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Martina, Sýkorová (2025) ‘Driving a Micra and working in nasty homes’: a qualitative study of a community nursing service in England. PhD thesis, University of Nottingham.

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Abstract

The National Health Service (NHS) is costly to run, which has led to numerous reforms aiming to improve quality of services and reduce costs. One of the more significant NHS reforms was the managerialist reform in the form of New Public Management (NPM) that led to attempts to resolve the inefficiencies of public administration through management. Three decades after the introduction of NPM, NPM policies are believed to have harmed the NHS. Although several studies researched the impact of NPM on nursing, most research focus on nursing managers or nurses working in a hospital setting with a limited knowledge of the impact on NPM on community nursing.

Since the 1990s NHS policies have started advocating for the delivery of evidence-based care in nursing. Evidence-based practice (EBP) promotes the use of best available evidence to guide decision-making and the provision of efficient and effective care. Introducing evidence into practice however brings several challenges. Most studies researching EBP in the community focus on factors influencing the uptake of EBP, however, less is known about how EBP impacts care delivery in the community.

This qualitative study which uses an ethnographic approach offers a contemporaneous view of a community nursing service at the point of implementing a new care pathway for patients with chronic oedema and wet legs. In this study, chronic oedema is used as a case study through which community nursing was explored. The account is presented from the perspective of nurses working in the community and how they navigate the healthcare system within which they are required to operate. The ethnographic approach used for this study combined participant observations and semi-structured interviews with nurses working in the community to provide an in-depth insight into their working lives. Data were analysed using a thematic analysis. In addition, the composite narrative approach was used to present similarities in community nurses’ experiences that are combined to create a joint narrative which depicts shared experiences of participants.

Findings are presented in three empirical chapters. First, a composite nurse chapter is presented to describe a typical day of a community nurse. The first chapter aims to provide context and sets the scene for the remaining two findings chapters. The second empirical chapter focuses on how community nurses respond to workplace policies that are imposed onto them by their employer. Community nurses did not display resistance to management control mechanisms but instead adopted workarounds by finding a way to deliver care to all patients. The third empirical chapter focuses on the overarching theme of assigning blame as presented from the perspective of community nurses. The intensification of care and growing caseloads, resulting from managerialist policies, led community nurses to make moral judgements about their patients and engage in the practice of labelling patients. Based on community nurses’ accounts of their patients, a typology of non-compliant patients is provided. The chapter also explores the issue of evidence-based practice and how evidence-based interventions that are ‘too rigid’ and ‘prescriptive’ contradict community nurses’ wishes to deliver patient-centred care.

To conclude, this study shows that community nurses adopt long-term workarounds to address long-term workplace issues triggered by managerialism. Community nurses were observed to employ the practice of labelling patients to make sense of their patients who did not behave as community nurses would expect them to. Community nurses wish to deliver patient-centred, holistic care which at times can contradict the delivery of evidence-based practice.

Item Type:	Thesis (University of Nottingham only) (PhD)
Supervisors:	Aimee, Aubeeluck Alison, Edgley Laurie, Cohen Christine, Moffatt
Keywords:	community nursing, managerialism, chronic oedema care pathway
Subjects:	W Medicine and related subjects (NLM Classification) > WY Nursing
Faculties/Schools:	UK Campuses > Faculty of Medicine and Health Sciences > School of Health Sciences
Item ID:	81244
Depositing User:	Sykorova, Martina
Date Deposited:	23 Jul 2025 04:40
Last Modified:	23 Jul 2025 04:40
URI:	https://eprints.nottingham.ac.uk/id/eprint/81244

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