Critical pedagogy in a health service management development programme: Can "critically thinking" managers change the NHS management culture?

Abstract

Management development programmes available to NHS managers focus on a performance orientation and sustain a culture of managerial and medical domination. This paper aims to question whether it is possible to consider NHS management development from a critical (empowerment culture) perspective. Features of the critical management studies approach (CMS) are identified. A new MSc is evaluated against these characteristics, examining the teaching and learning processes and students' perceptions of the programme. The aim is to develop critical thinkers who can return to their organizations and challenge existing power structures and practices to change local cultures and enhance health services. Empirical research employed anonymous student questionnaires and a focus group. Student evaluations suggest the MSc can deliver a critical pedagogy and help managers understand issues of power and empowerment, challenge dominant cultures, innovate and effect small, local changes in the NHS culture. There is a need to continue evaluating the programme and include other stakeholders. Longitudinal research should assess the impact of the managers' changed values, attitudes and behaviours on colleagues, clients and the local cultures. The paper identifies some of the tensions of developing critical health service managers, and the problems they encounter back in the uncritical NHS context, as well as some of the challenges in facilitating a critical curriculum. It questions the ethics of developing (or not) a critical perspective in a local context unfamiliar with CMS. Management development in the NHS largely ignores critical pedagogy. This paper makes a small and unique contribution to understanding how developing critically thinking managers can challenge the dominant culture. However, the limitations of such a small-scale study and ethical implications are noted.

Culture and climate in health organisations

Edited by P. Hyde, J. Braithwaite and A. Fitzgerald

Introduction and background

This paper contributes to the development of a critical pedagogy in healthcare management development. Much of the work associated with critical management studies (CMS) has ignored the health sector. The British National Health Service (NHS) has its own management development training programmes and universities have designed various postgraduate programmes. However, these tend to reinforce a managerialist culture and performance orientation. Is it possible to consider health service management development from a critical perspective, and if so, what are the implications for managers and the NHS?

The NHS has been subjected to considerable change since its inception in 1948, and [19] Handy (1976, p. 67) asks "So you want to change your organization? Then first identify its culture."

There has been considerable focus on organizational culture in the NHS. [25] Mannion et al. (2007) review how organizational culture in the NHS has evolved. An important change was the introduction of general management, following the Griffiths Report, in an attempt to introduce greater financial accountability and shift power and control of resource allocation from medical professionals to managers. Associated developments included the introduction of the internal market, a move towards a competitive business culture ([9] Davies and Mannion, 2000), and a focus on quality and performance improvement ([17] Goddard and Mannion, 1998).

Central to "achieving meaningful and sustainable quality improvements in the NHS requires a fundamental shift in culture ... to enable and empower those who work in the NHS to improve quality locally", (paragraph 5.6, [10] DoH, 1998). Following the tragic events at the Bristol Royal Infirmary, the [20] Kennedy (2001) Public Inquiry concluded that there were inadequacies in management and a prevailing "club culture" ([19] Handy, 1976), which afforded senior managers excessive power and fostered "a climate where dysfunctional behaviour and malpractice were not effectively challenged" ([25] Mannion et al. , 2007, p. 10). This drew greater attention to the NHS culture and Kennedy identified the need to transform the NHS. In response, the NHS Plan ([11] DoH, 2000) was a package of reforms to shift the balance of power to patients and frontline NHS employees, by empowering staff to develop innovative services, empowering patients to become active and informed partners in health care services, and challenging the NHS culture and structure by devolving power and decision-making to frontline staff and Primary Care Trusts ([12] DoH, 2001).

The concept of culture is complex and the notion of culture within the NHS has been reviewed by [25] Mannion et al. (2007). Key characteristics include values, attitudes, behaviours, ways of thinking and working, management, leadership and learning. Some suggest an organization has a culture that can be changed, suggesting it is a variable to be manipulated by managers, but others perceive culture as a root metaphor, and thus something an organization is and its beliefs and assumptions can only be changed by organization members themselves ([32] Smircich, 1983). In culture as "variable," "senior management only manipulate culture for organizational success ... [by] changing artefacts and espoused values" whereas in culture as "root metaphor," "managers, as well as other individuals and groups, all influence cultural direction of company ... reproduced by all culture members in an ongoing way through their negotiation and sharing of symbols and meaning" ([5] Buchanan and Huczynski, 1997, p. 514). This suggests that whilst the NHS culture might be dominated by managerialist (power) and medical (club) domination (senior managers and clinicians), there is scope for culture change by other organization members, including junior/middle managers and senior health professionals, who can be empowered to challenge and change the NHS culture.

This paper focuses on the development of such managers and health professionals through a new Masters degree in Health and Social Care Leadership. Drawing on the work of critical management learning scholars, and particularly [26] Reynolds (1997), I identify some features of the critical management studies approach (CMS) and attempt to evaluate this new MSc against these characteristics, examining the curriculum design and teaching and learning processes. The focus has been on developing critical thinkers, who can return to their organizations and challenge existing power structures, value perspectives and practices to change local cultures and enhance health care.

The MSc in health and social care leadership

The MSc aspires to help managers lead effective health and social care services, responding to various national initiatives, including the Wanless Report (2002) on the UK's health service and The Review of Health and Social Care in Wales ([52] NAW, 2003). The MSc is one of a suite of Masters' programmes studied full-time (one year) or part-time (two years). There is a common first year including, epidemiology, behavioural sciences, health economics, research methods and statistics. The second year provides the specialist pathway in Health and Social Care Leadership with four core modules: organisational behaviour (OB); managing and developing people (MDP); investing in a valued workforce; and leadership, quality, innovation and change (LQIC). These are all aspects relevant to the evolving NHS culture identified earlier, and to implementing the NHS Plan ([11] DoH, 2000) with its focus on empowerment and performance improvement. The final element is a dissertation in a leadership topic that provides participants with an opportunity to integrate and apply themes from these modules within their own context. The programme content and design was negotiated with senior representatives of healthcare organisations, and my aim to develop a critical perspective was welcomed. The pathway was launched in 2005 and the first part-time cohort (n =7) submitted their dissertations in September 2007. For issues of transparency and reflexivity, I was the programme leader, taught three of the four core modules (OB, MDP and LQIC) and was the dissertation supervisor. The implications of this are discussed later.

A critical management learning perspective

The MSc programme has been developed in the emerging context of "critical public sector management" (CPSM) and "critical HRD" (CHRD) ([30] Sambrook, 2004), within the wider area of critical management studies (CMS) ([2] Alvesson and Deetz, 1999; [3] Alvesson and Willmott, 1996; [7] Burrell, 2001):

Critical perspectives are based on a variety of ideas and theoretical sources. The starting point is obviously critique itself: the identification of the weaknesses, limitations and ideological functions of orthodoxy ... Through the critique an outline of a different agenda begins to emerge, with a concern for issues of power, control, domination, conflict, exploitation and legitimation ([53] Thompson and McHugh, 1995, p. 17).

Similarly, critical theory "seeks to highlight, nurture and promote the potential of human consciousness to reflect critically upon such oppressive practices, and thereby facilitate the extension of domains of autonomy and responsibility" ([3] Alvesson and Willmott, 1996, p. 13). However, little empirical CMS research has been conducted in the public sector, and particularly not in the health and social care context. Given the inherent problems with a "club" and "power" culture within the NHS, this degree programme attempts to develop junior/middle managers and other health professionals who are able and empowered to challenge dominant cultures and effect small, local changes to enhance meaningful employment, sustainable organizational performance and informed patient care.

Drawing on the work of critical management learning scholars ([6] Burgoyne and Jackson, 1997; [15] Fox, 1997; [26] Reynolds, 1997, [27] 1999; [35] Willmott, 1997) I identify some features of this approach and attempt to evaluate this new MSc against these characteristics, examining the curriculum design and teaching and learning processes. [26] Reynolds (1997, p. 320) suggests that "a critical perspective should at least lead to questioning the intentions, beliefs and values which underlie programme design and the methods used within it." Key issues include questioning:

- the underlying assumptions about how people learn;

- what values are reflected in the programme;

- whether the design supports critical reflection and dialogue; and

- whether teachers are aware of the assumptions implicit in the way they work with course participants.

Adopting a reflexive approach, I attempt to address each of these four issues. First, critically reflecting on my own assumptions and beliefs about learning and teaching, I developed the programme in recognition of the principles of andragogy, or adult learning ([21] Knowles, 1975, [22] 1990; [29] Rogers, 1983), discussed below. Second, as a former nurse, with experiences of being patronized and "ordered around" by medical staff, I acknowledge that my values of trying to empower nurse managers influenced the design of the programme. As such, third, my design explicitly incorporated space for critical reflection and dialogue, discussed below. Fourth, I have carefully reflected on my assumptions about the way I work with course participants, and note that whilst I hold certain values and pedagogical beliefs, I attempt to respect others' perspectives and not impose my own, which is antithetical to a critical perspective.

A critical perspective can focus on either content and/or process issues ([26] Reynolds, 1997, p. 320). Reynolds proposes four key characteristics of a critical pedagogy. The first focuses on the curriculum (content). The content can be critical in introducing students to critical theory. The other three focus on structures, procedures and methods (teaching and learning methods which are non-hierarchical, providing choice in programme design); an introduction to critical perspectives (gender, critical reflection) applied to the learning process; and reflexivity (understanding one's own position within the collaborative learning process). Later, I explain how the learning and teaching methods were non-hierarchical. For example, I did not present myself as expert or knowledge-giver, but facilitator of personal knowledge construction. Students were given considerable choice in assessment processes, e.g. selecting their own topic or issue to investigate. Within the classroom, students were encouraged to consider issues of gender and power (e.g. female/male nurses, female/male doctors/managers) in their discussions of clinical practice, and critically reflect on the implications of these. Students were also encouraged to challenge my material, thus practicing how to critically reflect on the nature of knowledge and the learning process. The process can be critical in empowering and emancipating students, within the classroom and hopefully beyond. Given the nature of the MSc, my emphasis has been on a critical process. However, whilst not directly challenging the nature (content) of the NHS culture per se , the degree attempted to develop and empower managers to challenge dominant practices within their local contexts.

The programme was developed in recognition of the principles of andragogy, or adult learning ([21] Knowles, 1975, [22] 1990; [29] Rogers, 1983), which include the need for: independence and choice, intrinsic motivators and curiosity, feedback with time for reflection, active involvement in real world tasks, and developing higher order abilities (critical thinking, problem-solving), high challenge-low threat environments and opportunities for practice. Methods for supporting adult learning include: collaboration, co-operation, problem-based learning, case method teaching, peer based methods, research based learning and portfolio systems ([51] Gibb, 2002). The classroom was used as a laboratory to reflect, explore and experiment with issues associated with power and domination apparent within higher education and inherent within the NHS culture. I did not present myself as expert and dominate discussions. I tried to ensure a non-hierarchical power structure, enabling students to steer classroom discussions, abandon "my" content in favour of their questions and concerns, and offer as much choice as possible with assignment topics.

Evaluation methodology

Data collection

The new Master's programme was formatively evaluated through a number of means and on numerous occasions, with careful consideration of data collection methods, given my role. First, there was formal, anonymous module evaluation, a requirement of the university. An evaluation questionnaire is distributed to all students and collected during the final session. This includes both Likert-type questions and open-ended questions, and for this study I drew on qualitative responses to these open questions.

Second, a specifically designed anonymous questionnaire was distributed to all module participants, including the Health and Social Care Leadership (H&SCL) MSc students (n=7) for which the four modules are core, and other students who selected these as electives. The questionnaire was designed to ask open questions about the learning and teaching process, deliberately avoiding the language of CMS to help reduce any bias. I asked various questions including: what did you find of particular benefit, what did you like, what did you dislike and how the module could be improved? Drawing on [26] Reynolds' (1997) work, I wanted to identify if any of the students mentioned (and even critiqued) features of critical pedagogy, such as a non-hierarchical learning process and what values appeared to underpin the programme. I also sought evidence of them developing as critical thinkers, and beginning to more carefully examine their own value perspectives and practices and challenge existing power structures to change local cultures and enhance health care. Also, I sought evidence of the principles of andragogy in students' responses to my open questions.

The first module, organisation behaviour, involved just the seven students on the specific H&SCL programme, and as only four students completed the formal evaluation sheet, I did not distribute my own questionnaire. However, a further three students joined the managing and developing people module, available as an elective on other pathways. Both the formal and my own questionnaires were completed by these ten students.

Third, interim module evaluation was conducted with the whole cohort of MSc students (n =20) on all pathways who take the final core module, leadership, quality, innovation and change, employing small group brainstorming, followed by a whole-class focus group discussion.

Fourth, having progressed to the dissertation, a further short anonymous questionnaire with similar open-ended free response questions was distributed to the six remaining H&SCL students.

Hence, the study was constructionist ([50] Easterby-Smith et al. , 2008), rather than the traditional relativist survey design, and this has implications for data analysis.

Analysis

The data collection methods generated qualitative data. These were analysed using [50] Easterby-Smith et al. 's (2008) process, including familiarization, reflection, coding and re-evaluation of data. Aware of my role as programme leader, I have presented the findings in a data rich way, to provide the student voice and not impose my own. I also justify providing such rich data to defend myself against charges of "anecdotalism" ([31] Silverman, 2000), presenting only selected evidence that supports my own values and interests. I have included verbatim quotations, some of which are lengthy and edited. In terms of reliability and validity, I draw upon [23] Lincoln and Guba's (1985, p. 145) "parallel" qualitative quality indicators and argue that this study demonstrates credibility (the findings are plausible); transferability (the findings can be transferred to other similar contexts); dependability (I have provided sufficient information regarding research methods): confirmability (I have acted in good faith during the study). I also offer [18] Golden-Biddle and Locke's (1993) criteria of authenticity, plausibility and criticality for judging the quality of the study. By providing such rich data I hope that readers will be convinced that I have demonstrated a sound understanding of what was taking place in the programme (authenticity), that this relates to wider issues in health service management development (plausibility) and that this challenges readers' own taken-for-granted assumptions (criticality).

Limitations

At this point, it is important to acknowledge the limitations of this study. First, critically reflecting on my role as programme leader, module leader for OB, MDP and LQIC, and dissertation supervisor, I note the potential concern over conflicting interests in this research. I developed this programme and now I am evaluating it. Perhaps, I will only report the positive findings but, adopting a critical perspective, I have been mindful to look for negative or inconsistent responses. Also, I am aware of the power dynamics and how this might influence the findings. The participants were "my own" students and I distributed both questionnaires myself. For the formal anonymous module evaluation sheet, this form of distribution is current practice, so students are used to this. For my own data collection tools, I carefully considered ethical implications and selected anonymous questionnaires, rather than in-depth interviews, which might have offered greater insight. I carefully explained why I was conducting this formative evaluation. Participation was voluntary, based on informed consent, and completion of my questionnaire was taken as implied consent. It is possible that they may have felt coerced to complete my own questionnaire, although these were also anonymous. I urged students to be as honest as possible as I was seeking their critical evaluation of the programme, and particularly the learning process. There is potential concern that I could recognise their handwriting, but students submit their assignments electronically and I was not familiar with their handwriting. Because of this, I also assured them that their responses could not have any bearing on their grades or our interactions. From the rapport that I had developed with these students over the three-year period, I am confident that they did not feel coerced and responded frankly. I have reported their answers verbatim, often in lengthy quotations, so the reader is able to judge the impact of my role on students' responses. It is possible that the students wanted to portray this new degree in a positive way to please me. However, I have also reported their "negative" responses, and am confident that this demonstrates their ability to be critical of me and the programme. As the focus group was conducted during class, participation was not anonymous, and this may have influenced the discussion. However, as this was towards the end of the module, I had developed a rapport with these students and they were confident to speak out and critique the programme. It is possible that only the confident contributed and I have ignored the views of the silent, but I was careful to facilitate the class discussion, and had split the class into small groups prior to encourage (although not enforce) full participation. Also, having intentionally avoided using any CMS language during the module evaluation to avoid threats of bias, I decided to explicitly introduce the concept of a critical approach in the final dissertation questionnaire. I asked students to think back over the MSc and reflect on whether my key aim of stimulating a critical approach to their studies, encouraging them to ask challenging questions and to challenge current practices, had been achieved. I acknowledge that students could have provided positive responses to please me, and their self-reporting of the impact of the course and changes effected are subjective and lack validation. However, I have provided lengthy quotations to enable the reader to judge the honesty of their responses. A final point to consider here is the small number of participants from one cohort, who all know one-another. It is possible that they have shared their views although, after working with them over the three-year period, I am confident that they are independent thinkers and will have presented their own free views.

Second, this is a small formative qualitative evaluation rather than an extensive quantitative survey. As such, my own short questionnaires were not piloted or tested, and it is unhelpful to consider validity and reliability. However, if the study is to be expanded, then these issues will need to be addressed. Instead, here, I draw upon criteria for judging the quality of qualitative research, such as [23] Lincoln and Guba (1985) and [18] Golden-Biddle and Locke (1993). I provide lengthy and verbatim quotations to allow the student voice to emerge and encourage the reader to judge the authenticity and plausibility of their responses.

Third, I recognise that it is too early to tell in formative evaluation, and especially in a small-scale study, what impact the programme will have on practice. A more thorough evaluation is needed with either a longitudinal component or a comparison with one or more similar programmes. Addressing this limitation, I hope to follow-up the seven H&SCL students to more thoroughly explore whether their emerging critical thinking has indeed influenced and improved their practice and effected small, local cultural change.

Findings

Having carefully explained my research methods and acknowledged the limitations of this study, this section presents comments from the formal evaluation of the OB and MDP modules; and findings from my own questionnaire for the MDP module; from the Leadership (LQIC) focus group discussion; and from my questionnaire on the dissertation stage.

Organisation behaviour

The formal module evaluation questionnaire was completed by only four of the seven students, and because of this small number, my own questionnaire was not distributed.

General comments included:

This was a really enjoyable course and I feel I benefited from the whole (small) team approach. It was a subject area that made sense to me which I know I can apply to my practice.

I really enjoyed the "emotional intelligence" aspect of the module. A fascinating subject that I knew little about but have enjoyed applying it to leaders within the organization - with interesting results.

It is encouraging that students can see the practical application of module content in their own work contexts and appear to be developing transferable managerial/leadership skills.

All four students indicated they would "recommend this module to a colleague." Comments included: "Definitely," "highly recommended - it should be 'accessible' to senior managers/directors. The MSc attracts nurses and yet would benefit general managers", and "should be compulsory to all potential/actual managers/leaders in the NHS".

Students are reflecting on colleagues in the NHS and suggesting they would benefit from this type of study. This suggests they are developing a critical orientation, and highlights the perceived need to develop more senior colleagues (senior managers and clinical directors) who appear to strongly influence the local NHS culture.

In response to the question, what changes or innovations in practice do you intend to make, comments included:

Service re-engingeering to resolve demand v capacity, workforce planning/HR strategy, team development, change management.

I have a much greater understanding of the theory behind organisational management/behaviour. It linked very well with my role in clinical governance.

These comments support the notion of relevant and practical application to their own work contexts, hopefully improving and enhancing practice in the public sector. These small, local changes are the sort envisaged in the NHS Plan ([11] DoH, 2000) and the NHS response to the Kennedy Report ([12] DoH, 2001), empowering frontline employees to innovate, improve performance and enhance the NHS culture. Key themes to emerge from this are: the benefit of small-group learning, the benefit of practical application, and the confidence to effect changes in practice.

Managing and developing people

General comments included "An excellent module," "Enjoyed very much the teaching format and group participation sessions," "Sally is an extremely effective facilitator." This last comment suggests a shift away from the traditional hierarchical teacher-learner relationship to my role as facilitator, thus hinting at a shift of power in the classroom to suggest similar possibilities within the NHS workplace.

In response to the question, what changes or innovations in practice do you intend to make, comments included:

Change the model of service provision in school nursing and health visiting.

Look at redesigning our service.

More development of volunteer staff and of support workers - which has not been seen as of value previously. More critical of HR dept - perhaps be more "demanding" of them and of training dept or trust.

Change approach to managing people taking into account theories and information gained.

Feel more empowered to pursue HRM issues.

Much more aware of HR and managerial issues that I now understand and could deal with differently.

Part of project team to introduce a change in practice roles - more aware of potential problems, group dynamics etc.

These comments illustrate the changes to practice students are proposing. They also begin to reveal subtle discursive and personal changes, such as an increasing criticality, a more challenging orientation and feeling more confident/able/empowered to effect structural and cultural changes.

When asked to suggest any changes or additions to improve the module, comments included:

It was beneficial that the group was quite small. This was conducive to learning.

? more on change management.

These comments relate to teaching/process issues, such as the benefits of small group teaching. In terms of the content, one student is requesting more on change management, which is perhaps unsurprising in a public sector organization undergoing constant change to meet the NHS modernization agenda.

For my own evaluation questionnaire, without using the language of CMS, I asked various questions including: what did you find of particular benefit, what did you like, what did you dislike and how the module could be improved?

Students found of particular benefit:

The relaxed learning environment, the informal teaching style and the group discussions - I learnt a lot from the latter.

The opportunity to learn with different people which don't normally come into contact with.

The teaching/learning atmosphere, the fact that the group wasn't too big.

Opportunity to apply theory to practice.

Lots of relevant theory that can be translated into practice - all of it was beneficial.

The linking and exploration of individual experience to theory.

Interesting subject as it is totally relevant personally and in practice.

Developing critical approach to systems of NHS, HR and training. Developed improved report writing (I think!).

Have never done a poster presentation or management report. They have been a useful learning practice but have also been daunting.

Many of these comments relate to the learning process in general, such as a relaxed learning environment and informal teaching style, again suggesting a non-hierarchical approach. Some relate specifically to andragogy, such as relevant content, practical application of theory to practice, and developing useful management skills. In addition, an interesting comment raises the issue of learning with other people. This is particularly important to help break down barriers associated with professional sub-cultures, by learning outside of traditional professional or structural silos. Also, unprompted, it is possible to detect an emerging critical orientation. Similar themes emerge: the benefit of small-group learning (particularly with different people), the benefit of practical application, and the confidence to effect changes in practice (through increased knowledge), but in addition, a new theme of developing a critical approach (feeling empowered, challenging colleagues).

Leadership, quality, innovation and change

This element of the evaluation was based on a small group brainstorming exercise, followed by a whole-class focus group discussion (n =20).

Talking of content, there was a request to include more on political awareness and organizational politics in the health and social care context. This might suggest students were gaining awareness of a critical approach and recognized the politicized culture and their need to better engage in this.

Many students acknowledged and welcomed my attempts to adopt the principles of adult learning, particularly my development of an environment in which students are "safe", indeed encouraged, to challenge and question the material presented. Several stated that they felt "empowered" as learners. "I do feel empowered to question things." The students appreciated my facilitation skills, and noted that other lecturers adopted a more didactic approach which they both disliked and did not learn from. They also noted that it requires a confident and knowledgeable lecturer to adopt this approach. I involved several external guest speakers on the various modules, many of whom, despite their roles as senior managers and OD facilitators, lacked these facilitation skills and appeared unable to deal with the students' critical thinking and questioning. The students felt that we had developed a trusting and respectful relationship over the two years, but some wondered if there were occasions when they might have exceeded this boundary and become disrespectful. "Sometimes I have gone home and wondered if I had pushed the boundary and perhaps upset you." I reassured them that this was not the case. However, in one or two session with guest speakers, I did admit that I felt the speakers were uncomfortable with the students' critical stance. Here, students who were used to my "open" non-hierarchical approach said they were frustrated when the speakers did not acknowledge or address their questions, and this frustration could be perceived as disrespect. "He just didn't answer our questions, he blocked them." "Perhaps you need better scrutiny of outside speakers in terms of their theoretical and political knowledge."

Again, there are similar themes but two new ones emerge: the request for more "critical content" (organizational politics) and the emphasis on the benefit of a non-hierarchical learning process (facilitating rather than telling/ignoring), both elements of a critical pedagogy.

Dissertation

Of the seven original students, six progressed to the dissertation. I asked students to think back over the MSc and reflect on whether my key aim of stimulating a critical approach to their studies, encouraging them to ask challenging questions and to challenge current practices, had been achieved. Most students indicated that they were now more carefully informed critical managers, with their thoughts, comments and decisions underpinned by theory and an "evidence base" or they knew where to find answers. They are more confident to challenge and debate, appear less intimidated and are able to see the "bigger picture" and "both sides". Each has an opportunity to apply their learning in practice, and most have aspirations to improve their work practices. However, it is too early to determine whether this achieves empowerment, equity or emancipation in the heavily politicised health and social care context and improves the workplace for other employees. A theme emerging in the earlier module evaluation recurs here, that of ensuring guest speakers have the skill and confidence to deal with these increasingly "critical" students:

Although I have always been a "questioner" I now have more theory behind my thoughts and definitely more confidence. I know where to look to find answers.

I think you have succeeded!! We were quite a vocal group anyway ... which I imagine helped. Lots of various experiences and knowledge base in group (some people in quite senior job positions). The open discussion and cross fertilization of ideas and concepts, certainly helped with my learning (I enjoyed these sessions). Disliked some of the guest speakers' talks/focus/style.

I think I've always been a challenge to people! But feel now can approach different theories and practices more critically and challenge normal boundaries.

I feel that the learning environment and teaching skills stimulated discussion and debate. As an individual who perhaps has been traditionally less "vocal" than some, I do now feel considerably more confident to challenge and debate issues. I think the most powerful achievement personally is losing the fear of "saying the wrong thing" and at times feeling intimidated by "senior" colleagues. I put this down to the openness and honesty of the group and appreciate that; despite experience and status we all have a unique level of contribution. I have also observed a change in how as an individual I process information in that I will debate "both sides" despite how I initially feel.

I feel that the course has formalized and given me a framework to use when needed to structure challenges and to back up new thinking with an evidence base. I feel that in the current working environment the skills gained from this course will be invaluable as I am now able to feel confident to approach situations from more than one angle. I feel that by spending an extended period of time with managers from other settings I have been able to learn from their experiences and utilize these within my workplace. I hope that I have developed a more critical approach although I remain a little unsure whether this is always welcomed in certain arenas at work, as it can affect the balance of working relationships which have already been established. However to ensure that the service develops I think that I need to continue to take this approach in the workplace.

Conscious of the difficulties of transferring classroom learning to the workplace ([34] Trehan et al. , 2005; [54] Turnbulll and Elliott, 2005), I was curious to know how this MSc affected the way they worked. Again, an overwhelming theme was their increased confidence in both what they did, and confidence to question and challenge others. An interesting, although minor theme, is reference to the use of a new "language" and "knowing the words to use." One student commented on the better "language" she could use, suggesting a shift in the discursive resources she now employs at work. In a culture dominated by senior managers and clinicians, it is important to understand "their" language, to engage with them and challenge their practices and perspectives. Another key theme was the opportunity to use their new knowledge and skills in practice, thus meeting some of the aims of andragogy, but more importantly developing their leadership and ability to effect local cultural change.

In many ways. The confidence to question because I now have more theory to my skills and knowledge. A better "language", knowing the words to use. Report writing skills, used a lot in my work.

Has helped me to challenge and discuss some of the present dynamics in our team culture. Have been able to provide managers with some useful articles/info that I have picked up on the way!

More confidence in placing ideas forward for consideration, practice changes. More aware of the bigger picture.

I feel I am less opinionated and less fearful of making the "wrong" decision. I think this allows me to take more risks personally as I am less concerned towards "pleasing" others.

The course was really "live" and translatable to the work situation. I feel that with the theoretical base which I have gained I now have the confidence to work with people throughout the organization and to constructively challenge existing practices and to make suggestions for developments within the service.

Here students talk of how they can now challenge and discuss their team culture, and challenge practices across the wider organisation. Aware of the potential dangers of developing critical managers ([33] Trehan, 2004; [34] Trehan et al. , 2005; [54] Turnbulll and Elliott, 2005), I wondered what the response had been from their colleagues, and whether they had encountered any support and/or resistance, particularly given [8] Currie's (1999) case study of an NHS management development programme:

This has varied greatly. A lot of the team have been encouraging and supportive ... Some have felt threatened that I am going to introduce even more changes than exists at present (not that I am in a position to really do this).

Some are dismissive of the need to obtain academic qualifications to undertake a nursing role. Interestingly, these comments appear more male orientated! Senior managers have remained supportive throughout. I cannot really identify any issues relating to resistance.

I have found that my colleagues who have always been receptive to new ideas and to changes within the service have been supportive and have taken an interest in my course and what I have shared with them. However the impression of other team members has been one of apathy and they have shown no real interest in any new ideas. However by using knowledge and skills learnt during the course it has been possible to utilize new ways of working and approaches to encourage some team members to explore new ways of working. My manager has been particularly supportive of the whole experience and has now strongly advocated that all managers should have the opportunity to gain further managerial skills. This has meant that I have had strong support to look at developing my working practices.

Support from all ... The acute focus of the Trust means my team feel unvalued and as a manager it is difficult to find the channels within the organisation by which I can connect the service with the corporate strategy. Having come from the LHB with a strategic head and exposure and experience that I treasure, I find myself being quite analytical and wanting to challenge what can sometimes seem to be a narrow vision and image of health and the political arena that the NHS sits in. I am learning to be measured and not to challenge everything!! (emotional intelligence!).

With evidence of some colleagues being dismissive and resistant, these comments identify the perceptions of the male dominated NHS culture and narrow, performance orientation. However, more encouragingly, these comments also demonstrate positive support for the new ideas and ways of working being introduced by these managers to effect small, local changes to culture.

Discussion

The students' comments suggest that the content of the taught modules is relevant and highly applicable/transferable to their work, thus meeting one of the principles of adult learning ([21] Knowles, 1975, [22] 1990). The material has helped them understand and challenge the NHS structure, strategy and culture. The students appreciated the safe environment in which to explore and challenge new material and attempt to apply this to their work contexts. They acknowledged the skills required of a lecturer to facilitate a critical approach, including the ability to manage and tolerate diverse, and sometimes conflicting views, and provide space for students to work through their own interpretations of the material. They particularly appreciated the purpose and format of assignments, providing significant choice to enable them to analyse real work problems and draw upon relevant theories to make recommendations for change. In these small projects, they enjoyed the role of organization consultant, even if they found it daunting at first. This again meets the principles of adult learning ([21] Knowles, 1975, [22] 1990). It also resonates with [28] Reynolds and Trehan's (2000) emphasis on the critical importance of less hierarchical methods of assessment, providing students with more choice. Such an approach to developing managers in the higher education context can help them challenge current practices and address issues of power and domination in the NHS context, although it is acknowledged that their workplace is more politicized and the classroom cannot completely or accurately simulate the complex NHS culture.

Interestingly, and without prompting, the students also employed new discursive resources ([14] Fairclough and Hardy, 1997) - suggesting a more critical approach to their learning, work roles and organizations. This was particularly evident in the MDP module. Students said they would be "More critical of HR dept - perhaps be more 'demanding' of them and of training dept or Trust," and "much more aware of HR and managerial issues that I now understand and could deal with differently." Another talked of "Developing critical approach to systems of NHS, HR and training". One student also commented "(I) feel more empowered to pursue HRM issues."

The dissertation phase appears to have reinforced many of these themes, with the students talking of their increased confidence, in what they do and how they question and challenge.

Having attempted to develop a critical pedagogy in the classroom, there are inherent difficulties in transferring this to the workplace. [33] Trehan (2004, p. 23) notes that "while examples of critical pedagogies are accumulating, they seldom exhibit corresponding changes in HRD practice." What has been the impact of this degree in practice? How have these managers been able to effect small, local changes in NHS culture? How sustainable are these? From their free response comments presented here, it appears that these students/managers are able to make changes in practice to address the modernisation and performance agenda. They also appear more confident and able to question and challenge dominant ideologies, drawing upon newly acquired discursive resources.

However, in addition to the limitations noted in the methodology, I acknowledge that this formative evaluation draws on the perceptions of only a small cohort, but this was the first cohort. I argue that it is still useful to evaluate the first delivery of this "new" critical approach to learn initial lessons and further improve the programme for subsequent, and probably larger, cohorts. However, the students themselves recognize that one of the strengths of this current programme has been the small numbers, and very friendly nature of group discussions. A key question is whether [26] Reynold's (1997) characteristics of a critical pedagogy can be achieved in a larger group.

A further limitation is the evaluation from just two perspectives - my own and the students - and at the end of the programme. Further longitudinal research would be useful to consider the impact of the managers' new attitudes and behaviours on colleagues (both junior and senior), the impact of their new managerial skills on local culture and practices and the impact of their changes and innovations on patient care.

Conclusions

I have presented a formative evaluation of a new MSc against characteristics of critical pedagogy. Early student evaluation suggests the introduction of critical pedagogy into an NHS management development programme has succeeded. However, as noted, this may be a function of the small cohort size and raises the question of whether such a critical approach is more "manageable" with such a small cohort? How successful could this be with larger cohorts? I have identified some of the tensions of developing critical health services managers and particularly the need to ensure guest speakers, who in this case were senior NHS managers, can deal with students' challenging questions.

I have considered the problems students encounter when they return to their organisational context, such as the apathy and resistance from some colleagues. This could create ethical issues, sending critical managers back to an uncritical context. However, overall, most students received support for their attempts to change practice and challenge norms of behaviour. Students themselves talk about how they have developed their criticality, and now feel confident to challenge the dominant local culture. Findings also suggest the programme has positively impacted on the local health culture and working practices, although this is based on self-report and further research is needed to validate these findings from management, peer and client perspectives.

To conclude, these early findings suggest that students can return to their health and social care organizations and challenge some of the practices associated with an increasing "business" culture and managerialism. These are a small cadre of managers, speaking a new language and developing a new philosophy of empowerment, and of critique. However, how ready is the NHS? These students have achieved small wins in their own local patches, but how ethical is it to develop critical managers who then return to practice in a managerialist NHS culture?

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Further Reading

1. Allio, R.J. (2005), "Leadership development: teaching versus learning", Management Decision, Vol. 43 No. 7, pp. 1071-7.

2. Billig, M. (2000), "Towards a critique of the critical", Discourse and Society, Vol. 11 No. 3, pp. 291-2.

3. Elliott, C. and Turnbull, S. (2005), "Critical thinking in human resource development: an introduction", in Elliott, C. and Turnbull, S. (Eds), Critical Thinking in Human Resource Development, Routledge Studies in Human Resource Development, Routledge, London, pp. 1-7.

4. French, J.R.P. and Raven, B. (1968), "The bases of social power", in Cartwright, D. and Zander, A.F. (Eds), Group Dynamics: Research and Theory, 3rd ed., Harper & Row, London.

5. Mannion, R., Davies, H. and Marshall, M. (2003), Cultures for Performance in Health Care: Evidence on the Relationships between Organisational Culture and Organizational Performance in the NHS, Centre for Health Economics, York.

Appendix

About the author

Sally Sambrook is Professor of Human Resource Development, Director of Postgraduate Studies (Business and Management) and Deputy Head of School at Bangor Business School. She leads the school's research and teaching in management, particularly human resource management. Her research interests focus on learning and development in small and large organisations, particularly the health service, given her nursing background. Sally has published numerous journal articles, edited texts and book chapters on HRD, including the health and social care context, and was awarded Outstanding Paper, for her work on critical HRD in 2005. She has also been awarded an Honorary Teaching Fellowship in recognition of her excellence in teaching and enhancing the student learning experience. Sally Sambrook can be contacted at: [email protected]