This feels like I am being broken – broken open

195 Pages·2012·1.31 MB·English

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Complexity and the Practices of Communities in
Healthcare:

Implications for an Internal Practice Consultant

Marion C. E. Briggs, BScPT, MA

April 2012

A thesis submitted in partial fulfilment of the
requirements of the University of Hertfordshire
for the degree of Doctor of Management

The programme of research was carried out in the
Complexity Research Institute of
The School of Business
University of Hertfordshire, Hatfield, UK
ABSTRACT
Current literature regarding quality health services frequently identifies
interprofessional collaboration (IPC) as essential to patient-centred care, sustainable
health systems, and a productive workforce. The IPC literature tends to focus on
interprofessionalism and collaboration and pays little attention to the concept of
practice, which is thought to be a represented world of objects and processes that have
pre-given characteristics practitioners can know cognitively and apply or manage
correctly. Many strategies intended to support IPC simplify and codify the complex,
contested, and unpredictable day-to-day interactions among interdependent agents
that I argue constitute the practices of a community. These strategies are based in
systems thinking, which understand the system as distinct from experience and
subject to rational, linear logic. In this thinking, a leader can step outside of the
system to develop an ideal plan, which is then implemented to unfold the
predetermined ideal future. However, changes in health services and healthcare
practices are often difficult to enact and sustain.
This thesis problematises the concept of ‗practice‘, and claims practices as
thoroughly social and emergent phenomenon constituted by interdependent and
iterative processes of representation (policies and practice guidelines), signification
(sense making through negotiation and reflective and reflexive practices), and
improvisation (acting into the circumstances that present at the point and in the
moments of care). I argue that local and population-wide patterns are negotiated and
iteratively co-expressed through relations of power, values, and identity. Moreover,
practice (including the practice of leadership or consulting) is inherently concerned
with ethics, which I also formulate as both normative and social/relational in nature. I
argue that theory and practice are not separate but paradoxical phenomena that remain
in generative tension, which in healthcare is often felt as tension between what we
should do (best practice) and what we actually do (best possible practice in the
contingent circumstances we find ourselves in). I articulate the implications this has
for how knowledge and knowing are understood, how organisations change, and how
the role of an internal practice consultant is understood. An important implication is
that practice-based evidence and evidence-based practice are iterative and co-
expressed (not sequential), and while practice is primordial, it is not privileged over
theory. I propose that a practice consultant could usefully become a temporary
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participant in the practices of a particular community. Through a position of ‗involved
detachment‘, a consultant can more easily notice and articulate the practices of a
community that for participants are most often implicit and taken for granted.
Reflective and reflexive consideration of what is taken for granted may change
conversations and thus be transformative.

Keywords: Practice, Complexity, Theory/Practice, Interprofessional Collaboration,
Practice Consultant, Healthcare.
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DEDICATION
I dedicate this thesis to the memory of my parents, to whom I owe so much:
James Walter Briggs (1916 – 1998) and Agnes Christine Briggs (1915 – 2005).
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ACKNOWLEDGMENTS
No thesis is the sole work of its author. Scholars past and present (including
student colleagues), family, friends, colleagues at work, and although unwittingly,
even strangers, have made significant contributions to this thesis, and for this I am
deeply grateful.
I am particularly indebted to Professor Chris Mowles whose guidance and
support was exceptional throughout the program. As any good supervisor would be,
Chris was sometimes irritating in his belief in what my best work was and his
insistence that I produce nothing less. Chris remained critically engaged with my
work throughout the program and it is, as result, much better than it would otherwise
have been. He is a wise and patient mentor, who has my deepest respect. Kevin Flinn
and Eric Wenzel were superb learning set partners whose deep commitment to my
work in the midst of their own was vital. I am grateful for the support and friendship
that Eric and Kevin so generously offered from the first day we met, and I look
forward to lifelong friendships that have been forged, particularly with Kevin, Eric,
and Chris. In a truly collaborative process, it was my privilege to learn from, with,
and about both the faculty group (Chris Mowles, Ralph Stacey, Douglas Griffin, Nick
Sara, and Karen Norman) who were so inspiring and the full DMan student cohort. I
am grateful to Shanaya Nelson for her support in editing my work and for having
copies of everything important when, at the last minute, my computer failed.
Finally, my thanks go to my family—Bill and Bernice, Suzie and Glenn, and
Richard—whose love and support mean so much to me. To Jan—my partner, my
love, my inspiration—thank you. Were it not for your support and encouragement I
would not even have started this incredible journey. With your support, I not only
started, I finished and enjoyed every minute of it—thank you. What is next?!

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TABLE OF CONTENTS
ABSTRACT ...................................................................................................................2
DEDICATION ...............................................................................................................4
ACKNOWLEDGMENTS .............................................................................................5
LIST OF FIGURES .......................................................................................................9
INTRODUCTION .......................................................................................................10
PROJECT 1: TOWARD THE UNKNOWN ...............................................................14
Introduction ............................................................................................................14
Narrative ................................................................................................................15
Thinking about Action: Values and Ethical Action ...............................................17
―Drawing Myself Up‖ ......................................................................................17
Understanding Patterns of Ethical Action........................................................19
The Magico-Mythical Hero ...................................................................................20
Thinking More about Ethics and Identity ..............................................................22
The Fall of the Hero .........................................................................................22
Who is ‗In‘ and Who is ‗Out‘ ..........................................................................23
Thinking About How Organisations and the People in them Change ...................25
The Patient Care Project: Reengineering Healthcare .............................................27
Complex Responsive Process Theory – A Brief Exploration ................................30
Moving into the Unknown .....................................................................................33
PROJECT 2: INTERPROFESSIONAL COLLABORATIVE PRACTICE –
EXPLORING THE ‗TAKEN FOR GRANTED‘ ........................................................34
Introduction ............................................................................................................34
Narrative Part 1: An Invitation to Talk About Interprofessional
Collaborative Practice ......................................................................................35
Interprofessional Collaboration: The Widespread Interest in IPC ...................36
The Advantages of IPC ....................................................................................36
IPC Defined .....................................................................................................37
Reflecting on the Narrative ....................................................................................38
Understanding Practice ..........................................................................................39
Practice as Application of Theory....................................................................40
A Reflective Pause .................................................................................................43
Practice as a Model ..........................................................................................44
A Reflective Pause .................................................................................................48
Practice as Task-Related Competency .............................................................49
Narrative: Part 3 .....................................................................................................51
Practice as Complex Responsive Processes of Relating ..................................52
The Collapse of Practice ..................................................................................56
The Narrative – A Final Reflexive Turn ..........................................................58
Transition to Project 3 ............................................................................................61
PROJECT 3: ―YOU DID WHAT?‖ AN EXPLORATION OF POWER AND
KNOWLEDGE AT WORK ........................................................................................62
Introduction ............................................................................................................62
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Background to the Narrative ..................................................................................63
Narrative: Initiating a New Role ............................................................................64
First Impressions ..............................................................................................64
Tethered ...........................................................................................................64
Reflexive Pause Initial Reflection .........................................................................66
Thinking about Power ............................................................................................67
Introduction ......................................................................................................67
Power as Conceived in the IPC Discourse .......................................................67
Power and Foucault..........................................................................................69
Reflexive Pause II ..................................................................................................72
Making Sense of my Experience .....................................................................72
Thinking About Power with Scott, Mead, and Elias .......................................76
Exploring Knowledge (Remembering Power).......................................................80
Thinking about Habermas and Foucault ..........................................................80
Exploring Knowledge (Remembering Power).......................................................81
Returning to the Narrative ...............................................................................81
Revisiting Complex Responsive Processes of Relating...................................83
Rethinking the Relationship between Practice and Action ....................................85
Beginning to Disarticulate Action and Practice ...............................................89
Conclusion and Implication for my Practice .........................................................90
Moving to Project 4 .........................................................................................90
PROJECT 4: THINKING THROUGH PRACTICE – ON BECOMING A
PRACTICE CONSULTANT ......................................................................................93
Introduction ............................................................................................................93
The Narrative .........................................................................................................94
Background Context ........................................................................................94
Starting out with the EDP Team ............................................................................95
Thinking About Boundaries ...................................................................................96
Thinking About Ethics ...........................................................................................96
Potential Changes in Understanding Experience ...................................................98
A Shift in the Conversation....................................................................................99
Reflecting in More Complex Ways .....................................................................100
Themes Arising from the Narrative .....................................................................101
Introduction: Explaining the Interest in the Logics of Practice and Science .101
The Logics of Science and Practices ...................................................................104
Introduction ....................................................................................................104
The Logic of Science ...........................................................................................105
The Logic of Practice ...........................................................................................109
Interpreting the Narrative Further ........................................................................112
A Rendezvous with Goffman via Lewis and Reeves...........................................113
Implications for Becoming a Practice Consultant ...............................................114
Implications of Differentiating the Rationality of Science and Practice .............115
Complex Responsive Processes of Relating: Where/How Does Practice
Theory Fit.......................................................................................................116
The Context of Practices ......................................................................................118
Implications for Becoming a Practice Consultant ...............................................121
Engaging with the Practices of a Community................................................121
Proceeding to the Synopsis ..................................................................................122
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SYNOPSIS .................................................................................................................123
Introduction ..........................................................................................................123
The Structure of this Synopsis .............................................................................123
Brief Overview of Projects ..................................................................................124
Entering the Program and Project 1 ...............................................................124
Projects 2 through 4 .......................................................................................125
Theme 1 ...............................................................................................................126
Introduction ....................................................................................................126
Interprofessional Collaborative Practice – The Dominant Discourse ............127
A Critique of the Dominant View of IPC ......................................................129
From IPC to Practice as a Social Phenomenon ..............................................132
A Social Understanding of Practices – from IPC to Practice(s) ....................134
Theme 2: From Practices to the Practices of a Particular Community ................136
Introduction ....................................................................................................136
Sites of Practices – Practices of Communities ...............................................137
Relations of Power and Interdependence in the Practices of Communities ..141
Theme 3 ...............................................................................................................145
Introduction ....................................................................................................145
Loosening my Attachment to Consultant as Expert ......................................146
The Social Construction of Knowledge .........................................................147
Becoming a (Temporary) Engaged Participant in the Practices of a
Particular Community ....................................................................................148
The Practices of Communities as a Context for Relational Ethics ................150
The Research Method ..........................................................................................152
Introduction ....................................................................................................152
Research in the DMan – The Perspective of Complex Responsive
Processes of Relating .....................................................................................152
A Brief Overview of Methods Similar to those used on the DMan
Program ..........................................................................................................154
Seeking the Generative Tension between Positivist and Interpretivist
Scholarship .....................................................................................................161
A Note about Research Ethics .............................................................................166
Original Contributions .........................................................................................168
A Final Narrative ...........................................................................................171
Conclusion ...........................................................................................................175
REFERENCES ..........................................................................................................177
APPENDIX: PROGRAM DESCRIPTION OF MASTER OF ARTS IN
LEADERSHIP (HEALTH) .......................................................................................194

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LIST OF FIGURES
Figure 1. A depiction developed in a small group discussion of how moral, social,
ethical, legal constraints form boundaries and create behavioural norms .... 97

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INTRODUCTION
Over more than 40 years as a clinician, administrator, researcher, and
consultant in healthcare, I have advocated for collaboration between members of the
health disciplines. Over the last 20 years, the health policy, human resource, and
patient safety literature has pointed more intensely to the need for interprofessional
collaborative practice (IPC). Despite this widespread interest in and commitment to
the principles and practices espoused in the IPC literature, its enactment in practice
settings has been slow to emerge. This has given rise to efforts to promote
interprofessional education and collaborative practice through defining what is meant
by ‗interprofessional‘ and ‗collaboration‘, articulating the competencies required for
interprofessionalism and collaboration, and by identifying processes through which
teams can: develop shared goals and values and enhance skills in interprofessional
communication and conflict resolution, commit to shared leadership, and work
together in ways that support learning about and appreciating one another‘s roles
(Canadian Interprofessional Health Collaborative, 2010).
Thinking about organisation and change in the dominant discourse is
grounded in systems thinking (Senge, 1990/2006), which assumes a system exists
apart from ordinary interactions between people as they work together. It is thought
that a leader/consultant can stand outside the system to observe and analyse it,
determine ‗best practice‘, and develop a plan that can be rolled out to increase the
correspondence between the predetermined ideal and what is actually happening in
practice. For some time, I accepted this view unreflexively. However, I grew
increasingly sceptical that this was a useful way of thinking about organisation or
change. If, as systems thinking claims, leaders can isolate, disarticulate, improve, then
rearticulate and unproblematically ‗roll out‘ an improved system that will achieve the
desired state, how is it that these well-designed systems remain imperfect when they
are implemented?
Through a chance encounter with the work of the Complexity Research Group
(CRG) at the University of Hertfordshire (Griffin, 2002; Shaw, 2002; Stacey, Griffin,
and Shaw, 2000; Stacey, 2005; 2007; Stacey and Griffin, 2005), I encountered
another view—something quite different. These scholars claimed that organisations
are not systems, but ―on-going iterative processes of cooperative and competitive
relating between people [and that these] … patterns of human interaction simply
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