| This dissertation studies a process of change as evidenced in the everyday conduct of cancer nursing within the context of the ambulatory care setting. The purpose of this study was to explicate relationships of leaders of nursing practice, practitioners, and patients and families, and how these relationships serve to shape, in particular ways, the outcome of planned organizational change. The study enabled a questioning of how leaders, widely thought to be ‘responsible’ for marshaling change processes through organizations, would know that practice, had, in fact, been positively changed or improved as a result of the change. Further, the study undertook to question whether and how leadership practices operate to resist consensus and foster the inclusion of conflicting knowledges arising out of differences in position, and knowledge of practitioners, patients and families, and managers.; Analysis did not reveal a discernible model of care, but did suggest that nurses predominantly draw upon their disease related knowledge when caring for cancer patients and families. The ‘local’ knowledge of ‘how things get done’ in the everyday is not acknowledged. I suggest that relying on ‘expert’ knowledge, ‘disciplines’ the behavior of patients and families.; What emerges from this study is that nurse leaders are one of the powerful influences that affect how practices are accounted for. The incongruence between nurses' accounts and leaders' accounts is not merely about differences in hierarchical position. Nurse leaders' accounts rely upon proxies such as timeliness, workload measures, patient and physician feedback, and are framed against a technical, managerial perspective of practice. Revealing these differing practice interpretations provides nurses and leaders a way of understanding how successful changes to practice must be planned in a way that takes up the knowledge of not only the leaders but also the nurses.; Lastly, the knowledge of patients and families was not immediately apparent in the organizational documentation or the observations. Individualization of care competes with organizational standardization. In a time of continuous changes in health care, the perspectives of patients should not be relegated to the background, but must take their rightful place in the foreground with other health care providers. (Abstract shortened by UMI.)... |
