National healthcare strategy and the management of risk in a National Health Service trust
A central concern of this research has been to understand more about how and why organisations change. My initial research question posed was: What is 'strategy', how does it emerge in health care organisations and how can I influence its development? This is explored within the context of my field of practice as a Director of Nursing in a National Health Service (NHS) Trust. I have approached this enquiry through using a methodology known as emergent exploration of experience (Stacey et al., 2003). This methodology is informed by insights from Complexity Science and the theories of complex responsive processes of relating. What emerged through the enquiry were a number of key areas of concern related to national healthcare strategy and the management of risk within my NHS trust. The findings from this research radically challenge the way we are practising together in my organisation in moving from the position of locating accountability for mistakes with either the individual or the system. Instead it is suggested that, as part of our ongoing process of interaction, we co-create what others are describing as a 'system' through our participation with each other. Accepting the notion of co-creation requires us to examine very carefully the influence of our own participation in the dangerous situations that arise in our everyday work, and to acknowledge our own accountability for what emerges. I am proposing that this makes a new contribution to knowledge in this field for two reasons. First, because it explores for what I believe to be the first time the validity of the theory of complex responsive processes in the discourse of risk management in health care. I am proposing that this theory has a legitimate contribution to make in this field of practice, that is worthy of further enquiry and research. Second, in making this shift to a perspective that understands accountability for error as something that we co-create in groups, my thesis poses a radical challenge to many of the activities that are traditionally undertaken when mistakes occur in organisations. Specifically, I have questioned the usefulness of approaches that seek remedies through focusing on individuals outside the context of the group and those that focus on re-engineering what other authors refer to as the 'whole system'. I offer an alternative through describing examples in my narrative of a different approach grounded in the research methodology of emergent exploration of experience. This focuses on the micro-interactions between participants in groups as a way of understanding the transformation of practice .I am arguing that such transformation may not always be an improvement, because we cannot always accurately predict the outcomes of our actions in advance. This perspective therefore also challenges the assumption made by some authors in this field, who believe it is possible to 'human-proof' systems and thus guarantee ‘zero defects'. In seeking an answer to my research question I have therefore moved from understanding strategy as a vision for the future that can be planned and implemented by a few powerful individuals whom others follow to a different understanding. I now see strategy as an emergent phenomenon arising from micro-interactions between people in the present – hence we co-construct our future as the actions we take in the present. From this perspective I have argued we all have the potential to influence what is emerging through our actions, for which we are constantly held to account, through both our inner dialogue with ourselves and our conversations with each other.