Summary of the impact

Front-line nursing managers in French hospitals are often perceived, by themselves and others, as cogs in an administrative machine, trapped between conflicting demands for increased economic efficiency and health-care quality. Vaughan Rogers' work with ca. 180 managers, trainees and training officers in the Rhône-Alpes region's hospital service has challenged this perception. Within the framework of continuing professional development, he has enhanced nursing management's awareness of its capacity to influence the conduct of change in the profession and has inspired reinvigoration of the design of training programmes for this staff at the major Teaching Hospital for healthcare professionals in Grenoble.

Underpinning research

In 2007 Rogers (Lecturer 1983-99, Senior Lecturer 1999-) began his comparative research at the University of Edinburgh on reform in the French Hospital Service and the NHS (England). This research underpins his work with French nursing managers and has produced publications, co- authored with Philippe Mossé of the French National Scientific Research Council (CNRS, see 3.1, 3.2, 3.3).

Rogers's work on the NHS mainly involved analysis of primary and secondary documents. Conversely, knowledge exchange between other academics and practitioners enriched his research into the French system: the workshops he ran with healthcare staff provided him with a rare opportunity for lengthy exchanges with these professionals. "Getting inside" the organisation in this way led Rogers to a better understanding of the nature and context of their work.

His findings identify shortcomings in the dominant, top-down explanatory models of change, management and implementation. They also highlight the importance of looking beyond the centralised appearance of formal arrangements in order to understand the key role of sub-central actors in policy implementation. This approach illuminates the need for an explanatory model that is more open to uncertainty, critical tension and creative arrangements.

In the book co-authored with Mossé et al. (3.2), Rogers analyses the demonstrably unsatisfactory quality of care in some NHS hospitals, such as the Mid-Staffordshire Foundation Trust. He finds that poor quality care is an unintended consequence of local actors' predominant focus on ministerial economic efficiency targets, and that the failure of centralist regulation exacerbates this situation further. The 2009 study (3.1) of French Regional Hospital Agencies (Agences Régionales d'Hospitalisation) provides a more positive illustration of how sub-national actors can become policy substance providers, rather than simply executors of centrally-determined objectives. Rogers highlights the different ways in which sub-central actors can appropriate centrally- determined norms, which may themselves be mutually antagonistic. The focus on implementation reveals how actors respond to the uncertainty resulting from such pressures from the centre: they construct situated compromises, for example, or even clear deviations from official policy objectives. Rogers finds that the outcomes of this leeway, forged from attempts by local and regional actors to manage such tensions and turn them into operational practice, can be advantageous.

At local level, a 2012 study by Rogers and Mossé (3.3) of two care-quality improvement initiatives, one in France, one in the NHS, showed how French nursing managers (Cadres de Santé, CdS) and English Modern Matrons use the above leeway. In the NHS, the weakening of nursing management structures at the point of care delivery enables Modern Matrons, who implement the "Essence of Care" initiative, to redefine pre-established, quality-related norms. This normative capacity can transform formal hierarchies and influence the conduct of other professionals, including doctors. The capacity for influence of CdS depends on the essential role of Nursing Management Training Institutes (Instituts de Formation des Cadres de Santé, IFCS): Rogers shows how the pedagogical training activities these Institutes conceive have significant policy implications. Through the appropriation of micro-projects integrated into their training programmes, CdS participate in the co-construction of care quality norms.

Rogers's research thus demonstrates how nursing managers can be empowered through the very way they negotiate competing pressures, and not by the frequently requested "recognition" from the upper echelons of the hospital hierarchy, nor by direct resistance to managerial constraints. Guidance from front-line training structures, such as the IFCS, can support this process of empowerment.

References to the research

Details of the impact

The impact of Rogers's research has been to change in a positive way the self-perception of French nursing staff in the Rhône-Alpes region, and, following on from this, to inspire reinvigoration of the design of training programmes for this staff at the major Teaching Hospital in Grenoble.

The first stage in creating the impact was engagement with CdS in the Rhône-Alpes region, in order to analyse and compare the logic and outcomes of hospital reform in France and in the NHS (England), and to establish what lessons can be learned from the comparison. (Telling experienced professionals about the nature of their own work is potentially offensive and counter- productive; hence the importance of the comparative method and analogy.) This took place in two phases:

a) in the major Teaching Hospital in Grenoble (Oct. 2011), where Rogers took a leading role in the "Semaine de l'Encadrement", a week-long professional development conference at the IFCS.

b) at the Institut d'Etudes Politiques (IEP) in Grenoble (April and Dec. 2011), where Rogers led seminars within the professional training programme for CdS in the region (4 groups of 20 participants), in conjunction with the development programmes provided by the IFCS.

Participants at both sets of seminars were persuaded to see themselves as policy "translators", who must understand and appropriate the varying forms of "grammar" available in order to provide the most effective translation of centrally formulated policy into local action. This was illustrated through discussion of different modes of appropriating ("translating") modernisation norms, as well as the different ways in which "regulation" (economic or social) can be interpreted. Rogers drew attention to the danger of confusion between means and ends in the focus on the attainment of quantified targets: the risk of the ethical "wood" becoming obscured by the "trees" of technocracy. This risk, which CdS mentioned as a concern, figured prominently in Rogers's keynote address to the Semaine de l'Encadrement.

Monika Steffen, Director of the Professional Masters Programme in Public Health Policy and Management at the IEP, acknowledged the impact of Rogers's comparative approach on health care professionals, stating that "through comparison with changes taking place elsewhere", they had gained "insights into the developments taking place within their own system and work environment", which "deepened their understanding of the challenges which they face in their professional lives" (5.1).

During the Semaine de l'Encadrement, Rogers also created a CdS Forum (in the form of two 3-hour workshops), inspired by the Modern Matron Forum, which he analysed in his research on the NHS (3.2). The forum afforded CdS a rare opportunity collectively to confront the causes and effects of their malaise. Rogers introduced a text which structured the discussion; this approach encouraged intense engagement, as CdS shared their experiences concerning the problems of stress, isolation and "estrangement" from the professional nursing body to which they initially belonged. They also discussed how they coped with contradictory pressures in the workplace (5.2).

Stage 2 of engagement with healthcare professionals developed out of these activities. The Grenoble IFCS invited Rogers to return to their institution in April 2012, to contribute to training programmes for senior nursing staff who were about to move into front-line management as CdS. This invitation represented an opportunity to exert influence on the attitudes and understanding of CdS before they became enmeshed in the administrative "machine". Rogers's contribution to these programmes was informed by the insights he had gained from "getting inside" the organisation. The Grenoble IFCS is the major training centre for CdS in the southern part of the region. It provides many hospitals with their front-line nursing managers, who impart the lessons learned in training at the IFCS to their colleagues within these other institutions. In a 3-hour session with 49 trainee CdS, attended by the Training Officer responsible for the design of their training programme, Rogers communicated and demonstrated the potential of the micro-projects integrated into their training programmes for building policy-moulding capacity. This session has impacted the conceptualisation of training programmes in the region (5.3).

Building on stage 2, stage 3 began in 2013. Rogers was invited to return to the Institute in April 2013, not only to reinforce his insights with a new cohort of 50 CdS trainees, but also to evaluate the CdS training programme, as it feeds into the professional practice of newly-qualified CdS. Rogers has thus spread the message that professionals throughout the implementation chain are not mere objects of policy, but actors, whose policy translations can have a vital influence on the conduct of change in healthcare provision.

The following excerpts (anonymous and translated from French), are an indicative sample of comments provided by participant trainees after this latest visit:

"Your presentation changed my thinking about the potential for front-line managers to adapt quality performance instruments, using them as a means, rather than an end."

"I found the presentation by Vaughan Rogers particularly interesting and thank him for helping me to reflect on my professional role, especially the need for caution with evaluation mechanisms which create an image of our work that does not fit with reality."

"I particularly appreciated the instructive comparison with another country. This presentation was a warning, leading me to reflect on the participation of Cadres in the construction of norms and indicators, to avoid being subjected to their dictatorial authority" (5.4).

Sources to corroborate the impact

The following sources can be supplied by the HEI on request. English translations of the French documents can also be supplied by the HEI if necessary:

5.1 Letter from the Director of Research (Health Policy), (Centre National de la Recherche Scientifique), Director of Professional Masters Programme for Health Care Managers Institut d'Etudes Politiques de Grenoble, France (PDF file). Corroborates the impact of Rogers's comparative approach to the conceptualisation of change and agency in the CPD of health care professionals in France, which he communicated to them during training sessions at the IEP in April and Dec. 2011.

5.2 Transcript of discussions in Forum (PDF file). Corroborates the intensity of engagement of CdS in the CdS Forum that Rogers created and led during the Semaine de l'Encadrement at the major Teaching Hospital in Grenoble, April 2011.

5.3 Letter from the Training Officer, Institut de Formation des Cadres de Santé, Centre Hospitalier, Universitaire de Grenoble, France (PDF file). Corroborates how Rogers's comparative perspective has influenced the Training Officer's approach to the design of training programmes at the Teaching Hospital in Grenoble.

5.4 Email from the Training Officer, Institut de Formation des Cadres de Santé, Centre Hospitalier, Universitaire de Grenoble, France (PDF file). Corroborates the feedback given by participant trainees who took part in Rogers's CPD initiatives at the Teaching Hospital in April 2013.

The following individual can be contacted to comment on Rogers's activities:

5.5 The Director of Research (Economie de la santé), Laboratoire d'Economie et de Sociologie du Travail, Centre National de la Recherche Scientifique, 13626 Aix en Provence, France.