history, gender and a traditional subservience to medicine. This paper reports on a focus group study of UK nurses participating in post-qualifying professional development in a London university in 2008. Three groups of nurses in different specialist areas comprised a total of 26 participants. The study uses accounts of decision-making to gain insight into contemporary professional nursing. The study also aims to explore the usefulness of a theory of professional work set out by Jamous and Peloille in 1970. The analysis draws on notions of interpretive repertoires and elements of narrative analysis. We identified two interpretive repertoires: ‗clinical judgement' which was used to describe the different grounds for making judgements; and ‗decision-making' which was used to describe organisational circumstances influencing decision-making. Jamous and Peloille's theory proved useful for interpreting instances where the nurses collectively withdrew from the potential dangers of too extreme claims for technicality or indeterminacy in their work. However, their theory did not explain the full range of accounts of decision-making that were given. Taken at face value, the accounts from the participants depict nurses as sometimes practising in indirect ways in order to have influence in the clinical and bureaucratic setting. However, a focus on language use and in particular, interpretive repertoires, has enabled us to suggest that despite an overall picture of severely limited autonomy, nurses in the groups reproduced stories of the successful accomplishment of moral and influential action.

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Professional autonomy in 21st century healthcare: Nurses’ accounts of clinical decision-making

Traynor

Boland

Buus

2010

Social Science & Medicine

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“…[9][10][11][12] Although one panacea would include a more egalitarian professionalism, 3,10, 13 Degeling et al have argued that doctors' individualistic attitudes to their work make them less supportive of teamwork than nursing colleagues and managers. 1 Such underlying tensions have not been widely examined in maternity settings, yet lively public controversies about the appropriate "social design" of birth impact directly on organisational and professional arrangements. 14,15 As midwives have sought enhanced professional status, the relationship between midwifery and nursing has become contentious and the role boundaries between midwifery and obstetrics increasingly disputed.…”

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Working together: collaboration between midwives and doctors in public hospitals

Reiger¹,

Lane²

2009

Aust. Health Review

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While collaborative, multidisciplinary teamwork is widely espoused as the goal of contemporary hospitals, it is hard to achieve. In maternity care especially, professional rivalries and deep-seated philosophical differences over childbirth generate significant tensions. This article draws on qualitative research in several Victorian public maternity units to consider the challenges to inter-professional collaboration. It reports what doctors and midwives looked for in colleagues they liked to work with -the attributes of a "good doctor" or a "good midwife". Although their ideals did not entirely match, both groups respected skill and hard work and sought mutual trust, respect and accountability. Yet effective working together is limited both by tensions over role boundaries and power and by incivility that is intensified by increasing workloads and a fragmented labour force. The skills and qualities that form the basis of "professional courtesy" need to be recognised as WORKPLACE CULTURES and professional relationships in contemporary hospitals are in upheaval from several factors: the impact of neo-liberal health reforms requiring increased efficiencies, greater accountability and managerial power; 1 the questioning of doctors' traditional authority by the consumer health movement, 2 and challenges to traditional medical dominance by nurses and midwives. Relationships between staff in maternity hospitals are especially contentious. Since the 1990s, struggles to introduce new models of care, notably midwifery teams and caseload models, have faced deep-seated professional rivalries and conflicts and sometimes foundered. In Australia as in Britain, tensions are widespread across the maternity care sector, but they are played out in specific local contexts. 3-6 While contemporary state policy initiatives increasingly promote multidisciplinary teamwork and collaboration, 5,7,8 they can underestimate the difficulty of implementing change in practice, especially in an environment of financial stringencies, increased cultural diversity, staff shortages and increased birth numbers.Drawing on qualitative research in several Victorian maternity units, this article considers interprofessional collaboration between midwives and doctors, arguing that new forms of working This study found that effective collaboration among doctors and midwives was limited by tensions over role boundaries, power relationships and incivility that appeared to be related to increasing workload and fragmentation of the workforce. There is a need to address these issues more effectively at policy and education levels to improve future collaborative practice.

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“…We wouldn't go as far as Degeling et al, 6 who suggested that some doctors were 'equivocal about financial realism'. However, it is hard to imagine the sheer amount of change management, information management, strategic management, and financial management that is necessary for the running of the NHS, being able to succeed without professional managers having a central role.…”

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confidence: 99%

What have NHS managers ever done for us?

Granter¹,

Hyde

2010

London Journal of Primary Care

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Medicine, management, and modernisation: a "danse macabre"?

Abstract: To break their destructive antagonism over issues of health service modernisation, doctors and managers should engage more directly with nursing and allied health professionals when responding to reform initiatives

Cited by 172 publications

References 10 publications

Professional autonomy in 21st century healthcare: Nurses’ accounts of clinical decision-making

Professional autonomy in 21st century healthcare: Nurses’ accounts of clinical decision-making

Working together: collaboration between midwives and doctors in public hospitals

What have NHS managers ever done for us?

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