In the name of cancer nursing: organizational change and oncology practices
Date
2018-11-22
Authors
Stevenson, Roberta Lynn
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Abstract
This dissertation studies a process of change as evidenced in the everyday conduct
of cancer nursing within the context of the ambulatory care setting. The purpose of this
study was to explicate relationships of leaders of nursing practice, practitioners, and
patients and families, and how these relationships serve to shape, in particular ways, the
outcome of planned organizational change. The study enabled a questioning of how
leaders, widely thought to be ‘responsible’ for marshaling change processes through
organizations, would know that practice, had, in fact, been positively changed or
improved as a result of the change. Further, the study undertook to question whether and
how leadership practices operate to resist consensus and foster the inclusion of
conflicting knowledges arising out of differences in position, and knowledge of
practitioners, patients and families, and managers.
In order to contextualize and keep central the concept of practice in the study, I
have drawn on the work of Michel Foucault. Foucault’s conceptualization of practice
links action with language in ways that require a careful analysis of how action changes
when discourses, such as ‘specialty practice’ or ‘organizational change’ are introduced as
part of a program associated with changing how nurses undertake their work. Following
Foucault’s claim that our knowledge is manufactured and produced by our discourses and
practices, the focus of the analysis was to reveal the knowledges that the nurses draw
upon to explicate and conduct their practice.
A detailed examination of the organizational change initiative documentation and
interviews revealed contradictory aims in the proposed changes to the patient care team.
Nurses were seemingly unaware of these competing aims. Nurses explicated their
practice differently at each of the clinics revealing how ‘membership’ and ‘belonging’
mediate the discourses that they draw upon to ‘talk’ about their practice. Analysis of
observational materials revealed remarkably similar practices in each of the clinics. This
finding points out how powerful organizational structures, such as schedules, routines,
assignments, and policies affect the enactment of practice.
Nurses described their practice using the language and discourses of ‘expert’ and
‘specialist’. Analysis did not reveal a discernible model of care, but did suggest that
nurses predominantly draw upon their disease related knowledge when caring for cancer
patients and families. The ‘local’ knowledge of ‘how things get done’ in the everyday is
not acknowledged. I suggest that relying on ‘expert’ knowledge, ‘disciplines’ the
behavior of patients and families.
What emerges from this study is that nurse leaders are one of the powerful
influences that affect how practices are accounted for. The incongruence between
nurses’ accounts and leaders’ accounts is not merely about differences in hierarchical
position. Nurse leaders’ accounts rely upon proxies such as timeliness, workload
measures, patient and physician feedback, and are framed against a technical, managerial
perspective of practice. Revealing these differing practice interpretations provides nurses
and leaders a way of understanding how successful changes to practice must be planned
in a way that takes up the knowledge of not only the leaders but also the nurses.
Lastly, the knowledge of patients and families was not immediately apparent in
the organizational documentation or the observations. Individualization of care competes
with organizational standardization. In a time of continuous changes in health care, the
perspectives of patients should not be relegated to the background, but must take their
rightful place in the foreground with other health care providers.
Description
Keywords
Cancer, Nursing, Organizational change