Nursing Practice and Organisational Change Within the NHS: A Critical Realist Methodological Approach to the Analysis of Discursive Data

Abstract

This methodological paper draws upon the results of a piece of qualitative research which explored nurses perceptions of the ways in which the organisational changes that occurred within the NHS over the past decade have mediated their working practices. This paper seeks to go beyond traditional forms of qualitative analysis in posing the question: Can the views and beliefs of social agents captured in social research inform a realist understanding of the social world? In addressing this question, the paper draws upon the insights of critical realist philosophy which takes as its central theoretical assumption, the interdependence of social structures and social interaction. This methodological approach conceptualises „discourse‟ (here defined as the articulation by social agents of their understanding of their world of social practices) as being as „real‟ as the structural interrelations to which it is materially linked through practice. Following Sayer (1997), analysing discourse in this way emphasizes its „performative‟ aspect rather than its representational aspect alone. Nevertheless, the accounts given by nurses as social agents are fallible and so interpretive analysis must involve a process of „theoretical transformation‟ or re-conceptualisation of these presentations of social practice. This paper sets out an analytical framework for the realist analysis of discourse which seeks to go beyond inductively or deductively-derived explanations of the social processes that shape nurses' working practices. Background The origins of this methodology paper lie in research conducted by the author, which was concerned with the impact of the organisational changes occurring within the NHS in the 1990‟s upon nursing practice. Nurses were then experiencing the consequences of new organisational priorities which were subjecting their practice to levels of managerial regulation and scrutiny not previously experienced by the profession. The working practices and attitudes of nurses were widely perceived by the Department of Health at the time to be old-fashioned and resistant to change, and therefore seen as representing an obstacle to the organisational goal of rationalisation and efficiency (DoH, 2002; Allen, 2001; Walsh and Gough 2000). The study itself sought to focus upon nurses‟ own perceptions of the ways in which these organisational changes mediated their working practices. The implicit aim of the research was to interrogate the nature of the interactive relationship that exists between structure and agency in the shaping of practice. This required firstly establishing what were the common (and deviant) themes that characterised the frames of meaning or „discourses‟ that these nurses drew upon in their day-to