Workforce matters : exploring a new flexible role in health care
This thesis describes an action research study that took place in the context of increasing intervention by UK central government in the shaping and delivery of health services, and broadening expectations about who could deliver services. The study was aimed at exploring the issues arising from the development of the interprofessional care co-ordinator (IPCC) role in an acute in-patient setting. The role was new, introduced with an inherent flexibility that enabled IPCCs to speed patients through their in-patient stays as fast as clinically possible. None of the four IPCCs appointed held a registrable qualification in health or social care. A review of the literature identified that very little is known about care co-ordinator roles in practice, particularly those held by non-registered workers. The study reported in this thesis began two years after the IPCCs took up post. The study’s objectives were to describe the characteristics, impact, issues and influences on the role. A wide range of qualitative and quantitative data were gathered and analysed between October 1998 and July 2000 within the framework of an action research approach. The findings identified that the IPCC role had informally shifted over time to take up the complex discharge planning work previously carried out by nurses. This shift was not reflected in Trust policy and had not been accompanied by a review of training, regulation or supervision. This had led to situations of risk for some patients. The findings threw light on contextual factors that enabled the role shift and disrupted the reflective leadership and long-term overview needed to monitor and respond to the shift. These factors included nursing staff shortages and a turbulent environment for managers characterised by multiple pressures, top-down targets particularly for acute efficiency, and high managerial turnover. In addition, nurses did not perceive that they had an influence on the ongoing development of the IPCC role. The findings support Abbott’s (1988) theory that an occupational group can take up the discarded work of a higher status occupational group, but challenge the theory that the work discarded is always more routine than the work retained. They support theories of a growing challenge to the primacy of professional knowledge and the existence of an organisational culture in the NHS in which there are broader expectations of who can deliver which health services. They also indicate that role substitution can lead to the routinisation and marginalisation of aspects of patient care. The findings also illustrate how an innovation can continue to be re-invented following its establishment into routine practice, and how the journey of an innovation can be influenced by its context. The findings throw light on a role in practice that is a cameo of current policy on new roles and have a number of implications for practice, policy, education and research.