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Title: Performing politics in the clinical team : context and subtext
Author: Allard, Jon
Awarding Body: Exeter and Plymouth Peninsula Medical School
Current Institution: Exeter and Plymouth Peninsula Medical School
Date of Award: 2013
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Healthcare and politics are intimately bound and are expressed at three levels. The macro level concerns policy, where politics and ideology shape multiple, sometimes serial, and often conflicting, health care 'reforms'. The meso level concerns translation of such policy at the level of institutional operation such as the workings of a hospital, and may involve 'management style'. Finally, policy and management decisions will interact with the day-to-day practices of clinicians and support workers at the micro level. Micropolitics involve translation of policy and management decisions into daily working practices, involving the complex interaction of evidence-based care, local traditions, patients' idiosyncratic needs, and the skill and capability mix of multiprofessional clinical teams working with a variety of hi- and lo-tech artefacts. Following the advice of Actor-Network-Theory's (ANT) methodology - to conduct an ethnography by 'digging where you stand' - this thesis looks deeply into a small slice of micropolitical teamwork activity in the UK National Health Service (NHS) for better appreciation and understanding. Two case study contexts - an Emergency Department (EO) and a Mental Health (M H) ward - were studied in depth over an extended period th rough postmodern observation and video ethnography, supplemented by interviews. Data were analysed to reveal patterns of micropolitical activity - ways in which power acted locally to shape clin ical activities. Major forms of sovereign power ('power over') or key 'texts' in the NHS - dictated at the macro level of policy, and translated at the meso level of hospital management - include what have become 'mantras', such as 'patient-centredness'. However, at the micro level, such texts were seen to be disrupted by a variety of 'subtexts' of activity. Subtexts in both contexts included (i) 'patient throughput' (and throughput pressure); (i i) 'patients and their relatives as key decision makers'; (ii i) 'risk and patient safety'; and (iv) 'clinical uncertainty'. Such emergent 'subtexts' of activity explicitly shape micropolitical teamwork practices and behaviours, often reshaping , and even subverting , stated macropolitical imperatives or policy texts such as 'patient-centred ness' . Power was seen to be productive, as forms of resistance to sovereign (reproductive) power. Such 'capillary power' characterized the playing out of subtexts across systems of work to shape identi ties in flu id team settings. Drawing particularly on Cultural-Historical Activity Theory (CHAT) as a conceptual framework, th is thesis challenges lingering sociological models of 'medical dominance' and doctor-nurse power differences, to promote a more complex picture of daily micropolitical teamwork life in two clinical settings in which politics are 'performed'.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available