development and a sense of forward trajectory at multiple levels. There are interfaces between all of
Organisational position
these positions and it is an assumption of the refl exive positioning approach that using these multiple lenses to view any organisational task can be fruitful.
Organisational position We have considered above some of the
Consultant position
TASK
Production position
Relational position
shifting contexts that were highly pertinent to the task of outcome measurement from the organisational position. It has been useful at points both to consider and explore the multiple organisational contexts that have driven this requirement for outcome data. In both formal meetings and informal conversations, it has proved important to co- construct a coherent rationale for this change, while not over-emphasising the threat of being decommissioned in favour of IAPT-LTC – the psychodynamic notion of “titrating the dose of external reality” (Huffi ngton & Armstrong, 2004) as a means of promoting change while not provoking too much anxiety in staff . We now go on to describe our thinking
and engagement with the task through the remaining refl exive positions.
• Relational position – the emphasis from this position is on coordinating the human resources of the organisation in the most benefi cial way for the organisation, its members and stakeholders. The quality of relationships is key here as is the creation and maintenance of particular kinds of organisational culture. Staff wellbeing, motivation, creativity and job satisfaction are all important considerations from this position.
• Production position – the emphasis from this position is on professionalism,
eff ectiveness and service-quality issues. Codes of professional conduct, risk management, hard data, key performance indicators, activity statistics and demonstrable outcomes are important from this position.
• Consultant position – the emphasis from this position is on achieving the right balance between providing support, challenge and development to the organisation, whether at the level of the individual, professional group, work group, department etc. This position prioritises
“Artifi cial to the start of sessions which creates a barrier to client’s ability to direct sessions”
“Some people have major issues understanding the measure and completing it in a timely manner” “Interrupts a conversation” “You question yourself based on SRS scores” “Feeling defl ated when the scores don’t refl ect the conversation”
In comparison to other measures clinicians said; “You have outcome data even if the client stops attending. It becomes part of the work rather than an add on”
Box 1 38
Relational position Within the relational position, we have
been particularly infl uenced in our work by social constructionist conceptualisations of organisations as conversations (Campbell, 2000; Hersted & Gergen, 2013). In particular, we have attended to the constitutive eff ects of language – the ways in which conversations shape the identities of the department, of individuals within it, of the relationships between us and the task in hand of implementing an outcome measurement system. As in therapy, language is too important to
leave to chance given the power of dominant discourses, so we have taken great care to frame the project using positive, non-critical, appreciative language. We are well aware that top-down initiatives can be met with a mix of anxiety, cynicism and resentment. Staff have expressed concerns at times (more to me [Chloe] than to Rob, for obvious reasons) that the measures would be time consuming, disruptive to therapy, that patients won’t understand the purpose of them, that clinicians will feel guilty and pressured to use them, and that they might demonstrate therapists’ ineff ectiveness with consequences for their morale and putting them at risk of criticism from management. It has been
Context 170, August 2020
Refl exive positioning as a tool for organisational change: Systemic approaches to implementing outcome measurement
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