Biopolitics, space and hospital reconfiguration

A matter of (good) faith? Understanding the interplay of power and the moral agency of managers in healthcare service reconfiguration

Previous studies of service reconfiguration in healthcare have explored the influence of power on processes and outcomes. However, in these accounts the moral agency of managers is often underemphasised. This paper draws on the theoretical tools provided by the sociology of morality to help deepen understanding of the interaction between power and moral agency in service reconfiguration in healthcare. It presents results from a qualitative study of a pan-organisational service reconfiguration in the NHS in England, involving nineteen in-depth interviews with those leading the change and the analysis of twelve programme documents. We combine concepts of the moral background and epistemic governance to interpret participants' conviction that the service change was 'the right thing to do'. The paper shows how epistemic work carried out by service change regulations shaped the moral background within which participants worked. This, in turn, channelled their moral agency - specifically their commitment to patient care - in a way that also reflected central priorities. The paper adds to sociological understandings of service reconfiguration through considering the interaction of structure, agency and power, while also developing the concept of the moral background to show how power relations can influence moral beliefs.

Certified Registered Nurse Anaesthetists' and Critical Care Registered Nurses' perception of knowledge/power in teamwork with Anaesthesiologists in Sweden: a mixed-method study

Efficient teamwork is crucial to provide optimal health care. This paper focuses on teamwork between Anaesthesiologists (ANES), Certified Registered Nurse Anaesthetists' (CRNA) and Critical Care Registered Nurses (CCRN) working in challenging environments such as the intensive care unit (ICU) and the operating room (OR). Conflicts are common between physicians and nurses, negatively impacting teamwork. Social hierarchies based on professional status and power inequalities between nurses and physicians plays a vital role in influencing teamwork. Foucault was a famous thinker especially known for his reasoning regarding power/knowledge. A Foucauldian perspective was therefore incorporated into this paper and the overall aim was to explore CCRN/CRNA perception of knowledge/power in teamwork with ANES.Methods A mixed-method approach was applied in this study. Data was collected using a web-based questionnaire containing both closed-end and open-ended questions. A total of 289 CCRNs and CRNAs completed the questionnaire. Data analysis was then conducted through five stages as outlined by Onwuebugzie and Teddlie; analysing quantitative data in SPSS 27.0 and qualitative data with a directed content analysis, finally merging data together in ATLAS.ti v.23.Results The result reveals a dissonance between quantitative and qualitative data; quantitative data indicates a well-functioning interdisciplinary teamwork between CCRN/CRNA and ANES - qualitative data highlights that there are several barriers and inequalities between the two groups. Medicine was perceived as superior to nursing, which was reinforced by both social and organisational structures at the ICU and OR.Conclusion Unconscious rules underlying current power structures in the ICU and OR works in favour of the ANES and biomedical paradigm, supporting medical knowledge. To achieve a more equal power distribution between CCRN/CRNAs and ANES, the structural hierarchies between nursing and medicine needs to be addressed. A more equal power balance between the two disciplines can improve teamwork and thereby reduce patient mortality and improve patient outcomes.

The Pervasiveness of Power: Dilemmas for Researchers of Major System Change in Healthcare Comment on "'Attending to History' in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration"

To study major system change (MSC) in healthcare, it is crucial to consider the influence of power. Despite this, dominant perspectives on MSC in healthcare present these as relatively neutral processes, where reconfigurations are logical solutions to clearly defined problems. Perry and colleagues' paper adds to a growing body of research which challenges the presentation of MSC as neutral, managerial processes, instead identifying how power dynamics lie at the heart of why service change happens, how it unfolds, and its outcomes. However, the introduction of power considerations raises several overlapping methodological and ethical dilemmas for researchers, and questions regarding research design and dissemination. In this commentary, we use the insights generated by Perry et al to further explore these issues.

Negotiating body and power in forensic mental health care

Since the beginning of the 2000s, the reduction of coercive methods has been a tendency in psychiatric care in Finland. Combined with the transforming ideas of healing, the reduction has changed practices in the institutions of forensic mental health care, by encouraging efforts to increase self-determination and individual responsibility. This article addresses the coexistence of the previous and current bodily regimes, and the resulting complex and contested spatial and bodily arrangements. We combine the discussions on biopower and bodily regimes in our analysis of the practices and negotiations related to the alternative methods to coercion (special observation and restricting garments), mundane practices (eating and exercising), and negotiations related to touch and sexuality. As our study shows, bodily regimes and care practices are constantly under negotiation, during which there may be inconsistences in what is or is not allowed. Moreover, what seems to be a positive tendency towards increased self-determination has led to new forms of pressure, resulting from the increased possibility to protest by using one’s own body (e.g. by ignoring hygiene), or from the diminishing self-determination of the nurses (e.g. during special observation).

Loss associated with subtractive health service change: The case of specialist cancer centralization in England

OBJECTIVE

Major system change can be stressful for staff involved and can result in 'subtractive change' - that is, when a part of the work environment is removed or ceases to exist. Little is known about the response to loss of activity resulting from such changes. Our aim was to understand perceptions of loss in response to centralization of cancer services in England, where 12 sites offering specialist surgery were reduced to four, and to understand the impact of leadership and management on enabling or hampering coping strategies associated with that loss.

METHODS

We analysed 115 interviews with clinical, nursing and managerial staff from oesophago-gastric, prostate/bladder and renal cancer services in London and West Essex. In addition, we used 134 hours of observational data and analysis from over 100 documents to contextualize and to interpret the interview data. We performed a thematic analysis drawing on stress-coping theory and organizational change.

RESULTS

Staff perceived that, during centralization, sites were devalued as the sites lost surgical activity, skills and experienced teams. Staff members believed that there were long-term implications for this loss, such as in retaining high-calibre staff, attracting trainees and maintaining autonomy. Emotional repercussions for staff included perceived loss of status and motivation. To mitigate these losses, leaders in the centralization process put in place some instrumental measures, such as joint contracting, surgical skill development opportunities and trainee rotation. However, these measures were undermined by patchy implementation and negative impacts on some individuals (e.g. increased workload or travel time). Relatively little emotional support was perceived to be offered. Leaders sometimes characterized adverse emotional reactions to the centralization as resistance, to be overcome through persuasion and appeals to the success of the new system.

CONCLUSIONS

Large-scale reorganizations are likely to provoke a high degree of emotion and perceptions of loss. Resources to foster coping and resilience should be made available to all organizations within the system as they go through major change.

An unproblematized truth: Foucault, biopolitics, and the making of a sociological canon

Foucault’s argument that a major break occurred in the nature of power in the European Eighteenth century—an unprecedented socialization of medicine and concern for the health of bodies and populations, the birth of biopolitics—has become since the 1990s a dominant narrative among sociologists but is rarely if ever scrutinized in its premises. This article problematizes Foucault’s periodization about the politics of health and the way its story has been solidified into an uncritical account. Building on novel historiographic work, it challenges the modernist bias of histories of biopolitics and public health and considers an earlier and more plural history of collective practices of health of which the story told by Foucault is just one important episode. Finally, it discusses the implications of this revised model for wider sociological debates on the link between modernity, health and the body.

The contingencies of medical restratification across inter-organisational care networks

The contemporary social organisation of medical work is characterised by internal hierarchies and stratification in the form of professional elites and managerial hybrids. This paper examines the changes in medical restratification brought about by the introduction of inter-organisational care networks. The study focuses in particular on the social position of doctors and the contingencies that enable or constrain intra-professional hierarchies across inter-organisational boundaries. This ethnographic study of major system change within the English healthcare system finds that a relatively small group of 'multiplex' elites have significant influence in both national policy-making and regional service re-configuration based upon multiple sources of clinical and reputational capital. Subsequent forms of restratification at the regional level are found to mirror such status markers whilst also revealing important local contingencies, especially where professional markers of distinction are coupled with and dependent upon organisational markers of distinction.

The Whole Lifecycle Management Efficiency of the Public Sector in PPP Infrastructure Projects

The management role of the public sector in public–private partnership PPP infrastructure projects has been extensively expanded to the whole lifecycle rather than in the traditional infrastructure projects. The performance of the public sector in a PPP is the key for the PPP to achieve sustainability; however, there is a lack of research on the whole lifecycle management efficiency of the public sector in a PPP. This research aims to examine the governance role of the public sector in PPP projects, and therefore evaluate their whole lifecycle management efficiency. An evaluation framework is developed through the lens of governmentality to evaluate the performance of the public sector. Multiple case studies on PPP infrastructure projects in China have identified loopholes during the whole lifecycle of a PPP at the local governmental level. On the basis of the findings of case studies, a conceptual model is proposed to demonstrate ways for the public sector to improve efficiency through integrated governance of PPP projects. The research findings benefit both the central government in terms of evaluation and decision making and the local government by improving their efficiency in PPP infrastructure projects for the purpose of achieving sustainability. According to the findings, policy strategies are provided for the central government on how to further regulate the PPP market and address the loopholes, including further standardizing regulations and instruction, providing unified quantitative calculation or measurement tools, training, and education for the public sector to integrate whole lifecycle project management, and quality control of consultancy for the PPP infrastructure projects.