‘I mean, obviously you're using your discretion’: Nurses Use of Discretion in Policy Implementation

Hoyle, Louise

doi:10.1017/s1474746413000316

Cited by 33 publications

(30 citation statements)

References 53 publications

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“…For some (Frenkel, Tam, Korczynski, & Shire, 1998;Kinnie, Hutchinson, & Purcell, 2000) NPM's constraining of actors' use of discretion calls the whole bottom-up perspective into question. However, many other empirical studies in various public sectors maintained the sustained use of discretion and even in more sophisticated and subtle ways (Ellis, 2011;Gilson, 2015;Brodkin, 2012;Tummers, Vermeeren, Steijn, & Bekkers, 2012;Hoyle, 2014;Zedekia, 2017). For the purpose of our argument, -showing the potential of frontline actors at policy delivery -we mainly focus on the manifestations of the sustained use of discretion by professional front-line actors since, as mentioned above, higher education sector is often subsumed, along with health care and engineering sectors, under the "more general archetype of the professionalized sectors developed by Mintzberg (1979)" (Ferlie, Musselin, & Andresani, 2009, p. 2).…”

Section: Lipsky's Bottom-up Perspective: Misgivings and Legitimacymentioning

confidence: 99%

“…This entailed the need to follow up policies at the shop floor so that taxpayers could ascertain 'return on their investment' (Gornitzka et al, 2005), thereby leading to the entrenchment of a new awareness where public policy "is not best understood as made in legislatures or top-floor suites of high-ranking administrators [but as] actually made in the crowded offices in the daily encounters of street-level workers" (Lipsky, 2010, p. xiii). Theoretically, the renewed appeal that Lipsky's work on street-level bureaucracy (SLBy) has had among policy researchers in other fields (Hoyle, 2014;Brodkin, 2012;Zedekia, 2017) has not had a matching echo in higher education research. 1 Re-thinking the implementation approach in higher education has thus begun to rise.…”

Section: Introductionmentioning

confidence: 99%

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Interplay between Politics and Institution in Higher Education Reform

Khelifi¹

2019

EUROPEAN J ED RES

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The advent of the new economy brought university reforms to the limelight, and higher education research concentrated on the study of interactions of multi-level, multi-actor policy reforms, to the detriment of studying policy implementation. The ebbing of implementation analysis in the mid-1980s has probably put researchers off following up policies to the point of delivery, resulting in what critics dubbed a 'missing link'. Policymakers more pronounced need to evaluate the impact of the policies they adopt, inter alia, has led to a renewed interest in bottom-up implementation in other public policy fields, but not as much in higher education research. The article builds on a Network Governance-informed approach for studying policy reform in higher education and adapts it to study of policy implementation with a focus on transition systems. Witte's actor-centered new institutional framework is taken as a springboard, and some of its underlying assumptions are reviewed for that purpose, adding insights from public administration literature (NPM) and Lipsky's street-level bureaucracy (SLBy). Ultimately, it proposes a politics-institutions framework to account for the institutional change entailed to the reforms.

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Section: Lipsky's Bottom-up Perspective: Misgivings and Legitimacymentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Interplay between Politics and Institution in Higher Education Reform

Khelifi¹

2019

EUROPEAN J ED RES

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“…However, unlike the usual top-down explanations attributing such failures to unruly or incompetent workers, his bottom-up perspective examined policy from the perspective of those delivering it at the frontline. This approach has been adopted in a range of subsequent studies, exploring the street-level work of occupational groups such as social workers (Evans and Harris 2004;Keiser 2010), the police (Buvik 2016;Maynard-Moody and Musheno 2003), politicians (May and Winter 2009), teachers (Maynard-Moody and Musheno 2003;Taylor 2007), liquor inspectors (Wilkinson and MacLean 2013) and nurses (Hoyle 2014;Walker and Gilson 2004). To the best of my knowledge, this is the first study to subsume triage nurses under the umbrella of street-level bureaucrats.…”

Section: Street-level Bureaucracymentioning

confidence: 99%

Between standardisation and discretion: the priority setting of triage nurses

Johannessen¹

2018

Preprint

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This dissertation explores the relationship between standardisation and discretion in professional work at street level, using the priority setting of triage nurses as its case. Triage nurses are employed at the frontline of emergency medical services, where they work to assess the urgency of patients’ complaints. This work can be very challenging, requiring rapid assessments of a large group of unknown and unsorted patients, some of whom may be critically ill. To aid these assessments, emergency services have increasingly introduced standardised triage systems that specify how nurses should proceed in interpreting and prioritising cases. Triage systems reflects a broader trend in healthcare, which has seen a widespread introduction of clinical practice guidelines, all seeking to generate uniformity and quality control by streamlining clinical decision making. The introduction of these guidelines has been described as an unprecedented form of standardisation of professional clinical work, but there is little consensus regarding their effects. While proponents argue that clinical practice guidelines are an important means of improving quality and efficiency, critics denounce them for promoting bureaucratisation, homogenisation and so-called ‘cookbook medicine’. Observing this impasse, there have been calls for an empirically grounded ‘sociology of standardisation’ to acknowledge that guidelines can have different effects in different settings and to explore standardisation on a case-by-case basis. Informed by that proposal, this dissertation explores the relationship between standardisation and discretion in triage nurses’ priority setting. The dissertation is based on nine months of fieldwork in a Norwegian emergency primary care clinic (EPCC), where nurses were required to assess patients using the Manchester Triage System (MTS). Observations revealed that nurses regularly departed from the MTS while also seeming to be influenced by the system in a number of ways. On this basis, the dissertation addresses the question of how and why nurses departed from the MTS and, conversely, how the MTS influenced their assessments. The introduction and the four associated articles show how nurses supplemented the MTS with additional skills and knowledge, and how this led them to adjust or override the priorities formally prescribed by the system. While they had several reasons for so doing, their primary concern was to ‘correct’ the MTS and to ensure more precise prioritisation of patients. However, the MTS also played a significant role in their assessments by restricting, enabling and supporting priority setting.Beyond shedding light on discretionary practices among triage nurses, the dissertation makes three more general contributions to the sociology of standardisation. First, it helps to bridge the gaps between the sociology of standardisation and the literatures on street-level bureaucracy and categorisation. In so doing, it identifies fruitful theoretical linkages for future studies of standardisation and discretion in street-level categorisation of clients.Secondly, the in-depth exploration of nurses’ use of the MTS provides a rich account of the difficulties of streamlining clinical practice. Despite its elaborate design, the MTS was too ‘thin’ to match the complexity of triage nurses’ work, and to follow it unreflectively would be to the detriment of both patients and staff. For that reason, nurses found it necessary to render the guidelines ‘thicker’ by making situated judgments, illustrating the crucial role of additional skills and knowledge in making standards work.Finally, the dissertation shows how the MTS (despite its shortcomings) affected nurses’ work in multiple ways, illustrating how guidelines interact with professional practice. In so doing, the dissertation transcends the either/or language that characterises much of the debate around standardisation, instead providing a nuanced account of the interplay between prescribed and discretionary aspects of triage nursing.

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“…Street‐level bureaucracy has become a dominant approach in the study of frontline encounters between workers and clients across a range of settings (for overviews, see Brodkin ; Buffat ; Maynard‐Moody and Portillo ; Peters and Pierre ). Studies have explored the street‐level work of social workers (Evans and Harris ), police (Buvik ), teachers (Maynard‐Moody and Musheno ), nurses (Hoyle ) and pharmacists (Chiarello ), to name but a few. While these occupations differ widely, the street‐level approach holds that they are similar in some important respects, and one strength of the approach is that it encourages us to think horizontally across seemingly disparate settings.…”

Section: Introductionmentioning

confidence: 99%

Negotiated Discretion: Redressing the Neglect of Negotiation in “Street‐Level Bureaucracy”

Johannessen

2019

Symbolic Interaction

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This article proposes an interactionist update of "street-level bureaucracy," one of the most influential approaches for studying how public policy is translated into street-level practice. While the street-level approach assumes that bureaucrats are alone in enacting policy, the present article argues for seeing "street-level policy" as formed in negotiation between bureaucrats and clients. To demonstrate this, the article uses ethnographic data and a Straussian framework to analyze how nurses and patients negotiated access in a Norwegian emergency service. The article thus sets a new course for street-level research, helping researchers look beyond the individual to explore inter-individual negotiation and its influence on street-level decision-making.

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‘I mean, obviously you're using your discretion’: Nurses Use of Discretion in Policy Implementation

Cited by 33 publications

References 53 publications

Interplay between Politics and Institution in Higher Education Reform

Interplay between Politics and Institution in Higher Education Reform

Between standardisation and discretion: the priority setting of triage nurses

Negotiated Discretion: Redressing the Neglect of Negotiation in “Street‐Level Bureaucracy”

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