A qualitative exploration of the role frontline health workers play in defining the quality of services provided to women experiencing an early miscarriage

Abstract

It is proposed that frontline health care workers in the English National Health Service (NHS) should have an important role in managing the quality of the services they deliver. Formal NHS quality management processes are structured in a highly rationalised way and the extent to which frontline workers have agency to apply their own knowledge to address suboptimal care practices is not well understood. This study explores how frontline NHS workers manage the quality of services offered to women experiencing an early miscarriage using qualitative semi-structured interview data collected from 34 frontline health care workers and managers from three hospitals in the North East of England. Secondary thematic data analysis, informed by micro-organisational theories, was used to explore the role of frontline health care workers in managing the quality of their services. This secondary analysis identified three key themes in the data; (1) the link between the quality gap and the difficulties associated with delivering humane and individualised care, (2) the role of collective understandings in defining the parameters of acceptable versus ideal quality of care, and (3) the use of discretionary practices to manipulate quality of care. These findings suggest that management of health care quality is complex and characterised by bureaucratic constraints that support narratives of powerlessness and compromise amongst NHS workers. Structures that privilege rational models of organisational management pose a significant challenge to the delivery of relational aspects of care. This study contributes to the evidence base by providing insight into the unseen discretionary practices frontline workers engage in to improve quality of care whilst also maintaining organisational functionality. These practices, based on collective beliefs about the parameters of “acceptable” quality of care, are paradoxical; they can improve quality for individual patients but they also support the structures that create quality shortfalls in the first place. The findings of this study offer a model of optimal care for early pregnancy loss that could be used as a framework on which to base quality improvement activities in this area. They also offer a unique insight into the issues that may result in suboptimal care practices perpetuating in the NHS, especially in relation to the delivery of humane and relational aspects of health care; this finding has implications for frontline clinicians, managers, educationalists and policymakers alike.