Paula Hyde

Role redesign: new ways of working in the NHS

Purpose – To examine the introduction of role‐redesign in the NHS and highlight implications for employment relations.Design/methodology/approach – A 12‐month independent evaluation (2003‐2004) of a role redesign initiative in the NHS is reported. The study followed a developmental, case‐study design and included secondary data analysis, semi‐structured interviews and observations at five case‐study sites.Findings – The role redesign process involved four types of change to job content: skill‐mix changes; job widening; job deepening; and development of new roles. Each of these changes had implications for employment relations in terms of remuneration, management and accountability, and education and training.Research limitations/implications – The research involves one initiative in the NHS and was evaluating a developing programme. Whilst implications are suggested for efforts at role redesign generally the research specifically relates to NHS organisations.Practical implications – Three aspects of emplo...

Service design, culture and performance: Collusion and co-production in health care:

While there is emerging evidence to suggest that (organizational) culture can affect the performance and quality of health services, little attention has been directed at how these relationships might be mediated, facilitated or attenuated by aspects of service design (i.e. those arrangements that combine facilities, staff and service users in the co-production of care). Using two case studies set in mental health services, this article explores how both culture and performance may be viewed as emergent properties of service design configurations. Thus central to ideas of service re-design should be notions of service users as the co-producers (with staff) of both organizational culture and organizational performance, as well as a clearer understanding of how such co-production processes are modulated by specific design configurations.

Organizational Failure and Turnaround: Lessons for Public Services from the For-Profit Sector

As the performance of public services is increasingly scrutinized, it is now commonplace for some schools, hospitals, local authorities and other public organizations to be deemed ‘failing’ and for attempts to be made at creating a turnaround in their performance. This article explores the literature on failure and turnaround in for-profit organizations, presents a number of models or frameworks for describing and categorizing failure and turnaround, and examines the relevance and transferability of theoretical and empirical studies in the for-profit sector to the emerging field of failure and turnaround in public services.

Casting the lean spell: The promotion, dilution and erosion of lean management in the NHS:

Lean thinking has recently re-emerged as a fashionable management philosophy, especially in public services. A prescriptive or mainstream literature suggests that lean is rapidly diffusing into public sector environments, providing a much-needed rethink of traditional ways of working and stimulating performance improvements. Our study of the introduction of lean in a large UK public sector hospital challenges this argument. Based on a three-year ethnographic study of how employees make sense of lean ‘adoption’, we describe a process in which lean ideas were initially championed, later diluted and ultimately eroded. While initially functioning as a ‘mechanism of hope’ (Brunsson, 2006) around which legitimacy could be generated for tackling longstanding work problems, over time both ‘sellers’ and ‘buyers’ of the concept mobilized lean in ambiguous ways, to the extent that the notion was rendered somewhat meaningless. Ultimately, our analysis rejects current prescriptive or managerialist discourses on lean while offering support for prior positions that would explain such management fashions in terms of the ‘life cycle of a fad’.

Human relations management, expectations and healthcare: A qualitative study

Despite substantial evidence for a relationship between human resource management (HRM) and the performance of individuals, relatively few studies have examined the role of employee expectations. This article reports on a study involving six National Health Service (NHS) organizations across England. Healthcare employees expected their employers to provide: infrastructure, HR practices and support, which they linked to improved performance especially in relation to patient care and service innovations. Counterintuitively, effort was maintained towards immediate patient care when expectations were unmet, seemingly, because of public service values. The findings indicate that public service values may be a strong determinant of performance as it relates to patients, moderating potential short-term adverse effects of unmet expectations. In contrast, longer term effects on patient care and service development were less readily moderated by these values. This study offers differential accounts illustrating effects on performance gained through improved working conditions and through work intensification.

Wicked problems or wicked people? Reconceptualising institutional abuse

Institutional abuse is a global issue, sometimes ascribed to the behaviour of a few wicked people. It persists despite regulatory measures, interventions from enforcement and protection agencies, organisational policies and procedures. Therefore, the accurate recognition and early detection of abuse and taking corresponding steps to deal with perpetrators are critical elements in protecting vulnerable people who live in institutions. However, research is less clear about why and how abuse (re)occurs. Using the tame and wicked problem analysis of Rittell and Webber (1973) as a lens, we examine the ways institutional abuse is formulated in care settings. Drawing on case study data from eight care homes for older people, we show how solutions seeking to reduce institutional abuse and improve care quality can cause additional problems. The article reconceptualises institutional abuse through the lens of wicked problem analysis to illustrate the multifaceted and recurring, wicked problem characteristics of residential care provision.

When a Leader Dies

The reactions of followers after losing a leader are an important and neglected area of study. In fact, little is known about reactions to changes of leadership in organizational settings, generally. The effects of loss and specifically of bereavement within the family are well known. Whilst organizational life differs from family life, some relationships and reactions to loss may be comparable. One way of illuminating reactions to the loss of a leader is to look empirically at cases of leadership loss. This article presents one example taken from the health service of a team whose leader died after a short illness. Members of this team reacted differently according to their previous attachment to the leader and their reactions ranged from grief to indifference. The death of a leader is an extraordinary occurrence that may illuminate reactions to loss more generally within organizations.

Organizational blind spots: Splitting, blame and idealization in the National Health Service:

The article examines the escalation of commitment to failing strategies from a psychodynamic perspective as an affective process connecting organizational, systemic and individual levels. We propose a theory of organizational blind spots to explain how such escalation of commitment occurs. Blind spots develop as an organizational defence mechanism for coping with problems resulting from attempts to implement unrealistic strategy or policy goals. Unrealistic strategic aims mobilize and reinforce blind spots through processes of splitting, blame and idealization, thus enabling organizations to persist with unsuccessful courses of action. Organizational blind spots arise when leadership and/or operational members in organizations are unable to acknowledge unworkable strategies. Vignettes from the National Health Service in England (the NHS) are used to illustrate how blind spots sustain an illusory possibility of success while commitment to a failing strategy escalates. The theory of blind spots offers a novel social-psychological approach to understanding how these dysfunctions of strategy develop and become institutionalized, putting organizations in jeopardy and threatening their survival.

Fool's Gold: Examining the Use of Gold Standards in the Production of Research Evidence.

Research designs, and the methods that they dictate, normally arise from the nature of the questions being asked. However, in most medical research, a hierarchy of evidence is in common use that influences choice in favour of research designs that include methods with a higher ranking. The acceptance of superior research methods consequently limits the types of question that can be asked. The randomised controlled trial (RCT) has enjoyed a long reign as the gold standard in health research methodology. The RCT is used here as a case example of how hierarchies of research methods can distort the production of evidence relating to health care. The acceptance of the RCT as a superior method in the hierarchy of evidence production has been promoted by claims that RCTs offer reliability, objectivity and levels of certainty about treatment effectiveness (inferred through statistical significances) that other methods do not. These statistical significances depend upon mathematical probabilities that imply a level of uncertainty. Mathematical significance has been confused with the substantive or practical importance of research results. The importance of research findings cannot be determined by hierarchies, nor by statistical techniques alone; other types of method can provide findings that are equally valid, true or useful to evidence production in occupational therapy.

Managing across boundaries: identity, differentiation and interaction

The impact of organisational restructuring on organisational boundaries has become increasingly important, especially because modernisation of work practices within large organisations generates increasing boundary complexity. Psychoanalytic theory offers a means of exploring boundaries and emphasises the importance of boundary in the emergence of an integrated sense of identity. In the UK, restructuring of health services has resulted in changes to organisational, professional and work group boundaries, seemingly, without attention being given to what may constitute a healthy set of boundary relationships. Four interrelated case studies illustrate a variety of organisational relationships and cross-boundary processes in mental health services, and how threats to particular boundaries can lead organisational members to engage in defensive activity. Whilst defences may be healthy for the individual or the organisation, they may generate more problems than they solve. Although the examples given here are highly specific, they may illuminate boundary systems more generally within organisations.