Int. J. Nun. Stud. Vol. 16, pp. 111-121. ~~~Pergamon Press Ltd., 1979. Printed in Great Britain.
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A ‘social systems’approach to research and change in nursing care DAVID TOWELL, M.A., Ph.D. King’s Fund Cen tre, 126 Albert Street, London NW1 lNF, England.
Introduction
This paper addresses three key concerns in the development of nursing research in the United Kingdom. First, there is the concern with encouraging more and better research which focuses precisely on nursing care. Bond (1975) has argued that the relative mushrooming of research related to nurses and nursing in recent years has still left largely neglected the study of “the practice of nursing as it pertains to patient care”. This neglect is gradually being corrected, but there seems to be every reason for seeking to encourage further work which builds on the progress which is being made. Second, there is the concern with the utilisation of nursing research in improving nursing practice. The general interest here, associated with the idea of nursing as a “research based profession” (Lancaster, 1973, is in the extent to which what is learnt from research is widely disseminated and used by practising nurses. More specifically there is also the question of how far particular research projects have themselves involved an application phase, in which the researchers assist in the development and testing of alternative methods. Certainly it was the case that even on well researched problems, rather few examples could be found of experimental approaches (Simpson, 1971) and Hockey (1974) more recently has argued the importance of giving greater attention to ‘action research’ strategies, in her review of research into nursing services. However, there is still great scope for development in this direction. Third, there is the concern with developing appropriate conceptual frameworks to guide research and innovation in nursing care, and to provide a better understanding of nursing practide. Again, past research in nursing has commonly been criticised for the absence of much theoretical sophistication, although this too may be changing (Inman, 1975; Fagerhaugh and Strauss, 1977). It will be gathered from the title of this paper that 1 want simultaneously to address these three concerns; and to suggest that a particular conceptual framework, which I shall call a ‘social systems’approach, provides a means of linking research with the problem of change in nursing care. However, this is not an attempt at theoretical imperialism. Rather, some ideas grounded in my own direct experience of research on patient care over 111
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the past 10 yr are presented for wider exarnination. This is also not a comprehensive framework. At best, 1 would argue that the ‘social systems’ approach, through seeking to engage in a ‘holistic’ way with key features of the organisation and delivery of care, provides a useful complement to the more common ‘atomistic’ studies which try to measure the impact of a variety of variables on a particular element of nursing care, examined to some extent in isolation. (For example, the early Royal College of Nursing studiesMcFarlane, 1970). The main aspects of my own research experience on which 1 intend to draw can be briefly outlined. My first substantial piece of work was the detailed study of psychiatric nursing practice which the RCN subsequently published as Understanding Psychiatric Nursing (Towell, 1975). In this project I adopted a social anthropological approach, involving more than 3 yr ‘participant observation’ in a single hospital, during which intensive field studies were undertaken on nursing in short-stay admission wards, long-stay geriatric wards, and a specialised ward being developed as a ‘therapeutic community’. In this way it was possible to build up a detailed understanding of everyday life in this hospital, and come to appreciate the meanings which nurses themselves gave to their work and their relationships with patients in these various ward settings. At the descriptive level, these studies showed the extent of the differences in the psychiatric nurse’s work in various contexts and examined the difficulties nurses face in more adequately realising the ‘personal relationships’ aspect of their role in psychiatric treatment. The project as a whole also provided a set of working hypotheses about the relationships between organisational factors, alternative approaches to treatment, staff training and the nurses’ contribution to patient care, in different types of ward. At the time of publication, it was claimed that this study should have practical relevance to those concerned with hospital organisation, the treatment of psychiatric patients and the training of psychiatric nurses. I was unusually fortunate in then having the opportunity to test this proposition myself, because my second major piece of work was an action research project in collaboration with staff of the same hospital, which has aimed to develop new ways of involving staff in efforts to achieve informed improvements in patient care. The central feature of this work has been the creation of a new role in the hospital, that of Social Research Advisor, through which assistance can be made available to any group of staff concerned to investigate.problems arising in their own work, and prepared to use the results of such investigations in trying to change existing aspects of hospital organisation and practice. I filled this advisory role in the 2-yr pilot phase of what has come to be called the ‘Hospital fnnovation Project’(HIP). Subsequently the hospital has sought to institutionalise the approach, so that now after 6 yr this work is still developing, and some of the key ideas are being utilised in other service-development programmes on a wider scale. The staff involved have recently completed a full analysis of this Project (Towell and Harries, 1978) and several articles describing particular initiatives have already been published in appropriate nursing journals. (Aitken el al., 1974; Fenn, Mungovan and Towell, 1975; Harries, 1974; Savage and Widdowson, 1974; Savage and Wright, 1976). This work on innovation in psychiatric care was largely developed while I was part of a small group of staff at the Tavistock Institute of Human Relations engaged in a wider programme of action research in health care systems, including projects concerned with patterns of care in residential institutions for the physically handicapped (Miller and Gwynne, 1972), the processes involved in the hospitalisation of old people (Dartington,
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Jones and Miller, 1974), the psychological welfare of children in long-stay hospitals (Menzies-Lyth, Henry and Dartington, 1977) and the social rehabilitation of the mentally handicapped. Building on earlier Tavistock work, this programme has led to the development of a more or less common theoretical approach, the key aspects of which were reflected in our own designation within the Institute as the ‘Social Systems Group’. This paper outlines the main elements in the ‘social systems’ approach to understanding patient care; enlarges on this outline with illustrations from studies of different kinds of care; and, drawing particularly on my own experiences of HIP, examines the relevance of this approach to processes of change. The ‘social systems’ approach
Most of the work in which the ‘social systems’ approach has been developed entailed not only conducting research on health care issues, but also becoming involved in implementing change and confronting the problems that arise in trying to use social research. Typically then, these projects have implied an action research strategy: implying work carried out in a collaborative relationship with practitioners, in which the intention is both to contribute to the resolution of practical problems and to increase understanding of the issues being studied. Here, of course, fresh conceptualisations of problems may in themselves help to increase the awareness and widen the choices of the staff with whom we work; while the willingness to become involved in their efforts to bring about change provides further opportunities for illuminating the issues in question, and sometimes testing theoretical propositions. It follows that the roles taken up by action researchers may extend rather beyond what is common in academic social research, implying a closer working relationship and often the provision of support to those directly involved in the process of innovation. This methodological commitment has been described at the outset because the action research roles we have adopted have been an important influence on the kind of theoretical understanding which has been generated in this work. It is clear, for example, that starting with this commitment, action researchers are likely to be predisposed to formulate their analysis of issues in ways which link up to the problems likely to be involved in achieving informed change. Turning to the ‘social systems’ approach itself, it is worth noting that any attempt to understand significant health care issues is likely to be a complex undertaking, requiring attention, for example, to the interaction between patients and a variety of therapeutic staff; the tasks, technology and organisational arrangements through which services are provided; the social and psychological influences on the patient’s experiences during his contact with health agencies; and often other specific issues arising in relation to particular aspects of care. In this situation, any conceptual framework must have the function of focusing attention on some features of the total complexity, at the expense, naturally, of not attending to other features, which alternative frameworks might encompass more readily. In this sense then, conceptual frameworks provide an orientation to the subject of study, out of which more precise hypotheses can be generated during the process of field research. In the case of the ‘social systems’ approach, there are three core elements in this orienting framework. First, and drawing on a Weberian ‘social action’ perspective (Eldridge, 1971; Silverman,
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1970), our starting point in any study is an interest in discovering how the various participants in a health care setting themselves ‘define the situations’ in which they are involved, and what purposes and norms guide their activities. This setting can then be viewed as an arena (Strauss et al., 1963) in which different professional, non-professional and client groups meet, each with their own perspectives and purposes, to work out, through negotiation, the courses of action which add up to more or less enduring patterns of work and forms of organisation. These processes of interaction of course both reflect and are influenced by a variety of structural conditions, including the previous division of labour and distribution of power between the groups involved, and the technical and personal resources available for the tasks in question. In analysing the structure of health care organisations, the second core e!ement of this approach has been drawn from modern organisation theory. In particular, we have found it useful to adopt, at least as a heuristic device, what can be described as an ‘open systems’ model (Miller and Rice, 1967; Miller, 1976). At its most basic, the ‘open systems’ model invites attention to the inter-relatedness of various aspects of the internal functioning of organisations with each other and with factors in the organisation’s environment. A key aspect of this relationship between the organisation and its environment is the nature of its throughput; what is imported into the organisation from outside, how this is converted, and what is then exported back. In the case of hospitals, the main throughput is usually patients, who may be successfully treated and returned to active roles in society. The activities through which this is achieved can often be differentiated into a number of constituent sub-systems, each with their own import-conversion-export processes, and to some extent separable from other sub-systems of the organisation. Again, to take the hospital example; the ward, the pharmacy and the laundry, might all be so identified. Examination of possible alternative forms of organisation can then proceed through considering different ways in which boundaries can be drawn round sets of activities in order to achieve particular tasks. A nursing example would be the choice between assigning ward nursing activities by allocating patients or allocating discrete duties to the staff available. Or, on a larger scale, there is the choice involved in grouping wards into functional or geographical nursing units. Organisational design also requires identifying how transactions across these subsystem boundaries, and between the total organisation and its environment, can best be managed. It is questions of this kind, for example, which are tied up in the current debate in hospitals about the appropriate relationship between sector and functional management. The third core element of our approach involves complementing this sociological analysis with insights drawn from a psychodynamic perspective on group and organisational processes (Menzies, 1960; Bion, 1961). It is recognised that participants bring to organisations more than just the role-related aspects of their selves; they are present as people whose current attitudes and actions may reflect, not necessarily consciously, the precipitate of many previous experiences. In the case of nursing, the distinctive features of the task of caring, e.g. the extent of the patient’s dependence on the nurse, are likely to generate considerable anxieties and the way these are dealt with will be an important determinant of the patterns of interaction. These dynamic processes also enter into inter-group relationships, as can sometimes be seen in the conflicts which arise between the different professions caring for the same group of patients; and over time, the whole functioning of an institution may be shaped to support a particular set of defences against anxiety, as Menzies (1960) has illustrated most clearly in her classic study of general nursing. In thus seeking to understand some of the irrational aspects of the way organisations work, some of the
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difficulties in achieving social change are also identified, since ideas or innovations which threaten established defences are themselves likely to increase anxiety among those likely to be affected. Examples from different health care systems
These three elements of the ‘social systems’ approach, and how they are integrated together, can best be explained through some more detailed illustrations from the different kinds of health care setting in which we have undertaken action research projects. The significance of the first theme, that of beginning by trying to discover how participants in a setting are, themselves, defining the situations in which they are involved, is perhaps best brought out in those settings where what is going on is by no means apparent just on the basis of ‘common sense’. In the case of psychiatric nursing, for example, it could be suggested that the central problem for staff is precisely that of how they can make sense of the perplexing behaviour of patients and give meaning to their own work, in a variety of anxiety provoking situations. The first stage of my own research with psychiatric hospitals, described in more detail in Understanding Psychiatric Nursing (1975), tries to provide some illumination of this problem. In particular, by comparing observations across a range of wards where approaches to treatment differ, I argue that the nurse’s response to patients can be understood as arising from the interaction between interpretations they put on the patient’s behaviour and concerns they derive from their roles on the ward: these interpretations and concerns in turn reflecting respectively the way nurses adapt the prevailing ideologies of treatment and the patterns of ward organisation. For example, in an admission ward where treatment was largely based on somatotherapeutic techniques (drugs and electro-convulsive therapy), I discovered how the hierarchical and centralised organisation of the ward for ‘medical servicing’ of patients and the responsibilities for 24-hr staffing gave nurses a key linking role between patients and most other aspects of the hospital. From this role arose their dominant concerns with managing patients so as to maintain the ward schedule, and also ensuring as an adjunct of the doctor that somatic treatment was effectively provided. At the same time nurses gave meaning to the actions of patients through interpretations based upon the ‘medical model’, using diagnostic categories and symptomatic descriptions to make sense of recurrent situations which they confronted and provide a guide to the kinds of problems which could be anticipated. This medical treatment ideology was adapted however so that, for example, terms like ‘disturbed’ neatly aligned the nurses’ twin concerns with treatment and keeping order, through both describing the patient’s condition and justifying the nursing response. This analysis of the relationship between ward organisation, treatment ideology and the nurse’s contribution to patient care was further tested and illuminated in the later action research project with this hospital, when I was able to work with staff on the same ward during a period in which leading members were trying to develop a more ‘social psychiatric’ approach to treatment (Towell, 1978b). This later work also demonstrated the importance of new training arrangements on the ward in providing the support required if nurses were to adopt the more extended roles in relation to patients which this new approach to treatment entailed. While some elements of a systematic analysis can be seen in this work, the further importance of attending to the relationship between an organisation and its environment in
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‘open system’ terms, is more clearly evident in a second example, which comes from a study of residential instutions for the disabled, undertaken by my Tavistock colleagues (Miller et a/., 1972). Examination of the import-conversion-export processes in these institutions suggested that an important characteristic of the residents admitted to them was that they were not merely severely handicapped and unable to look after themselves, but also rejected, sometimes personally, by relatives who had previously been looking after them, and always socially, in the sense that they were defined as no longer having a valued role in the community outside. Moreover, once cripples were admitted, they were unlikely to be discharged again, except through death. Given this form of export, it is not surprising that participants found difficulty in agreeing upon the main purpose of these institutions, and there was particular difficulty in coming to terms with the function which society implicitly assigns-that of coping with the crippled in the period between social rejection and physical death, which may be a period of many years. These realities are very hard to face, for staff and residents alike. Consequently, these institutions were likely to develop ways of working which serve as social defence mechanisms against some of the pain and anxiety. Miller et al. (1972) suggest that in the institutions they studied, certain patterns repeated themselves so consistently that it was possible to identify two quite distinct approaches to residential care, reflecting two opposed ideologies, which they call the ‘warehousing model’ and the ‘horticultural model’. In the ‘warehousing’ model, there was a tendency for residents to be regarded as completely dependent, not only physically but also emotionally, and the staff focus was on prolonging physical life, with attempts by residents to display independence likely to be discouraged. Less commonly, the ‘horticultural’ model appeared to operate more on the assumption that the residents were ‘really normal’ and a related tendency to deny the extent of dependency, with staff focusing more on encouraging the individual development of residents in the direction of greater independence. While the ‘horticultural’ model may have much to be preferred over the ‘warehousing’ model, Miller et a/. (1972) point out that in the light of the realistic prognosis for most residents, both these approaches were inadequate. Rather, they suggest that there should be opportunities for residents to be able to move backwards and forwards between sets of activities which separately cater for their dependenf and independent needs. In addition, such institutions should also give more explicit attention to their usually unacknowledged task-of providing support for the individual in coming to terms with the realities of his remaining life. What emerges from this analysis, therefore, is a new organisafional design distinguishing at least three sub-systems of activity with different functions: that is, a system for psychophysical dependency (nursing care and occupational therapy); a system for psychophysical independence (valued work); and a system for support (external counselling); together with an overall management process for the institution as a whole, distinct from the management of these three functions. This analysis has some similarities with a third example based on another study by my colleagues (Dartington et a/., 1974) of geriatric hospitals and the stress on nurses associated with the philosophy of ‘Progressive Patient Care’. Again looking at the relationship between the hospital and the community in ‘open system’ terms, particularly through studying the processes of referral, treatment and
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discharge, it became clear that while the hospital was overtly there to provide treatment, which the ideology of ‘Progressive Patient Care’ emphasised, it was often also being asked by the outside society to remove old people who constituted problems for others. Staff commonly had to deal, therefore, with the ambivalent feelings of the patient’s family and other representatives of the community, as well as within the patient himself about whether to strive to get better or to accept decline. A particular source of stress for nursing staff in this situation was the conflict between pushing patients to be independent, as doctors were likely to demand, and wanting to look after patients in ways likely to encourage continuing dependency. Moreover, through looking at the total system of care for these elderly people, it was possible to identify how each agency involved-the family, general practitioner, social services and hospital-engaged in processes of negotiation aimed at protecting their own scarce resources of time or beds. Despite good intentions, then, this bargaining could easily mean that some patients were, in effect, dealt with as problems to be ‘dumped’ from one agency to another. For example, it was not uncommon for general practitioners to edit the information they presented in referring patients, in such a way as to emphasise the medical aspects of the case to the neglect of various social factors, which might only become more apparent when the hospital sought to discharge the patient again. In short, the socio-medical approach of ‘Progressive Patient Care’ could easily be undermined by the way this system actually worked. One important conclusion of this study, therefore, was that tackling the problems faced by the hospital might well requirejoint work with all the agencies involved, so as to reduce the discrepancies between what these agencies were actually doing, and what was expected of them; and also to encourage resources to be provided to fit the needs of the elderly in the community, not vice versa. Implications for change
Building on these observations it is now possible to show how the ‘social systems’ approach also illuminates the problem of achieving change in nursing care. As noted earlier, my role as Social Research Advisor to the Hospital Innovation Project gave me the chance to work with staff in tackling a wide range of problems which they saw their hospital as facing. A number of these projects were focused directly on trying to improve patient care at ward level, while others engaged with issues of hospital organisation, management roles and staff training. A comparative analysis of all these projects has provided a fuller understanding of how HIP contributed to the processes of service development (Towel1 et al., 1978). Drawing on this analysis of innovation in psychiatric care and the examples which have been discussed, a set of more general observations about how informed change can be fostered in health care systems can be summarised. These observations are, of course, mainly grounded in research on long term care, although some points may be of rather wider relevance to the current situation of the National Health Service (NHS). First, through adopting the kind of systemic approach which has been outlined, it is clear that changing practices in order to improve patient care can entail, or be assisted by, changes in a wide range of contributory factors. In the admission ward example, attention was drawn to the inter-relationship of organisational structure, treatment ideology and
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the pattern of nurse training in shaping nursing responses to patients. More generally, this and other work has illustrated the relevance of such factors as the number and skills of staff available, the physical environment and associated facilities, the equipment and techniques employed, and the pattern of management and collaboration between the professions and others involved in care. Moreover, perception of the need to change existing practices can arise from a wide variety of influences both inside and outside the health system in question. It follows that successful change is likely to be fostered by attempts to generate mutually reinforcing action through professional, administrative, educational and other channels, and at a number of different levels of health care organisation, from the ward or primary care team upwards. Put another way, attempts to change a particular element of nursing care, for example the nurses’ role in relationship to patients, are unlikely to be productive if account is not taken of the interdependence of this and other elements of the system, for example, the nurse’s relationship to the doctor and the wider pattern of management which defines the tasks nurses are there to perform. Recent examination of the reasons for deficiencies in the nursing care of long-stay patients, like that in the Report of the Committee of Enquiry at St Augustine’s Hospital (1976), provide a useful illustration of the importance of this principle. Second, and as an extension of this point, it is clear that since the hospital is only one part of the total system of patient care, it follows that what is done in the hospital will be affected by, and will affect what is done in other parts of this system, to the extent that changes in the relationships between all these parts, as represented for example in the process of admission, may often be a necessary condition for other changes within the hospital. As the study of geriatric hospital care illustrates, it is important therefore that efforts to produce change focused on the hospital should keep in mind the relationship between this and the contribution of the social services, the general practitioner, and the family to patient care-so that improvements in one area are not gained at the expense of deterioration elsewhere (Towel1 and Dartington, 1976). For example, one valuable set of innovations in an HIP project concerned with psychogeriatric care was an experiment in the joint management of beds between a ward and the social work team in the area this ward served, combined with a considerable extension of the nurse’s role across the ward boundary, so that nurses were involved in domiciliary assessment prior to admission or the provision of care in the home. All this made possible a significant change in the approach to care adopted within this ward (Savage, Widdowson and Wright, 1978). My third and fourth points are concerned with the implications of the ‘social systems’ approach for an understanding of the management and organisation of health care, and how this can encourage staff participation in the process of innovation. HIP has entailed the development of new ways in which staff at all levels can use their own initiative to seek and implement informed change. Experience elsewhere, however, particularly in very large institutions, and perhaps more generally in the reorganised NHS when one comes to look at the organisation of services to particular groups of clients, has suggested that often there is a great deal of confusion about who is managing what, and how a structure based on professional discipline and geographical areas can be put together to provide coordinated services which cross-cut professional and geographical divisions. Correspondingly, staff may easily feel lost in this wider confusion, unable to get a real
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grasp on what can be done to effectively tackle problems which they come up against. In this context, we have taken the view (particularly Miller, 1978) that the main function of the management of successively wider systems is to define jointly with staff the task of the system, and then seek to provide the boundary conditions within which participants working in it can manage their own work so as to perform this task most effectively. Translating this principle into the case of psychiatric care, HIP has suggested that the organisational conditions required to facilitate informed innovation are likely to include: first, a situation in which different professions co-operate together in treatment teams where the interdependence of their contributions is recognised, and where a participative mode of working seeks to ensure that the experience and skills of all staff are positively mobilised in patient care; second, sufficient decentralisation in the management of services to permit effective collaboration with other agencies and staff initiative in responding to problems which arise; and third, a multi-disciplinary management group for the institution as a whole, able to provide authoritative sanction for the efforts made by lower level staff to bring about improvements, and demonstrating through their own leadership that top managers regard themselves as part of the system to be changed (Towell, 1978a). Following on from this, the fourth general point, which again all discrete HIP projects have served to demonstrate, is the basic principle that the main asset available to the Health Service is the commitment and contribution of the staff directly involved in providing care, and clearly their motivation is essential to bring about improvements. Strategies of change therefore need to start from how care staff are themselves defining the situation, and then help them to discover their own capacity to achieve innovation. This, in turn, implies providing opportunities for groups of staff to critically examine existing practices, and themselves initiate better methods of care and ways of working. Here it is often likely to be most appropriate, because of the interdependence of their contributions, if the multi-disciplinary teams providing patient care are together the prime movers in considering possible changes. The fifth point relates to the psychodynamics of organisational processes. We have seen, in each of the earlier examples, how an arrangement of activities set up to perform a task also provides apattern of defences for those who have to face the stresses involved in that task. An appreciation of the dynamics of such processes can be helpful therefore in understanding the obstacles to change, and indicate the need for alternative forms of support during any transition processes which are likely to undermine such defences. Thus, experience suggests that the implementation of new practices of care, especially where this requires changes in professional roles and attitudes, is likely to provoke considerable opposition among staff because of the disruption of established ways of working and social relationships entailed, the guilt which may derive from the unfavourable reflection on past activities which innovation often implies, and other challenges to the existing socially-structured defences against anxiety. For example, these difficulties are particularly likely to arise in efforts to improve geriatric hospital care because of the way in which hospital staff in their work have to cope with the ambivalence about old people which exists in society outside, and the conflicts between the various parties involved in the total system of care to which attempts to deal with the ‘geriatric problem’ give rise. It follows therefore that groups of staff engaged in innovation are likely to require adequate support in overcoming these difficulties and successfully working through the emotional issues involved. In the HIP projects for example, a key aspect of the change
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strategy was the provision of opportunities for staff in a protected forum to review their own activities, consider problems and alternative solutions, experiment with new practices, monitor these experiments and implement the decisions reached. Finally, it should perhaps be emphasised that these points underline what many staff may have learnt from experience-namely that achieving innovation in nursing care, even under favourable conditions, is likely to be a complex, lengthy and difficult process. Efforts to apply these ideas in any new programmes designed to encourage improvements in care should therefore take account of relevant contingencies, motivations and resources in seeking to shape the optimum strategies for each situation. In broad terms, it has been suggested that the staff involved should be stimulated to examine their own work, have the opportunity to draw on the experience of others, and be provided with the support necessary to work through the problems entailed in successfully bringing about change. Within the hospital, each of these functions can be fulfilled through the exchange of experience among staff and the role taken up by managers during the process of change. Another significant resource, too often neglected, is the experience of staff in other hospitals, sometimes not far away, who may be facing similar problems. In addition, I have naturally emphasised the potential role for action research, both in helping staff achieve a better understanding of health care issues, and also providing, at least on a transitional basis, some of the support required in efforts to bring about improvements. At the same time I have sought to illustrate how the ‘social systems’ approach has guided some variety of endeavours towards these objectives. Not everyone of course will want to become action researchers; and clearly there are other conceptual frameworks through which nursing care can be understood. Whatever our approach, however, nursing researchers can share the basic aspiration of seeking-through careful study and analysis of alternative practices and their impact on patient care-to help nurses make more informed choices about the future patterns of nursing. Acknowledgements-As
will be clear, the ideas in this paper draw heavily on the author’s participation with colleagues in the ‘social systems group’ of the Tavistock Institute of Human Relations, and particularly the work of Eric Miller, who has been a continuing source of support and intellectual stimulation in my own thinking on these issues. I am also indebted to the many staff involved in the Hospital Innovation Project who have given me the opportunity to develop these ideas through sharing in their experiences of trying to bring about improvements in care. An earlier version of this paper was presented at the Annual Conference of the Royal College of Nursing Research Society (London, 1977).
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A ‘social systems’approach to research and change in nursing care DAVID TOWELL, M.A., Ph.D. King’s Fund Cen tre, 126 Albert Street, London NW1 lNF, England.
Introduction
This paper addresses three key concerns in the development of nursing research in the United Kingdom. First, there is the concern with encouraging more and better research which focuses precisely on nursing care. Bond (1975) has argued that the relative mushrooming of research related to nurses and nursing in recent years has still left largely neglected the study of “the practice of nursing as it pertains to patient care”. This neglect is gradually being corrected, but there seems to be every reason for seeking to encourage further work which builds on the progress which is being made. Second, there is the concern with the utilisation of nursing research in improving nursing practice. The general interest here, associated with the idea of nursing as a “research based profession” (Lancaster, 1973, is in the extent to which what is learnt from research is widely disseminated and used by practising nurses. More specifically there is also the question of how far particular research projects have themselves involved an application phase, in which the researchers assist in the development and testing of alternative methods. Certainly it was the case that even on well researched problems, rather few examples could be found of experimental approaches (Simpson, 1971) and Hockey (1974) more recently has argued the importance of giving greater attention to ‘action research’ strategies, in her review of research into nursing services. However, there is still great scope for development in this direction. Third, there is the concern with developing appropriate conceptual frameworks to guide research and innovation in nursing care, and to provide a better understanding of nursing practide. Again, past research in nursing has commonly been criticised for the absence of much theoretical sophistication, although this too may be changing (Inman, 1975; Fagerhaugh and Strauss, 1977). It will be gathered from the title of this paper that 1 want simultaneously to address these three concerns; and to suggest that a particular conceptual framework, which I shall call a ‘social systems’approach, provides a means of linking research with the problem of change in nursing care. However, this is not an attempt at theoretical imperialism. Rather, some ideas grounded in my own direct experience of research on patient care over 111
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the past 10 yr are presented for wider exarnination. This is also not a comprehensive framework. At best, 1 would argue that the ‘social systems’ approach, through seeking to engage in a ‘holistic’ way with key features of the organisation and delivery of care, provides a useful complement to the more common ‘atomistic’ studies which try to measure the impact of a variety of variables on a particular element of nursing care, examined to some extent in isolation. (For example, the early Royal College of Nursing studiesMcFarlane, 1970). The main aspects of my own research experience on which 1 intend to draw can be briefly outlined. My first substantial piece of work was the detailed study of psychiatric nursing practice which the RCN subsequently published as Understanding Psychiatric Nursing (Towell, 1975). In this project I adopted a social anthropological approach, involving more than 3 yr ‘participant observation’ in a single hospital, during which intensive field studies were undertaken on nursing in short-stay admission wards, long-stay geriatric wards, and a specialised ward being developed as a ‘therapeutic community’. In this way it was possible to build up a detailed understanding of everyday life in this hospital, and come to appreciate the meanings which nurses themselves gave to their work and their relationships with patients in these various ward settings. At the descriptive level, these studies showed the extent of the differences in the psychiatric nurse’s work in various contexts and examined the difficulties nurses face in more adequately realising the ‘personal relationships’ aspect of their role in psychiatric treatment. The project as a whole also provided a set of working hypotheses about the relationships between organisational factors, alternative approaches to treatment, staff training and the nurses’ contribution to patient care, in different types of ward. At the time of publication, it was claimed that this study should have practical relevance to those concerned with hospital organisation, the treatment of psychiatric patients and the training of psychiatric nurses. I was unusually fortunate in then having the opportunity to test this proposition myself, because my second major piece of work was an action research project in collaboration with staff of the same hospital, which has aimed to develop new ways of involving staff in efforts to achieve informed improvements in patient care. The central feature of this work has been the creation of a new role in the hospital, that of Social Research Advisor, through which assistance can be made available to any group of staff concerned to investigate.problems arising in their own work, and prepared to use the results of such investigations in trying to change existing aspects of hospital organisation and practice. I filled this advisory role in the 2-yr pilot phase of what has come to be called the ‘Hospital fnnovation Project’(HIP). Subsequently the hospital has sought to institutionalise the approach, so that now after 6 yr this work is still developing, and some of the key ideas are being utilised in other service-development programmes on a wider scale. The staff involved have recently completed a full analysis of this Project (Towell and Harries, 1978) and several articles describing particular initiatives have already been published in appropriate nursing journals. (Aitken el al., 1974; Fenn, Mungovan and Towell, 1975; Harries, 1974; Savage and Widdowson, 1974; Savage and Wright, 1976). This work on innovation in psychiatric care was largely developed while I was part of a small group of staff at the Tavistock Institute of Human Relations engaged in a wider programme of action research in health care systems, including projects concerned with patterns of care in residential institutions for the physically handicapped (Miller and Gwynne, 1972), the processes involved in the hospitalisation of old people (Dartington,
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Jones and Miller, 1974), the psychological welfare of children in long-stay hospitals (Menzies-Lyth, Henry and Dartington, 1977) and the social rehabilitation of the mentally handicapped. Building on earlier Tavistock work, this programme has led to the development of a more or less common theoretical approach, the key aspects of which were reflected in our own designation within the Institute as the ‘Social Systems Group’. This paper outlines the main elements in the ‘social systems’ approach to understanding patient care; enlarges on this outline with illustrations from studies of different kinds of care; and, drawing particularly on my own experiences of HIP, examines the relevance of this approach to processes of change. The ‘social systems’ approach
Most of the work in which the ‘social systems’ approach has been developed entailed not only conducting research on health care issues, but also becoming involved in implementing change and confronting the problems that arise in trying to use social research. Typically then, these projects have implied an action research strategy: implying work carried out in a collaborative relationship with practitioners, in which the intention is both to contribute to the resolution of practical problems and to increase understanding of the issues being studied. Here, of course, fresh conceptualisations of problems may in themselves help to increase the awareness and widen the choices of the staff with whom we work; while the willingness to become involved in their efforts to bring about change provides further opportunities for illuminating the issues in question, and sometimes testing theoretical propositions. It follows that the roles taken up by action researchers may extend rather beyond what is common in academic social research, implying a closer working relationship and often the provision of support to those directly involved in the process of innovation. This methodological commitment has been described at the outset because the action research roles we have adopted have been an important influence on the kind of theoretical understanding which has been generated in this work. It is clear, for example, that starting with this commitment, action researchers are likely to be predisposed to formulate their analysis of issues in ways which link up to the problems likely to be involved in achieving informed change. Turning to the ‘social systems’ approach itself, it is worth noting that any attempt to understand significant health care issues is likely to be a complex undertaking, requiring attention, for example, to the interaction between patients and a variety of therapeutic staff; the tasks, technology and organisational arrangements through which services are provided; the social and psychological influences on the patient’s experiences during his contact with health agencies; and often other specific issues arising in relation to particular aspects of care. In this situation, any conceptual framework must have the function of focusing attention on some features of the total complexity, at the expense, naturally, of not attending to other features, which alternative frameworks might encompass more readily. In this sense then, conceptual frameworks provide an orientation to the subject of study, out of which more precise hypotheses can be generated during the process of field research. In the case of the ‘social systems’ approach, there are three core elements in this orienting framework. First, and drawing on a Weberian ‘social action’ perspective (Eldridge, 1971; Silverman,
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1970), our starting point in any study is an interest in discovering how the various participants in a health care setting themselves ‘define the situations’ in which they are involved, and what purposes and norms guide their activities. This setting can then be viewed as an arena (Strauss et al., 1963) in which different professional, non-professional and client groups meet, each with their own perspectives and purposes, to work out, through negotiation, the courses of action which add up to more or less enduring patterns of work and forms of organisation. These processes of interaction of course both reflect and are influenced by a variety of structural conditions, including the previous division of labour and distribution of power between the groups involved, and the technical and personal resources available for the tasks in question. In analysing the structure of health care organisations, the second core e!ement of this approach has been drawn from modern organisation theory. In particular, we have found it useful to adopt, at least as a heuristic device, what can be described as an ‘open systems’ model (Miller and Rice, 1967; Miller, 1976). At its most basic, the ‘open systems’ model invites attention to the inter-relatedness of various aspects of the internal functioning of organisations with each other and with factors in the organisation’s environment. A key aspect of this relationship between the organisation and its environment is the nature of its throughput; what is imported into the organisation from outside, how this is converted, and what is then exported back. In the case of hospitals, the main throughput is usually patients, who may be successfully treated and returned to active roles in society. The activities through which this is achieved can often be differentiated into a number of constituent sub-systems, each with their own import-conversion-export processes, and to some extent separable from other sub-systems of the organisation. Again, to take the hospital example; the ward, the pharmacy and the laundry, might all be so identified. Examination of possible alternative forms of organisation can then proceed through considering different ways in which boundaries can be drawn round sets of activities in order to achieve particular tasks. A nursing example would be the choice between assigning ward nursing activities by allocating patients or allocating discrete duties to the staff available. Or, on a larger scale, there is the choice involved in grouping wards into functional or geographical nursing units. Organisational design also requires identifying how transactions across these subsystem boundaries, and between the total organisation and its environment, can best be managed. It is questions of this kind, for example, which are tied up in the current debate in hospitals about the appropriate relationship between sector and functional management. The third core element of our approach involves complementing this sociological analysis with insights drawn from a psychodynamic perspective on group and organisational processes (Menzies, 1960; Bion, 1961). It is recognised that participants bring to organisations more than just the role-related aspects of their selves; they are present as people whose current attitudes and actions may reflect, not necessarily consciously, the precipitate of many previous experiences. In the case of nursing, the distinctive features of the task of caring, e.g. the extent of the patient’s dependence on the nurse, are likely to generate considerable anxieties and the way these are dealt with will be an important determinant of the patterns of interaction. These dynamic processes also enter into inter-group relationships, as can sometimes be seen in the conflicts which arise between the different professions caring for the same group of patients; and over time, the whole functioning of an institution may be shaped to support a particular set of defences against anxiety, as Menzies (1960) has illustrated most clearly in her classic study of general nursing. In thus seeking to understand some of the irrational aspects of the way organisations work, some of the
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difficulties in achieving social change are also identified, since ideas or innovations which threaten established defences are themselves likely to increase anxiety among those likely to be affected. Examples from different health care systems
These three elements of the ‘social systems’ approach, and how they are integrated together, can best be explained through some more detailed illustrations from the different kinds of health care setting in which we have undertaken action research projects. The significance of the first theme, that of beginning by trying to discover how participants in a setting are, themselves, defining the situations in which they are involved, is perhaps best brought out in those settings where what is going on is by no means apparent just on the basis of ‘common sense’. In the case of psychiatric nursing, for example, it could be suggested that the central problem for staff is precisely that of how they can make sense of the perplexing behaviour of patients and give meaning to their own work, in a variety of anxiety provoking situations. The first stage of my own research with psychiatric hospitals, described in more detail in Understanding Psychiatric Nursing (1975), tries to provide some illumination of this problem. In particular, by comparing observations across a range of wards where approaches to treatment differ, I argue that the nurse’s response to patients can be understood as arising from the interaction between interpretations they put on the patient’s behaviour and concerns they derive from their roles on the ward: these interpretations and concerns in turn reflecting respectively the way nurses adapt the prevailing ideologies of treatment and the patterns of ward organisation. For example, in an admission ward where treatment was largely based on somatotherapeutic techniques (drugs and electro-convulsive therapy), I discovered how the hierarchical and centralised organisation of the ward for ‘medical servicing’ of patients and the responsibilities for 24-hr staffing gave nurses a key linking role between patients and most other aspects of the hospital. From this role arose their dominant concerns with managing patients so as to maintain the ward schedule, and also ensuring as an adjunct of the doctor that somatic treatment was effectively provided. At the same time nurses gave meaning to the actions of patients through interpretations based upon the ‘medical model’, using diagnostic categories and symptomatic descriptions to make sense of recurrent situations which they confronted and provide a guide to the kinds of problems which could be anticipated. This medical treatment ideology was adapted however so that, for example, terms like ‘disturbed’ neatly aligned the nurses’ twin concerns with treatment and keeping order, through both describing the patient’s condition and justifying the nursing response. This analysis of the relationship between ward organisation, treatment ideology and the nurse’s contribution to patient care was further tested and illuminated in the later action research project with this hospital, when I was able to work with staff on the same ward during a period in which leading members were trying to develop a more ‘social psychiatric’ approach to treatment (Towell, 1978b). This later work also demonstrated the importance of new training arrangements on the ward in providing the support required if nurses were to adopt the more extended roles in relation to patients which this new approach to treatment entailed. While some elements of a systematic analysis can be seen in this work, the further importance of attending to the relationship between an organisation and its environment in
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‘open system’ terms, is more clearly evident in a second example, which comes from a study of residential instutions for the disabled, undertaken by my Tavistock colleagues (Miller et a/., 1972). Examination of the import-conversion-export processes in these institutions suggested that an important characteristic of the residents admitted to them was that they were not merely severely handicapped and unable to look after themselves, but also rejected, sometimes personally, by relatives who had previously been looking after them, and always socially, in the sense that they were defined as no longer having a valued role in the community outside. Moreover, once cripples were admitted, they were unlikely to be discharged again, except through death. Given this form of export, it is not surprising that participants found difficulty in agreeing upon the main purpose of these institutions, and there was particular difficulty in coming to terms with the function which society implicitly assigns-that of coping with the crippled in the period between social rejection and physical death, which may be a period of many years. These realities are very hard to face, for staff and residents alike. Consequently, these institutions were likely to develop ways of working which serve as social defence mechanisms against some of the pain and anxiety. Miller et al. (1972) suggest that in the institutions they studied, certain patterns repeated themselves so consistently that it was possible to identify two quite distinct approaches to residential care, reflecting two opposed ideologies, which they call the ‘warehousing model’ and the ‘horticultural model’. In the ‘warehousing’ model, there was a tendency for residents to be regarded as completely dependent, not only physically but also emotionally, and the staff focus was on prolonging physical life, with attempts by residents to display independence likely to be discouraged. Less commonly, the ‘horticultural’ model appeared to operate more on the assumption that the residents were ‘really normal’ and a related tendency to deny the extent of dependency, with staff focusing more on encouraging the individual development of residents in the direction of greater independence. While the ‘horticultural’ model may have much to be preferred over the ‘warehousing’ model, Miller et a/. (1972) point out that in the light of the realistic prognosis for most residents, both these approaches were inadequate. Rather, they suggest that there should be opportunities for residents to be able to move backwards and forwards between sets of activities which separately cater for their dependenf and independent needs. In addition, such institutions should also give more explicit attention to their usually unacknowledged task-of providing support for the individual in coming to terms with the realities of his remaining life. What emerges from this analysis, therefore, is a new organisafional design distinguishing at least three sub-systems of activity with different functions: that is, a system for psychophysical dependency (nursing care and occupational therapy); a system for psychophysical independence (valued work); and a system for support (external counselling); together with an overall management process for the institution as a whole, distinct from the management of these three functions. This analysis has some similarities with a third example based on another study by my colleagues (Dartington et a/., 1974) of geriatric hospitals and the stress on nurses associated with the philosophy of ‘Progressive Patient Care’. Again looking at the relationship between the hospital and the community in ‘open system’ terms, particularly through studying the processes of referral, treatment and
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discharge, it became clear that while the hospital was overtly there to provide treatment, which the ideology of ‘Progressive Patient Care’ emphasised, it was often also being asked by the outside society to remove old people who constituted problems for others. Staff commonly had to deal, therefore, with the ambivalent feelings of the patient’s family and other representatives of the community, as well as within the patient himself about whether to strive to get better or to accept decline. A particular source of stress for nursing staff in this situation was the conflict between pushing patients to be independent, as doctors were likely to demand, and wanting to look after patients in ways likely to encourage continuing dependency. Moreover, through looking at the total system of care for these elderly people, it was possible to identify how each agency involved-the family, general practitioner, social services and hospital-engaged in processes of negotiation aimed at protecting their own scarce resources of time or beds. Despite good intentions, then, this bargaining could easily mean that some patients were, in effect, dealt with as problems to be ‘dumped’ from one agency to another. For example, it was not uncommon for general practitioners to edit the information they presented in referring patients, in such a way as to emphasise the medical aspects of the case to the neglect of various social factors, which might only become more apparent when the hospital sought to discharge the patient again. In short, the socio-medical approach of ‘Progressive Patient Care’ could easily be undermined by the way this system actually worked. One important conclusion of this study, therefore, was that tackling the problems faced by the hospital might well requirejoint work with all the agencies involved, so as to reduce the discrepancies between what these agencies were actually doing, and what was expected of them; and also to encourage resources to be provided to fit the needs of the elderly in the community, not vice versa. Implications for change
Building on these observations it is now possible to show how the ‘social systems’ approach also illuminates the problem of achieving change in nursing care. As noted earlier, my role as Social Research Advisor to the Hospital Innovation Project gave me the chance to work with staff in tackling a wide range of problems which they saw their hospital as facing. A number of these projects were focused directly on trying to improve patient care at ward level, while others engaged with issues of hospital organisation, management roles and staff training. A comparative analysis of all these projects has provided a fuller understanding of how HIP contributed to the processes of service development (Towel1 et al., 1978). Drawing on this analysis of innovation in psychiatric care and the examples which have been discussed, a set of more general observations about how informed change can be fostered in health care systems can be summarised. These observations are, of course, mainly grounded in research on long term care, although some points may be of rather wider relevance to the current situation of the National Health Service (NHS). First, through adopting the kind of systemic approach which has been outlined, it is clear that changing practices in order to improve patient care can entail, or be assisted by, changes in a wide range of contributory factors. In the admission ward example, attention was drawn to the inter-relationship of organisational structure, treatment ideology and
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the pattern of nurse training in shaping nursing responses to patients. More generally, this and other work has illustrated the relevance of such factors as the number and skills of staff available, the physical environment and associated facilities, the equipment and techniques employed, and the pattern of management and collaboration between the professions and others involved in care. Moreover, perception of the need to change existing practices can arise from a wide variety of influences both inside and outside the health system in question. It follows that successful change is likely to be fostered by attempts to generate mutually reinforcing action through professional, administrative, educational and other channels, and at a number of different levels of health care organisation, from the ward or primary care team upwards. Put another way, attempts to change a particular element of nursing care, for example the nurses’ role in relationship to patients, are unlikely to be productive if account is not taken of the interdependence of this and other elements of the system, for example, the nurse’s relationship to the doctor and the wider pattern of management which defines the tasks nurses are there to perform. Recent examination of the reasons for deficiencies in the nursing care of long-stay patients, like that in the Report of the Committee of Enquiry at St Augustine’s Hospital (1976), provide a useful illustration of the importance of this principle. Second, and as an extension of this point, it is clear that since the hospital is only one part of the total system of patient care, it follows that what is done in the hospital will be affected by, and will affect what is done in other parts of this system, to the extent that changes in the relationships between all these parts, as represented for example in the process of admission, may often be a necessary condition for other changes within the hospital. As the study of geriatric hospital care illustrates, it is important therefore that efforts to produce change focused on the hospital should keep in mind the relationship between this and the contribution of the social services, the general practitioner, and the family to patient care-so that improvements in one area are not gained at the expense of deterioration elsewhere (Towel1 and Dartington, 1976). For example, one valuable set of innovations in an HIP project concerned with psychogeriatric care was an experiment in the joint management of beds between a ward and the social work team in the area this ward served, combined with a considerable extension of the nurse’s role across the ward boundary, so that nurses were involved in domiciliary assessment prior to admission or the provision of care in the home. All this made possible a significant change in the approach to care adopted within this ward (Savage, Widdowson and Wright, 1978). My third and fourth points are concerned with the implications of the ‘social systems’ approach for an understanding of the management and organisation of health care, and how this can encourage staff participation in the process of innovation. HIP has entailed the development of new ways in which staff at all levels can use their own initiative to seek and implement informed change. Experience elsewhere, however, particularly in very large institutions, and perhaps more generally in the reorganised NHS when one comes to look at the organisation of services to particular groups of clients, has suggested that often there is a great deal of confusion about who is managing what, and how a structure based on professional discipline and geographical areas can be put together to provide coordinated services which cross-cut professional and geographical divisions. Correspondingly, staff may easily feel lost in this wider confusion, unable to get a real
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grasp on what can be done to effectively tackle problems which they come up against. In this context, we have taken the view (particularly Miller, 1978) that the main function of the management of successively wider systems is to define jointly with staff the task of the system, and then seek to provide the boundary conditions within which participants working in it can manage their own work so as to perform this task most effectively. Translating this principle into the case of psychiatric care, HIP has suggested that the organisational conditions required to facilitate informed innovation are likely to include: first, a situation in which different professions co-operate together in treatment teams where the interdependence of their contributions is recognised, and where a participative mode of working seeks to ensure that the experience and skills of all staff are positively mobilised in patient care; second, sufficient decentralisation in the management of services to permit effective collaboration with other agencies and staff initiative in responding to problems which arise; and third, a multi-disciplinary management group for the institution as a whole, able to provide authoritative sanction for the efforts made by lower level staff to bring about improvements, and demonstrating through their own leadership that top managers regard themselves as part of the system to be changed (Towell, 1978a). Following on from this, the fourth general point, which again all discrete HIP projects have served to demonstrate, is the basic principle that the main asset available to the Health Service is the commitment and contribution of the staff directly involved in providing care, and clearly their motivation is essential to bring about improvements. Strategies of change therefore need to start from how care staff are themselves defining the situation, and then help them to discover their own capacity to achieve innovation. This, in turn, implies providing opportunities for groups of staff to critically examine existing practices, and themselves initiate better methods of care and ways of working. Here it is often likely to be most appropriate, because of the interdependence of their contributions, if the multi-disciplinary teams providing patient care are together the prime movers in considering possible changes. The fifth point relates to the psychodynamics of organisational processes. We have seen, in each of the earlier examples, how an arrangement of activities set up to perform a task also provides apattern of defences for those who have to face the stresses involved in that task. An appreciation of the dynamics of such processes can be helpful therefore in understanding the obstacles to change, and indicate the need for alternative forms of support during any transition processes which are likely to undermine such defences. Thus, experience suggests that the implementation of new practices of care, especially where this requires changes in professional roles and attitudes, is likely to provoke considerable opposition among staff because of the disruption of established ways of working and social relationships entailed, the guilt which may derive from the unfavourable reflection on past activities which innovation often implies, and other challenges to the existing socially-structured defences against anxiety. For example, these difficulties are particularly likely to arise in efforts to improve geriatric hospital care because of the way in which hospital staff in their work have to cope with the ambivalence about old people which exists in society outside, and the conflicts between the various parties involved in the total system of care to which attempts to deal with the ‘geriatric problem’ give rise. It follows therefore that groups of staff engaged in innovation are likely to require adequate support in overcoming these difficulties and successfully working through the emotional issues involved. In the HIP projects for example, a key aspect of the change
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strategy was the provision of opportunities for staff in a protected forum to review their own activities, consider problems and alternative solutions, experiment with new practices, monitor these experiments and implement the decisions reached. Finally, it should perhaps be emphasised that these points underline what many staff may have learnt from experience-namely that achieving innovation in nursing care, even under favourable conditions, is likely to be a complex, lengthy and difficult process. Efforts to apply these ideas in any new programmes designed to encourage improvements in care should therefore take account of relevant contingencies, motivations and resources in seeking to shape the optimum strategies for each situation. In broad terms, it has been suggested that the staff involved should be stimulated to examine their own work, have the opportunity to draw on the experience of others, and be provided with the support necessary to work through the problems entailed in successfully bringing about change. Within the hospital, each of these functions can be fulfilled through the exchange of experience among staff and the role taken up by managers during the process of change. Another significant resource, too often neglected, is the experience of staff in other hospitals, sometimes not far away, who may be facing similar problems. In addition, I have naturally emphasised the potential role for action research, both in helping staff achieve a better understanding of health care issues, and also providing, at least on a transitional basis, some of the support required in efforts to bring about improvements. At the same time I have sought to illustrate how the ‘social systems’ approach has guided some variety of endeavours towards these objectives. Not everyone of course will want to become action researchers; and clearly there are other conceptual frameworks through which nursing care can be understood. Whatever our approach, however, nursing researchers can share the basic aspiration of seeking-through careful study and analysis of alternative practices and their impact on patient care-to help nurses make more informed choices about the future patterns of nursing. Acknowledgements-As
will be clear, the ideas in this paper draw heavily on the author’s participation with colleagues in the ‘social systems group’ of the Tavistock Institute of Human Relations, and particularly the work of Eric Miller, who has been a continuing source of support and intellectual stimulation in my own thinking on these issues. I am also indebted to the many staff involved in the Hospital Innovation Project who have given me the opportunity to develop these ideas through sharing in their experiences of trying to bring about improvements in care. An earlier version of this paper was presented at the Annual Conference of the Royal College of Nursing Research Society (London, 1977).
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