Professional autonomy in 21st century healthcare: Nurses’ accounts of clinical decision-making

Physician-nurse collaboration in the relationship between professional autonomy and practice behaviors

BACKGROUND

Nurses and physicians are key members of healthcare teams. While physicians are responsible for the diagnosis and treatment of patients, nurses are part of the treatment and the primary practitioners of patient care. Nurses' professional autonomy, collaboration with physicians, and practice behaviors in treatment and patient care practices are interrelated.

OBJECTIVES

In the present study, we examined the mediating effect of physician-nurse collaboration on the relationship between nurses' practice behaviors and their professional autonomy.

DESIGN

The present study utilized a cross-sectional survey design following quantitative methods.

METHODS

This study was conducted in the Istanbul Province of Turkiye from September to October 2022. The sampling method used was a convenience sampling strategy to provide easier access to participants when selecting nurses from different health institutions. The mean age of the 295 nurses was 31.23 years, with ages ranging from 21 to 59 years. The data analysis was conducted using IBM's SPSS 24.0 software package and the Process Macro 4.0 plug-in.

ETHICAL CONSIDERATION

Research ethics approval was obtained from the researcher's university.

RESULTS

Physician-nurse collaboration is positively associated with practice behaviors and professional autonomy. Nurses' professional autonomy in practice behaviors through physician-nurse collaboration is significant (95% CI [0.043, 0.135]).

DISCUSSION

Our results revealed the relationships among physician‒nurse collaboration, professional autonomy, and practice behaviors among nurses.

CONCLUSION

Our results provide evidence on the underlying factors of nurses' practice behaviors in patient care and guide the development of an intervention program to enhance this collaboration. Hospital managers can contribute to a collaborative physician‒nurse working environment.

Development of the nursing associate professional identity: A longitudinal qualitative study

AIM

The aim of this study was to understand the factors that contribute to the development of the nursing associate professional identity.

DESIGN

A 3-year longitudinal qualitative study of trainee nursing associates.

METHODS

Trainee nursing associates in England were interviewed remotely annually in February 2020, March 2021 and March 2022. They also provided diary entries. Data were anonymised, transcribed and analysed thematically.

RESULTS

Nursing associate professional identity was developed through: increased knowledge, skills and responsibility; and self-perceptions of identity alongside responses to the role by colleagues. Tensions arose when the scope of practice expected by organisations differed from that expected by the nursing associates. Frustrations occurred when nursing associates were perceived as substitutes for Registered Nurses in the context of nursing workforce shortages.

CONCLUSION

Nursing associates in this study clearly valued their new knowledge, skills and responsibility, enabling them to provide enhanced patient care. Increased clarity of role boundaries is necessary in enhancing the professional identity of nursing associates and reducing inter-professional tensions arising from role ambiguity within health and social care organisations.

IMPLICATIONS FOR THE PROFESSION

National guidance and employers should provide clarity on the boundaries of the nursing associate role which will strengthen their professional identity and mitigate role ambiguity within health and social care organisations.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research has been used to guide reporting.

PATIENT OF PUBLIC CONTRIBUTION

A patient and public involvement group was consulted during the initial study design stage.

IMPACT

This study aimed to understand the factors which contribute to the development of a nursing associate professional identity. Nursing associate professional identity is developed through increased knowledge, skills and responsibility, and the perceptions of identity by participants themselves and their colleagues. The findings should inform the implementation of initiatives to clarify nursing associate role boundaries and the development of similar roles internationally.

Interrogation in clinical supervision sessions: Exploring the construction of clinical psychology trainees’ professional identities

BACKGROUND

Professional socialisation is a complex process through which learners become healthcare professionals. This process occurs in relational spaces: learners are exposed to norms and expectations of them in interactions during formal and informal learning activities. Research exploring socialisation into the healthcare professions is extensive yet inadequately captures details of the actual processes of socialisation and forming of professional identity. Our study offers a moment-by-moment examination of clinical psychology trainee supervision to provide a deeper exploration of novice healthcare professionals' identity development within formal educational interactions.

AIMS

We sought to explore how, and in what ways, supervision interactions impact clinical psychology trainees' professional identity development.

METHOD

Our data comprises 12 audio recordings of supervisor-trainee interactions in a clinical psychology training clinic. Initial data engagement identified 20 instances of interrogation instigated by supervisors (i.e., repetitive questioning, enquiry) as being key events in which identities are contested and re-negotiated. These sections were transcribed verbatim. Drawing on positioning, framing and impression management theories, we explored identity construction in interrogations using discourse analysis.

RESULTS

Supervisors approached interrogations of trainees from either a quality control or a reflective frame focusing on the client or trainee respectively. These frames influenced the positions being made available to trainees. Reflective frame interrogations often defaulted back to quality control. Trainees employed impression management tactics to manage perceived face-threat.

DISCUSSION

Findings highlight challenges with maintaining a reflective space in supervision during interrogations. Supervisors had authority to initiate interrogations that could be taken up, negotiated or resisted by trainees, ultimately maintaining certain professional knowledge and truths. We illuminate the ways in which socialisation processes at the interactional level during formal learning activities ultimately make available (and restrict) certain ways for trainees to think, feel and be.

Exploring Ghanaian nurses knowledge and application of bio-ethical principles in postoperative pain management

Managing postoperative pain require good understanding of the bio-ethical principles in order to preserve patients’ rights. Bio-ethical principles in health care include autonomy, beneficence, justice and nonmaleficence. It is important that health care professionals understand that patients in pain have the right to satisfactory management. Good insight on ethical principles and how they relate to pain management places the nurse on a better pedestal to manage postoperative pain effectively. However, there is scanty literature on the level of Ghanaian nurses’ knowledge and application of bio-ethical principles in postoperative pain management. Therefore, the study objectives were to: explore nurses’ understanding of the bio-ethical principles in postoperative pain management; explore how nurses apply bioethical principles in postoperative pain management. The study employed qualitative exploratory descriptive design. Purposive sampling technique was used to recruit participants from the surgical wards. Semi-structured interview guide was designed for data collection. Data saturation was reached at the fourteenth participant. Thematic analysis method was used and themes emerged inductively. Three main themes identified through inductive content analysis of data were: beneficence, autonomy and justice. Findings showed that nurses had some appreciable level of knowledge of the fundamental principles related to ethics and applied them in postoperative pain management. Nurses knew their duties in advocating for patients. Patients rights to refuse treatment was also appreciated by some nurses. Nurses also demonstrated humanity by helping patients financially to settle hospital debts which explicitly shows the empathetic characteristics of nurses. The study concluded that nurses are knowledgeable in bioethical principles underpinning post operative pain management and also applied these principles when caring for surgical patients.

Disjunctures in practice: ethnographic observations of orthopaedic ward practices in the care of older adults with hip fracture and presumed cognitive impairment

Organisational priorities for health care focus on efficiency as the health and care needs of populations increase. But evidence suggests that excessive planning can be counterproductive, leading to resistance from staff and patients, particularly those living with cognitive impairment. The current paper adds to this debate reporting an Institutional Ethnography of staff delivering care for older patients with cognitive impairment on acute orthopaedic wards in three National Health Service hospitals in the United Kingdom. A key problematic identified in this study is the point of disjuncture seen between the actualities of staff experience and intentions of protocols and policies. We identified three forms of disjuncture typified as: ‘disruptions’, where sequenced care was interrupted by patient events; ‘discontinuities’, where divisions in professional culture, space or time interrupted sequenced tasks; and ‘dispersions’, where displaced objects or people interrupted sequenced care flow. Arguably disruption is an integral characteristic of care work; it follows that to enable staff to flourish, organisations need to confer staff the autonomy to address systemic disruptions rather than attempt to eradicate them. Ultimately, organisational representations of ‘good practice’ as readily joined up, impose a care standard ‘stereotype’ that obscures rather than clarifies the interactional problems encountered by staff.

Implementing Open Dialogue approaches: A scoping review

Open Dialogue approaches fall broadly into the area of systemic psychotherapeutic practices. They encourage active participation of families and social networks, and emphasize genuine collaboration within highly integrated systems of health-care service delivery. These approaches are currently being implemented in a growing number of services across the globe, and in this review, we summarize and discuss insights from papers concerned with the implementation of Open Dialogue. We used a scoping review method, which included systematic literature searches and summarizing data extraction as well as consultation with eight Open Dialogue implementation stakeholders who were invited to comment on preliminary review findings and a draft paper. We included 18 studies in the review and present their content under four thematic headings: 1. Training, 2. Family and network experiences, 3. Staff members' experiences, and 4. Structural and organizational barriers and resistance to implementation. In general, the studies did not include rich descriptions of the implementation contexts, which made it difficult to draw conclusions across studies about effective implementation practices. The discussion draws on Jamous and Peloille's (Professions and professionalisation, 1970, Cambridge University Press, 109-152) concepts of "indeterminacy" and "technicality," and we argue that the indeterminacy that dominates Open Dialogue is a challenge to implementation efforts that favor specific and standardized practices. We conclude by encouraging the development of implementation initiatives that theorize Open Dialogue practices with higher levels of technicality without corrupting the fundamental spirit of the approach.

Professional autonomy in nursing: An integrative review

AIM

To summarize knowledge of professional autonomy in nursing.

BACKGROUND

Professional autonomy is associated with experienced meaningfulness of the work. This refers to participation in decision-making and the ability to influence working practices.

EVALUATION

In an integrative review, relevant studies were retrieved from four databases. Quality was systematically evaluated using critical appraisal tools. PRISMA guidelines were followed. Inductive content analysis was used to analyse current knowledge of the focal subject.

KEY ISSUES

The search identified 27 relevant studies published between 2000 and 2019. Elements describing nurses' professional autonomy were independence in decision-making and ability to utilize one's own competence. Themes relating to nurses' professional autonomy were shared leadership, professional skills, inter- and intra-professional collaboration and healthy work environment.

CONCLUSION

Understanding the multidimensional nature of professional autonomy is essential to create attractive work environments. It is important to enable nurses to participate in decision-making and develop nursing through shared leadership to enhance the recruitment and retention of a skilled workforce.

IMPLICATIONS FOR NURSING MANAGEMENT

The findings have anticipated utility for supporting nursing practice and nurse leaders' understanding of approaches to foster nurses' professional autonomy.

Registered nurses' perceptions and experiences of autonomy: a descriptive phenomenological study

Background

Professional autonomy is a key concept in understanding nurses’ roles in delivering patient care. Recent research exploring the role of autonomy in the nursing work environment indicated that English and American nurses had differing perceptions of autonomy. This qualitative study aimed to explore the understanding and experiences of autonomy of nurses working in England.

Methods

A descriptive phenomenological analysis of data from 48 semi-structured interviews with registered nurses from two National Health Service (NHS) hospitals (purposive sample) was used to explore the concept of autonomy.

Results

Six themes were identified: working independently; working in a team; having professional skills and knowledge; involvement in autonomy; boundaries around autonomy; and developing autonomy requires support. A key finding was that nurses related autonomy to their clinical work and to the immediate work environment of their ward, rather than to a wider professional context. Nurses also perceived that autonomy could be turned off and on rather than comprising an integrated aspect of nursing.

Conclusions

Findings suggest that nurses in England, as framed by the sample, had a local ward-focused view of autonomy in comparison to nurses in America, who were reported to relate autonomy to a wider involvement in hospital level committees. Findings further indicate that autonomy was practiced occasionally, rather than incorporated into practice. Findings highlight the need for nurses in England to adopt a broader perspective and actively contribute to writing hospital guidelines and policies that recognise the importance of autonomy to nurse training and practice.

Strengthening nursing surveillance in general wards: A practice development approach

AIMS AND OBJECTIVES

To explore the context and culture of nursing surveillance on an acute care ward.

BACKGROUND

Prevention of patient deterioration is primarily a nursing responsibility in hospital. Registered nurses make judgements and act on emerging threats to patient safety through a process of nursing surveillance. Organisational factors that weaken nursing surveillance capacity on general wards increase the need for patient rescue at the end point of clinical deterioration with poorer outcomes. Yet little is known about cultures that enable and sustain ward nursing surveillance for patient safety.

DESIGN

Workplace observations and semistructured interviews using a critical lens as the first stage of a larger emancipatory practice development project.

METHODS

Researcher immersion including 96 hr of nonparticipant observation with 12 semistructured interviews during July-August 2017. This study adhered to the COREQ guidelines.

RESULTS

We offer a metaphor of nursing surveillance as the threads that support the very fabric of acute care nursing work. These hidden threads enable nurses to weave the tapestry of care that keeps patients safe. This tapestry is vulnerable to internal and external forces, which weaken the structure, putting patients and staff at risk.

CONCLUSION

Understanding local context is essential to supporting practice change. This workplace observation challenges us to find ways to creatively engage nurses with the underlying cultural and systems issues that so often remain hidden from view in the deteriorating patient literature.

RELEVANCE TO CLINICAL PRACTICE

Building cultural values that strengthen nursing surveillance is a prerequisite for safe and effective hospital care. As such, practice-based research that empowers frontline nurses and teams to develop person-centred workplace cultures can hold the key to unlocking sustainable improvements in patient safety.

Perceptions of critical and emergency department nurses regarding changes in their professional role

Objective Preliminary investigation of the way Greek critical and emergency department nurses conceptualize changes in their professional role. Method A qualitative focus-group methodology was applied. Following purposeful sampling and informed consent of participants. Results Participated eight individuals. The need for enhancement of nurses' participation in decision-making in order for an actual change in their professional role to be achieved was the central theme of participants' narratives. Perceived advancements in professional role performance regarded: evidence-based practice; technology; education, knowledge; clinical skills; research; heightened nurse-physician collaboration. Perceived reasons why these advancements failed to enhance nurses' professional role were lack of meritocracy; competitive relationships; lack of support among nurses; insufficient managerial support; budget limitations. Conclusion Despite advancements in clinical practice, participants did not deem that their professional role was enhanced significantly, as participation in decision-making and control over practice remain limited. Interventions targeted to enhance nurses' participation in clinical decision-making, and overall professional autonomy are recommended.

Nurses' Attitude towards Professionalization and Factors Influencing It

Introduction: Professionalism is one of the fundamental concepts in nursing and the result of the interaction with the environment and others. Nursing professionalism influences the quality of care and is affected by several factors. This study aimed to determine the attitude of nurses regarding professionalism and the factors affecting it. Methods: In this descriptive study, the attitude among nurses to professionalism has been measured through the questionnaire Hall, in five dimensions "membership in professional organizations", "public service", "a sense of calling", "self-regulation"," autonomy" and a researcher-made questionnaire about effective factors. One hundred eighty five nurses working in teaching hospitals affiliated to Tabriz University of Medical Sciences, participated in the study through stratified random sampling. The data were analyzed, using SPSS software, descriptive and inferential statistics. Results: The results showed that the nurses' attitude to professionalism is at the average level. Among the five dimensions, the scores from the highest to lowest belonged to "membership in professional organizations", "a sense of calling", "selfregulation", "autonomy" and "public service". The relationship between nurses' attitudes toward professionalism and variables of work experience and participation in training courses for individual empowerment was found to be statistically significant. Conclusion: The professional attitude among nurses is at the average level. Given the importance of the professionalism in nursing and the influence of various factors, efforts are directed at achieving the desired level and reducing the barriers.

Nurses' perception of the strategies to gaining professional power: A qualitative study

Background

Power in nursing is a broad concept that has a determining effect on the achievement of professional goals. Gaining power is essential for promoting the roles of nurses, improving their professional image and the consistent improvement of healthcare systems.

Objectives

This study was conducted to identify and clarify strategies for gaining power in the nursing profession through the experiences of Iranian nurses.

Methods

The present qualitative grounded theory study was conducted on fifteen participants selected through purposive sampling. Data were collected through individual, in-depth, semi-structured interviews. The data obtained were analyzed using the guidelines provided by Corbin and Strauss, (2008 edition). This study was carried out in Qazvin city of Iran and lasted fourteen months (2015–2016).

Results

The analysis of the data were classified under the main theme of gaining human-professional power based on individual and organizational capacities, divided into four main categories, including respecting human values and ethical principles (with two subcategories, keeping the human symbols of power and commitment to moral obligations of power), promoting professional interactions (with two subcategories, paying attention to intraprofessional communication and paying attention to interprofessional communication), attempting professional endurance (with two subcategories, raising self-confidence and having professional commitment), and valuing potential capacities (with two subcategories, regard for individual capacities and regard for organizational capacities).

Conclusion

The findings obtained suggest that success in gaining power in nursing, requires a cumulative focus on human, ethical, professional, individual and organizational capacities.

Barriers to intensive care unit nurses' autonomy in Iran: A qualitative study

BACKGROUND

The acute nature of the intensive care unit (ICU) environment necessitates that urgent clinical decisions are frequently made by the health care team. Therefore, it is important that critical care nurses have the authority to make decisions about their patient care.

PURPOSE

The purpose of this study was to explore perceived barriers to the practice of professional autonomy from the perspectives of ICU nurses in Iran.

METHODS

In this qualitative study, 28 critical care nurses were interviewed using a semistructured in-depth interview method. The interviews were recorded, transcribed verbatim, and analyzed using content analysis.

DISCUSSION

Data analysis led to identification of two main themes and five subthemes: (a) the profession-related barriers with two associated subthemes of "lack of capacity to exercise autonomy" and "lack of strong professional bodies"; (b) organizational barriers with the associated subthemes of "role ambiguity," "a directive rather than supportive workplace," and "lack of motivation."

CONCLUSION

ICU nurses in Iran may face many challenges in gaining professional autonomy. The identified inter- and intraprofessional barriers to the exercise of autonomy need to be addressed to promote critical thinking, job satisfaction, and motivation of ICU nurses, which can in turn lead to improved patient outcomes.

Workforce flexibility - in defence of professional healthcare work

Purpose The desirability of having a more flexible workforce is emphasised across many health systems yet this goal is as ambiguous as it is ubiquitous. In the absence of empirical studies in healthcare that have defined flexibility as an outcome, the purpose of this paper is to draw on classic management and sociological theory to reduce this ambiguity. Design/methodology/approach The paper uses the Weberian tool of "ideal types". Key workforce reforms are held against Atkinson's model of functional flexibility which aims to increase responsiveness and adaptability through multiskilling, autonomy and teams; and Taylorism which seeks stability and reduced costs through specialisation, fragmentation and management control. Findings Appeals to an amorphous goal of increasing workforce flexibility make an assumption that any reform will increase flexibility. However, this paper finds that the work of healthcare professionals already displays most of the essential features of functional flexibility but many widespread reforms are shifting healthcare work in a Taylorist direction. This contradiction is symptomatic of a failure to confront inevitable trade-offs in reform: between the benefits of specialisation and the costs of fragmentation; and between management control and professional autonomy. Originality/value The paper questions the conventional conception of "the problem" of workforce reform as primarily one of professional control over tasks. Holding reforms against the ideal types of Taylorism and functional flexibility is a simple, effective way the costs and benefits of workforce reform can be revealed.

The missing two Cs – commodity and critique: Obscuring the political economy of the ‘gift’ of nursing

This discussion paper argues for understanding nursing care as a commodity within capitalist relations of production, ultimately as a product of labour, whose use value far exceeds its exchange value and price. This under-recognised commodification of care work obscures the social relationships involved in the contribution to the social reproduction of labour and to capital accumulation by nursing care work. This matters, because many care workers give of themselves and their unpaid overtime to provide care as if in a ‘gift economy’, but in doing so find themselves in subordinate subject positions as a part of the social reproduction of labour in a ‘commodity economy’. Thus they are caught in the contradiction between the ‘appearance’ and reality. A focus on the individual moral character of nurses (e.g. the UK’s 6Cs), may operate as a screen deflecting understanding of the reality of the lived experiences of thousands of care workers and supports the discourse of ‘care as a gift’. The commodification of care work also undermines social reproduction itself. Many nurses will not have tools of analysis to critique their subject positioning by power elites and have thus been largely ineffectual in creating change to the neoliberalist and managerialist contexts that characterise many healthcare and other public sector organisations. The implications of this analysis for healthcare policy and nursing practice is the need for a critical praxis (an ‘action nursing’) by nurses and nursing bodies, along with their allies, which may include patient groups, to put care in all its guises and consequences central to the political agenda.

Nurses' Clinical Judgment Development: A Qualitative Research in Iran

Background:

Clinical judgment development is necessary because it leads to appropriate nursing diagnoses, clinical decision-making and health promotion.

Objectives:

In this study we explored the process of Iranian nurses’ development in clinical judgment.

Patients and Methods:

This qualitative study was conducted in 2013 at hospitals of Kurdistan University of Medical Sciences, located in the Sanandaj city of Iran. The data were collected based on semi-structured interviews and the study included 24 participants. Data analysis was carried out concurrently with data collection using the grounded theory method.

Results:

The study participants’ main concern was ‘being non-professional in clinical judgment’. In response to this concern, they were struggling for gaining professional autonomy, striving for integrating clinical judgment skills, scrambling to make effective educational interventions and striving for professional and inter professional collaboration in clinical judgment. The core category was ‘struggling for becoming professional in clinical judgment development’. When nurses were supported professionally, they were able to develop their professional clinical judgment.

Conclusions:

The findings of this study provided critical information about nurses’ professionalization in clinical judgment. Accordingly, the participants adopted different strategies to develop their clinical judgment ability. Integrating these strategies into nursing theory and clinical education can improve nurses’ clinical judgment ability.

Patient assessment within the context of healthcare delivery packages: A comparative analysis

BACKGROUND

Due to an increased focus on productivity and cost-effectiveness, many countries across the world have implemented a variety of tools for standardizing diagnostics and treatment. In Denmark, healthcare delivery packages are increasingly used for assessment of patients. A package is a tool for creating coordination, continuity and efficient pathways; each step is pre-booked, and the package has a well-defined content within a predefined category of diseases. The aim of this study was to investigate how assessment processes took place within the context of healthcare delivery packages.

METHODS

The study used a constructivist Grounded Theory approach. Ethnographic fieldwork was carried out in three specialized units: a mental health unit and two multiple sclerosis clinics in Southern Denmark, which all used assessment packages. Several types of data were sampled through theoretical sampling. Participant observation was conducted for a total of 126h. Formal and informal interviews were conducted with 12 healthcare professionals and 13 patients. Furthermore, audio recordings were made of 9 final consultations between physicians and patients; 193min of recorded consultations all in all. Lastly, the medical records of 13 patients and written information about packages were collected. The comparative, abductive analysis focused on the process of assessment and the work made by all the actors involved. In this paper, we emphasized the work of healthcare professionals.

RESULTS

We constructed five interrelated categories: 1. "Standardized assessing", 2. "Flexibility", which has two sub-categories, 2.1. "Diagnostic options" and 2.2. "Time and organization", and, finally, 3. "Resisting the frames". The process of assessment required all participants to perform the predefined work in the specified way at the specified time. Multidisciplinary teamwork was essential for the success of the process. The local organization of the packages influenced the assessment process, most notably the pre-defined scope of relevant diseases targeted by the package. The inflexible frames of the assessment package could cause resistance among clinicians. Moreover, expert knowledge was an important factor for the efficiency of the process. Some types of organizational work processes resulted in many patients being assessed, but without being diagnosed with at package-relevant disease.

CONCLUSION

Limiting the grounds for using specialist knowledge in structured health care delivery may affect specialists' sense of professional autonomy and can result in professionals employing strategies to resist the frames of the packages. Finally, when organizing healthcare delivery packages, it seems important to consider how to make the optimal use of specialist knowledge.

Moral decision-making among assertive community treatment (ACT) case managers: a focus group study

The context of care in assertive community treatment (ACT) can be precarious and generate ethical issues involving the principles of autonomy and paternalism. This focus group study examined case managers' situated accounts of moral reasoning. Our findings show how they expressed strong moral obligation towards helping the clients. Their moral reasoning reflected a paternalistic position where, on different occasions, the potential benefits of their interventions would be prioritised at the expense of protecting the clients' personal autonomy. The case managers' reasoning emphasised situational awareness, but there was a risk of supporting paternalistic interventions and denying the clients' right to autonomy.

Context and the leadership experiences and perceptions of professionals

Purpose

– Leadership studies which focus on categorising leadership styles have been critiqued for failure to consider the lived experience of leadership. The purpose of this paper is to use the framework of Jepson’s model of contextual dynamics to explore whether this framework assists understanding of the “how and why” of lived leadership experience within the nursing profession.

Design/methodology/approach

– Themes for a purposeful literature search and review, having regard to the Jepson model, are drawn from the contemporary and dynamic context of nursing. Government reports, coupled with preliminary interviews with a nurse leadership team, guided selection of contextual issues.

Findings

– The contextual interactions arising from managerialism, existing hierarchical models of leadership and increasing knowledge work provided insights into leadership experience in nursing, in the contexts of professional identity and changing educational and generational profiles of nurses. The authors conclude that employing a contextual frame provides insights in studying leadership experience. The author propose additions to the cultural and institutional dimensions of Jepson’s model.

Practical implications

– The findings have implications for structuring and communicating key roles and policies relevant to nursing leadership. These include the need to: address perceptions around the legitimacy of current nursing leaders to provide clinical leadership; modify hierarchical models of nursing leadership; address implications of the role of the knowledge workers.

Originality/value

– Observing nursing leadership through the lens of Jepson’s model of contextual dynamics confirms that this is an important way of exploring how leadership is enacted. The authors found, however, the model also provided a useful frame for considering the experience and understanding of leadership by those to be led.

The Evolution of Professional Nursing Culture in Italy: Metaphors and Paradoxes

We explored the perceptions of Italian nurses regarding their developing culture as a health profession. We sought to understand the ongoing evolution of the nursing profession and the changes that were central to it becoming an intellectual discipline on par with the other health professions in Italy. In 2010, the Regulatory Board of Nursing established a center of excellence to build evidence-based practice, advocate for interdisciplinary health care, and champion health profession reforms for nursing. In this study, focus groups—involving 66 nurse participants from various educational, clinical, and administrative backgrounds—were utilized to better ascertain how the profession has changed. Six themes, three of them metaphors—“vortex,” “leopard spots,” and “deductive jungle”—explain nurses’ experiences of professional change in Italy between 2001 and 2011 and the multiple dimensions that characterize their professional identity and autonomy.

Risk, rationality and learning for compassionate care; the link between management practices and the 'lifeworld' of nursing

The nursing care experiences of older people in the United Kingdom, has been much reported in the national and international press. Reasons for that poor quality of care in hospitals often focus on the 'culture' of organisations, as well as focusing on individual failings. However, discussions about culture change are partial explanations without a deeper analysis of how cultures and leadership operates in socio-political contexts which characterise nurses' 'habitus' and 'lifeworlds'. Therefore the solutions may not address wider determinants of care such as risk governance, managerialism, instrumental rationality and of course staffing and skill mix. Instead, organisations may be exhorted to change their cultures, without addressing these wider determinants and thus poor care practices may continue to occur. If targets are abolished, this may still leave a layer of managerialist thinking. This impacts on education because students, who are 'working and learning', experience occupational socialisation through immersion in the lifeworlds of their clinical colleagues. What is required is much less manageralism in the care of older people. Instead, there is a need for clinical leadership, based on critical reflective understanding of the occupational socialisation of nurses operating in a context of risk and rationality and organisational objectives; collegiate political and moral action by health professionals and society on behalf of the older person, and support for front line staff who require more autonomy and control over care practices.

Work demands, social support, and job satisfaction in eating disorder inpatient settings: a qualitative study

In this qualitative study, we aimed to investigate work demands experienced by health-care workers in an adult eating disorder inpatient service. We also aimed to investigate the use of social support and job satisfaction in this setting. Twelve health-care workers from an eating disorder inpatient ward, including nurses, health-care support workers, and occupational therapists, participated in semistructured interviews. Interviews were transcribed verbatim and analysed using thematic analysis. A number of work demands were discussed relating to therapeutic care, physical care, and organizational demands. Most participants discussed social support at work as being highly valuable, formally and informally, whereas external support was viewed as less important. Despite the challenges of caring for patients with eating disorders, the majority of participants reported good patient-related job satisfaction, but poor job satisfaction in relation to organizational factors. Eating disorder inpatient care is complex and demanding, necessitating effective teamwork, communication, and support systems among health-care workers. Interventions should be developed to target barriers to care, including time constraints, administrative workload, and insufficient allocation of staff.

Decision-making and accountability: differences of distribution

The cognitive and individual framing of clinical decision-making has been undermined in the social sciences by attempts to reframe decision-making as being distributed. In various ways, shifts in understanding in social science research and theorising have wrested clinical decision-making away from the exclusive domain of medical practice and shared it throughout the healthcare disciplines. The temporality of decision-making has been stretched from discrete moments of cognition to being incrementally built over many instances of time and place, and the contributors towards decision-making have been expanded to include non-humans such as policies, guidelines and technologies. However, frameworks of accountability fail to recognise this distributedness and instead emphasise independence of thought and autonomy of action. In this article I illustrate this disparity by contrasting my ethnographic accounts of clinical practice with the professional codes of practice produced by the General Medical Council and the Nursing and Midwifery Council. I argue that a 'thicker' concept of accountability is needed; one that can accommodate the diffuseness of decision-making and the dependencies incurred in collaborative work.

Knowledge claims, jurisdictional control and professional status: the case of nurse prescribing

Over the past decades, professional boundaries in health care have come under pressure, and the expansion of prescriptive authority to include nurses touches on issues of professional domains and interprofessional competition. Knowledge claims play an important role in achieving jurisdictional control. Knowledge can take on multiple forms, ranging from indeterminate to technical (I/T ratio) and from everyday to exclusive knowledge. To investigate the interrelatedness of jurisdiction, knowledge claims and professional status, we examine which knowledge claims were made by the medical and nursing professions in the Netherlands to secure or obtain, respectively, jurisdictional control over prescribing, and which form this knowledge took. The study is based on thirteen semi-structured stakeholder interviews and an extensive document analysis. We found that the nursing profession in its knowledge claims strongly emphasized the technicality and everyday knowledge character of the prescribing task, by asserting that nurses were already prescribing medicines, albeit on an illegal basis. Their second claim focused on the indeterminate knowledge skills of nurses and stated that nurse prescribing would do justice to nurses’ skills and expertise. This is a strong claim in a quest for (higher) professional status. Results showed that the medical profession initially proclaimed that prescribing should be reserved for doctors as it is a task requiring medical knowledge, i.e. indeterminate knowledge. Gradually, however, the medical profession adjusted its claims and tried to reduce nurse prescribing to a task almost exclusively based on technicality knowledge, among others by stating that nurses could prescribe in routine cases, which would generate little professional status. By investigating the form that professional knowledge claims took, this study was able to show the interconnectedness of jurisdictional control, knowledge claims and professional status. Knowledge claims are not mere rhetoric, but actively influence the everyday realities of professional status, interprofessional competition and jurisdictional division between professions.

Intensive care unit nurses' perceptions of patient participation in the acute phase of chronic obstructive pulmonary disease exacerbation: an interview study

Aim

To report a study conducted to explore intensive care unit nurses’ perceptions of patient participation in the acute phase of chronic obstructive pulmonary disease exacerbation.

Background

An acute exacerbation is a life-threatening situation, which patients often consider to be extremely frightening. Healthcare personnel exercise considerable power in this situation, which challenges general professional notions of patient participation.

Design

Critical discourse analysis.

Methods

In the autumn of 2009, three focus group interviews with experienced intensive care nurses were conducted at two hospitals in western Norway. Two groups had six participants each, and one group had five (N = 17). The transcribed interviews were analysed by means of critical discourse analysis.

Findings

The intensive care nurses said that an exacerbation is often an extreme situation in which healthcare personnel are exercising a high degree of control and power over patients. Patient participation during exacerbation often takes the form of non-involvement. The participating nurses attached great importance to taking a sensitive approach when meeting patients. The nurses experienced challenging ethical dilemmas.

Conclusion

This study shows that patient participation should not be understood in universal terms, but rather in relation to a specific setting and the interactions that occur in this setting. Healthcare personnel must develop skill, understanding, and competence to meet these challenging ethical dilemmas. A collaborative inter-professional approach between physicians and nurses is needed to meet the patients’ demand for involvement.