“A Fine Race of Girls”: Occupational Therapy and Clinical Governance in the District Health Boards of Aotearoa New Zealand
Clinical governance frameworks were constructed in New Zealand District Health Boards (DHBs) to address increasingly visible problems in the delivery of a high quality, value for money, safe and client-focussed publicly-funded healthcare system, staffed by clinically competent professionals. Prominent discourses favour an environment where health workers are considered responsible and accountable for their conduct and practices, reflecting DHB preferred knowledge and beliefs. The construction of clinical governance frameworks incorporates technologies of discipline, both foregrounding the emergence of subject positions aligned with quality and safety, and acting as instruments of surveillance so that conduct at all levels of the organisation can be monitored and corrected. This research explores how clinical governance discourses circulating within DHBs have produced a change in the subjectivities of occupational therapists and how their resulting subject positions have affected their everyday practices with clients. A post-structural Foucauldian discourse analysis methodology was used to identify the prominent discourses within a range of documents from two moments in time: just after the emergence of DHBs in New Zealand (2003-05) and twelve years later (2015-17), to make transparent changes in occupational therapist subject positions and practices. Research goals were twofold: firstly, to identify both dominant and receding discourses impacting the formation of occupational therapy subject positions; secondly, to reveal how occupational therapist subject positions influenced what practitioners did in the name of occupational therapy in New Zealand DHBs. Findings suggest that clinical governance frameworks have produced changes in the behaviour and practices of occupational therapists working in the DHBs. Subject positions whereby they engage in and demonstrate responsible, accountable and competent practice, risk minimisation, quality improvement, value for money, and client-centred behaviours and practices are foregrounded. Their practice extended beyond face-to-face client interventions, to include participation in activities which ensured the system as a whole conformed with discourses that prioritised efficiency and value for money across a population through standardisation of processes and focus on core practices. Coveted professional occupational therapy subject positions embracing a holistic, problem-solving, compassionate and individual approach somewhat receded, but appeared under certain conditions when the therapists exhibited resistive behaviour. Occupational therapists now hold two complex jobs: their front-line face to face patient intervention, and their behind-the-scenes quality, efficiency and risk management on behalf of the organisation. This means that they have to ‘walk the line’ between valued professional subject positions and those preferred by the DHB. It is an ethically and professionally tricky path to navigate. Serious engagement in reflective practices through external, confidential supervision as well as application of political reasoning through occupational justice activities are possibilities for future discussion.