Separating, replacing, intersecting: The influence of context on the construction of the medical-nursing boundary

Assessment of the Psychometric Characteristics of the Italian Version of the Nurse Manager Actions Scale

Nurse managers play a vital role in healthcare organizations, wielding the ability to substantially enhance work environments, foster nurses' autonomy, and bolster retention within workplaces. In this context, this study focuses on the Nurse Manager Actions scale, aiming to evaluate its items' scalability as well as the scale's validity and reliability among nurses and nurse managers operating within the Italian healthcare context. The study protocol was not registered. To ensure linguistic and cultural alignment, an iterative and collaborative translation process was undertaken. Subsequently, a multi-center cross-sectional design was adopted. Using a web-survey approach, data were collected among 683 nurses and 188 nurse managers between August 2022 and January 2023. The Nurse Manager Actions scale was found to be a valid and reliable instrument in Italian after a Mokken Scale Analysis. For nurses (HT= 0.630, Molenaar-Sijtsma rho = 0.890), the scale included 6 items, while 11 items were confirmed for nurse managers (HT= 0.620, Molenaar-Sijtsma rho = 0.830). Nurse Manager Actions scale scores were correlated with increased satisfaction and decreased intention to leave for both nurses and nurse managers. The employed validation process enhanced the scale validity for use in Italy and provided a model for other researchers to follow when assessing similar measures in different populations. Measuring and empowering nurse manager actions in work contexts is essential to improve the general well-being and retention of nurses, especially in the current nursing shortage.

Nursing experience during COVID-19 pandemic in Korea: a qualitative analysis based on critical components of the professional practice models

BACKGROUND

Nurses have an essential role and responsibility to work at the forefront of patient care during the COVID-19 pandemic. Although the press and public have praised the dedication of nurses in the COVID-19 pandemic, there are several points to consider for nursing professional development. The purpose of this study is to collect the experiences of the nursing profession in the COVID-19 pandemic through interviews, seek improvements for the development of the nursing profession, and suggest directions for the future.

METHOD

This qualitative study adopts semi-structured interviews analyzing the nursing experience of the COVID-19 pandemic based on the professional practice models (PPMs). Ten nurses with at least two years of working experience and thorough work changes in the COVID-19 pandemic from various settings have participated in the study.

RESULTS

We identified thirty-nine problematic codes and nineteen improvement codes which mapped to 12 key concepts and corresponded to 6 constructs of the PPM model.

CONCLUSION

Nurses had to take on tasks beyond their duties in urgent situations, which restrained nurses from concentrating on their work. Clarifying working boundaries is fundamental for collaborative care and independent nursing practice. Collaboration and communication among healthcare workers based on mutual understanding can create a respectful working environment. Although there were many difficulties due to the uncertain situation, we can find that the nursing profession can make achievements through systematic and organizational support for sticking to the basics of nursing, securing technical expertise, cultivating critical thinking, and developing various professional attributes. In this way, the establishment of roles based on professional values and duties and the ascertainment of clear boundaries for nursing will ultimately help to improve the quality of patient care.

The evolution of advanced nursing practice: Gender, identity, power and patriarchy

To address longstanding workforce shortages, increase efficiency and control the costs associated with the modern health-care provision, there has been a worldwide policy to promote increased flexibility within the health-care workforce. This is being done primarily by extending the 'scope of practice' of existing occupational roles into what is referred to as 'advanced' practice. The development of the advanced practice nurse (APN) has occurred within the context of a shortage of medical staff, and the need to control cost. However, the means by which substantially repurposed occupational groups such as these, are incorporated into complex, hierarchical organisations such as the UK national health service (NHS) remains poorly understood. Using modern sociological theory, the development of the APN role has been examined in terms of power, control, professional identity and gender relations. Each of the theoretical approaches used adds to the quality of the discussion, although none provide a comprehensive picture. However, when synthesised, they do provide an enhanced insight into the evolution of the role. It is argued here that by critically examining the development of the APN role, this will enable both a better understanding of, and the means to influence, its future direction of travel.

A qualitative exploratory study of training requirements for general practitioners attending older people resident in care homes

Purpose

Older people who reside in care homes have varying access and quality of medical care; in the UK, this is provided by general practitioners (GPs). The authors aimed to explore the experiences of trainee GPs in delivering integrated care and discuss, with senior GPs, opportunities to improve training.

Design/methodology/approach

Two trainees and thirteen senior GPs were recruited through professional networks and participated in semi-structured interviews. Transcriptions were analysed using thematic analysis, and the theory of negotiated order was used to interpret findings.

Findings

Trainees received no specific training on working with care homes. Exposure to the care home setting was variable, and could be negligible, depending on the GP practice placement. Senior GPs expressed concerns about patient safety, due to practical challenges of the consultation and a sense of lack of control. Considering the theory of negotiated order, where GPs had trusting relationships with care home staff, the input of the staff could mitigate the sense of risk. Care plans could communicate needs and preferences within the team and may be a way of extending the negotiated order, for example giving care homes authority to implement end-of-life care when the GP is not present.

Research limitations/implications

The authors identified a need for trainees to engage with the organisational aspect of the care home to deliver integrated care. Trusted relationships with staff led to improved consultations, care plans, and better management of risk.

Originality/value

This is the first study of learning needs for GP trainees to provide integrated care for older care home residents.

It is like taking a ball for a walk: on boundary work in software development

In this paper, we explore how the choices of boundary work in software development influence the team autonomy enacted by team members. Boundary work is when people protect their professional individual autonomy, when they downplay that autonomy to collaborate over professional boundaries, and when they create new boundaries. Team autonomy is here defined as a team using their autonomy to collaborate in deciding their own output. We use an action research design, with varied methodologies carried out through three action cycles. Our findings show that when collective, collaborative boundary work is not performed, a sort of individualized zone occurs where individuals either try to do collaborative boundary work by themselves or seek individual autonomy. We propose that individual autonomy can be divided into professional individual autonomy and situationally dependent individual autonomy. This research contributes theoretically by showing how the absence of collaborative boundary work can lead to an individualized zone. Practically, it can improve team autonomy by enhancing the understanding of why teams should perform collaborative boundary work. The value of the concept of boundary work used in this setting involves studying the intentions for collaboration, not whether collaboration actually takes place.

Exploring the role of power during debriefing of interprofessional simulations

Interprofessional simulation aims to improve teamwork and patient care by bringing participants from multiple professions together to practice simulated patient care scenarios. Yet, power dynamics may influence interprofessional learning during simulation, which typically occurs during the debriefing. This issue has received limited attention to date but may explain why communication breakdowns and conflicts among healthcare teams persist despite widespread adoption of interprofessional simulation. This study explores the role of power during interprofessional simulation debriefings. We collected data through observations of seven interprofessional simulation sessions and debriefings, four focus groups with simulation participants, and four interviews with simulation facilitators. We identified ways in which power dynamics influenced discussions during debriefing and sometimes limited participants' willingness to share feedback and speak up. We also found that issues related to power that arose during interprofessional simulations often went unacknowledged during the debriefing, leaving healthcare professionals unprepared to navigate power discrepancies with other members of healthcare teams in practice. Given that the goal of interprofessional simulation is to allow professionals to learn together about each other, explicitly addressing power in debriefing after interprofessional simulation may enhance learning.

Boundary work in response to professionals’ contextual constraints: Micro-strategies in interprofessional collaboration

Boundary-work research has extensively explored how professionals engage in boundary work to protect or expand their professional boundaries in interprofessional collaboration (IPC). Yet professionals’ contextual constraints in everyday work, such as time pressure or legal restrictions, often result in competing interests of the professionals involved in IPC, prompting them to engage in boundary work to limit—instead of protect or expand—their boundaries. Our empirical analysis uses comprehensive qualitative data on IPC in Germany between self-employed general practitioners (GPs) and registered nurses employed in nursing homes in which GPs’ efficiency interests compete with nurses’ safeguarding interests, leading both professionals to engage in boundary-work efforts to limit their boundaries. Our findings provide a comprehensive understanding and framework of professionals’ boundary work, showing that individual GPs and nurses typically hold a portfolio of various defending and accommodating micro-strategies. Based on our first-order findings, we identify how different sources of power enable particular micro-strategies and explore how the choice of micro-strategies depends on different forms of trust in the collaborating partner. Lastly, we outline interactions of micro-strategies, illustrating how the outcomes of professionals’ bilateral boundary work depend on the sequence of these strategies.

The experiences and needs of re-entering nurses during the COVID-19 pandemic: A qualitative study

Background: During the COVID-19 outbreak in the Netherlands, thousands of former nurses have returned to nursing to support healthcare staff. After a period of absence and with little time to prepare, these former nurses re-entered  during a challenging, uncertain and rapidly evolving pandemic. Little is known about the experiences and needs of these re-entering nurses.

Objectives: Assessing the needs and experiences of re-entering nurses during the COVID-19 pandemic.

Design: Qualitative study using a pragmatist approach within the interpretative paradigm.

Settings: This study took place in the following settings within the Dutch healthcare system: Intensive care units, COVID and regular departments within hospitals, nursing home settings, a rehabilitation centre and newly established COVID-19 departments within nursing home settings.

Participants: We purposively selected 20 nurses who had re-entered nursing during the first wave of the COVID-19 pandemic between March 2020 and June 2020 in the Netherlands. The first interview was conducted on the eighth of May 2020.

Methods: We conducted 20 semi-structured interviews in Dutch. Interviews were transcribed verbatim and analysed via thematic content analysis in the coding program of MAXQDA2020. This study followed the SRQR and COREQ  guidelines.

Results: Seven main themes were identified. Clear job description: Participants mentioned that a lack of a clear job description led to lack of clarity  about the kind of tasks that re-entering nurses were expected and allowed to perform. Training: the majority of the participants had received none or little training prior to their return. Training content:  Re-entering nurses mentioned to wish for an easily accessible mentorship structure and an individualised and practical training program. Positive team dynamic: Re-entering nurses felt supported by a positive team dynamic, which was shaped by the sense of urgency and relevance of their work and helped them deal with stressful experiences. Mental health: Nearly all participants mentioned that re-entering during a pandemic did not lead to impairment of their mental health. mental health support:  Most participants mentioned being able to cope with their mental health independently, sharing experiences with family and colleagues

Conclusion:  The results indicate that a rapid and safe return to nursing during a pandemic could be facilitated by: a clear description of roles and responsibilities; an individualised assessment determining the competences and knowledge disparities of re-entering nurses; practical training focussing on competencies needed during a pandemic; and a collaborative mentorship structure to guide re-entering nurses.

Tweetable abstract: In-depth interviews with former nurses who returned to #nursing during the first wave of the #COVID19 #pandemic in the Netherlands

Implementation of a central-line bundle: a qualitative study of three clinical units

Background

Evidence for the central line-associated bloodstream infection (CLABSI) bundle effectiveness remains mixed, possibly reflecting implementation challenges and persistent ambiguities in how CLABSIs are counted and bundle adherence measured. In the context of a tertiary pediatric hospital that had reduced CLABSI by 30% as part of an international safety program, we aimed to examine unit-based socio-cultural factors influencing bundle practices and measurement, and how they come to be recognized and attended to by safety leaders over time in an organization-wide bundle implementation effort.

Methods

We used an interpretivist qualitative research approach, based on 74 interviews, approximately 50 h of observations, and documents. Data collection focused on hospital executives and safety leadership, and three clinical units: a medical specialty unit, an intensive care unit, and a surgical unit. We used thematic analysis and constant comparison methods for data analysis.

Results

Participants had variable beliefs about the central-line bundle as a quality improvement priority based on their professional roles and experiences and unit setting, which influenced their responses. Nursing leaders were particularly concerned about CLABSI being one of an overwhelming number of QI targets for which they were responsible. Bundle implementation strategies were initially reliant on unit-based nurse education. Over time there was recognition of the need for centralized education and reinforcement tactics. However, these interventions achieved limited impact given the influence of competing unit workflow demands and professional roles, interactions, and routines, which were variably targeted in the safety program. The auditing process, initially a responsibility of units, was performed in different ways based on individuals’ approaches to the process. Given concerns about auditing reliability, a centralized approach was implemented, which continued to have its own variability.

Conclusions

Our findings report on a contextualized, dynamic implementation approach that required movement between centralized and unit-based approaches and from a focus on standardization to some recognition of a role for customization. However, some factors related to bundle compliance and measurement remain unaddressed, including harder to change socio-cultural factors likely important to sustainability of the CLABSI reductions and fostering further improvements across a broader safety agenda.

Transferring, translating and transforming knowledge: the role of brokering in healthcare networks

PURPOSE

This research examines how knowledge and information are managed within two care networks. We develop a conceptual framework drawing on the notion of brokering and the 3T framework, which is used to describe the relative complexity of boundaries (referred to in the framework as syntactic, semantic and pragmatic) as well as capabilities and processes required to exchange information within the network. Previous research on brokering has focused on healthcare managers and professionals, but this research extends to patients and caregivers. Understanding knowledge exchange and brokering practices in healthcare is critical to the delivery of effective services.

DESIGN/METHODOLOGY/APPROACH

For this case research, non-participant observation and experienced-based interviews were undertaken with healthcare professionals, patients and caregivers within two care networks.

FINDINGS

The findings reveal brokering roles occupied by healthcare professionals, patients and caregivers support the transfer, translation and transformation of knowledge and information across functional and organisational boundaries. Enablers and disablers to brokering and the exchange of knowledge and information are also identified.

RESEARCH LIMITATIONS/IMPLICATIONS

The study is limited to two care networks for long-term conditions within the UK. Further research opportunities exist to examine similar care networks that extend across professional and organisational boundaries.

PRACTICAL IMPLICATIONS

This research informs healthcare professionals of the brokering capabilities that occur within networks and the enabling and disabling factors to managing knowledge across boundaries.

ORIGINALITY/VALUE

This paper provides a conceptual framework that categorises how increased levels of knowledge and information exchange and brokering practices are managed within care networks.

Interprofessional and multiprofessional approaches in quality improvement education

The imperative for all healthcare professionals to partake in quality improvement (QI) has resulted in the development of QI education programs with participants from different professional backgrounds. However, there is limited empirical and theoretical examination as to why, when and how interprofessional and multiprofessional education occurs in QI and the outcomes of these approaches. This paper reports on a qualitative collective case study of interprofessional and multiprofessional education in three longitudinal QI education programs. We conducted 58 interviews with learners, QI project coaches, program directors and institutional leads and 135 h of observations of in-class education sessions, and collected relevant documents such as course syllabi and handouts. We used an interpretive thematic analysis using a conventional and directed content analysis approach. In the directed content approach, we used sociology of professions theory with particular attention to professional socialization, hierarchies and boundaries in QI, to understand the ways in which individuals' professional backgrounds informed the planning and experiences of the QI education programs. Findings demonstrated that both interprofessional and multiprofessional education approaches were being used to achieve different education objectives. While each approach demonstrated positive learning and practice outcomes, tensions related to the different ways in which professional groups are engaging in QI, power dynamics between professional groups, and disconnects between curricula and practice existed. Further conceptual clarity is essential for a more informed discussion about interprofessional and multiprofessional education approaches in QI and explicit attention is needed to professional processes and tensions, to optimize the impact of education on practice.

Dynamics of interprofessional teamwork: Why three logics are better than one

Much research has used three logics to understand the dynamics of interprofessionalism: 1) assimilation, that is, adapting the work of others; 2) segregation, where professional roles are separated and boundaries defended; and 3) integration, a perspective on the complementarity of professional roles. However, we found no studies analysing all three logics in connection with each other. Based on an ethnographic study of interprofessional teamwork in the field of mental health and substance use in Norway, this article explores the dynamics of interprofessionalism from all three perspectives. The data collection consisted of 14 observation sessions and 18 in-depth interviews of professionals in the field of health and social work. Investigating how, when and why each logic came into play, the results show the importance of including all three logics to leverage each one's purpose and function, and how they appear almost simultaneously in many situations. By investigating all three logics, the paper provides a broader, more comprehensive view of interprofessional teamwork.

Challenging the interprofessional epistemic boundaries: The practices of informing in nurse-physician interaction

Interprofessional management of knowledge in health care settings appears to be particularly vital for the ways in which information circulates, medical decisions are taken, and nursing practices are implemented. Drawing on an extensive ethnographic fieldwork in an Italian Intensive Care Unit, this article investigates how the nurses orient to and concurrently challenge the nurse-physician epistemic boundaries by the different ways through which they perform "informing", and make it work as a diagnostic-relevant activity. Adopting an ethnographic-nurtured discursive approach to a dataset of video-recorded morning briefings, we analyze the nurses' informing contributions in terms of sequential position, turn-taking and turn design. We identify five practices of informing and show how they display different degrees of agency and differently impact on the team's "infectious diseases diagnostic reasoning". This article contributes to nurse-physician interaction studies by showing how the epistemic imbalance at play is interactionally accomplished by participants one interaction at a time. Particularly, the analysis demonstrates that the nurses actively contribute to the teamwork by a skillful management of knowledge that precedes the exercise of the physicians' epistemic and deontic rights implied in diagnosing and planning. Our findings illustrate how the nurses: a) exert their interactional agency without crossing the institutionally sanctioned epistemic and deontic boundaries to which they are observably oriented to; b) cautiously challenge the epistemic imbalance at play in nurse-physician interaction and c) actively contribute in setting the premises of the team's collective decisions. Conclusion and practical implications are proposed.

How do team experience and relationships shape new divisions of labour in robot-assisted surgery? A realist investigation

Safe and successful surgery depends on effective teamwork between professional groups, each playing their part in a complex division of labour. This article reports the first empirical examination of how introduction of robot-assisted surgery changes the division of labour within surgical teams and impacts teamwork and patient safety. Data collection and analysis was informed by realist principles. Interviews were conducted with surgical teams across nine UK hospitals and, in a multi-site case study across four hospitals, data were collected using a range of methods, including ethnographic observation, video recording and semi-structured interviews. Our findings reveal that as the robot enables the surgeon to do more, the surgical assistant's role becomes less clearly defined. Robot-assisted surgery also introduces new tasks for the surgical assistant and scrub practitioner, in terms of communicating information to the surgeon. However, the use of robot-assisted surgery does not redistribute work in a uniform way; contextual factors of individual experience and team relationships shape changes to the division of labour. For instance, in some situations, scrub practitioners take on the role of supporting inexperienced surgical assistants. These changes in the division of labour do not persist when team members return to operations that are not robot-assisted. This study contributes to wider literature on divisions of labour in healthcare and how this is impacted by the introduction of new technologies. In particular, we emphasise the need to pay attention to often neglected micro-level contextual factors. This can highlight behaviours that can be promoted to benefit patient care.

How to be a very safe maternity unit: An ethnographic study

Maternity care continues to be associated with avoidable harm that can result in serious disability and profound anguish for women, their children, and their families, and in high costs for healthcare systems. As in other areas of healthcare, improvement efforts have typically focused either on implementing and evaluating specific interventions, or on identifying the contextual features that may be generative of safety (e.g. structures, processes, behaviour, practices, and values), but the dialogue between these two approaches has remained limited. In this article, we report a positive deviance case study of a high-performing UK maternity unit to examine how it achieved and sustained excellent safety outcomes. Based on 143 h of ethnographic observations in the maternity unit, 12 semi-structured interviews, and two focus groups with staff, we identified six mechanisms that appeared to be important for safety: collective competence; insistence on technical proficiency; monitoring, coordination, and distributed cognition; clearly articulated and constantly reinforced standards of practice, behaviour, and ethics; monitoring multiple sources of intelligence about the unit's state of safety; and a highly intentional approach to safety and improvement. These mechanisms were nurtured and sustained through both a specific intervention (known as the PROMPT programme) and, importantly, the unit's contextual features: intervention and context shaped each other in both direct and indirect ways. The mechanisms were also influenced by the unit's structural conditions, such as staffing levels and physical environment. This study enhances understanding of what makes a maternity unit safe, paving the way for better design of improvement approaches. It also advances the debate on quality and safety improvement by offering a theoretically and empirically grounded analysis of the interplay between interventions and context of implementation.

Demarcating the dirty work: Canadian Fertility professionals' use of boundary-work in contentious egg donation

The potential medical risks to egg donors, in addition to the concern over the commodification of life, has led to debates surrounding the ethics of paying donors. In Canada, payment for eggs is prohibited by law; however, what is considered payment is contentious and has yet to be defined. The lack of legislative clarity coupled with increased ethical concerns over paying a donor has shifted egg donation from a medically-controlled procedure to a legal and social endeavor involving multiple professionals. Through semi-structured interviews with 52 medical and non-medical fertility practitioners, I show how medical practitioners use boundary-work to remove their practice from the ethical and legal debates surrounding egg donation, the "dirty work". I examine how the medical profession relies on discourses of "practicing science" to present their work as favorable and removed from current debates and potential legal ramifications. In showing how medical practitioners rely on boundary-work to distinguish their work from non-scientific and non-medical activities, I expand Gieryn's original conceptualization of boundary-work to demonstrate how medical practitioners can selectively draw on their practice of science to remove their work from ethically and legally contentious issues, the dirty work.

Formalisation and subordination: a contingency theory approach to optimising primary care teams

OBJECTIVE

While there is consensus on the need to strengthen primary care capacities to improve healthcare systems' performance and sustainability, there is only limited evidence on the best way to organise primary care teams. In this article, we use a conceptual framework derived from contingency theory to analyse the structures and process optimisation of multiprofessional primary care teams.

DESIGN

We focus specifically on inter-relationships between three dimensions: team size, formalisation of care processes and nurse autonomy. Interview-based qualitative data for each of these three dimensions were converted into ordinal scores. Data came from eight pilot sites in Quebec (Canada).

RESULTS

We found a positive association between team size and formalisation (correlation score 0.55) and a negative covariation (correlation score -0.64) between care process formalisation and nurses' autonomy/subordination. Despite the study being exploratory in nature, such relationships validate the idea that these dimensions should be analysed conjointly and are coherent with our suggestion that using a framework derived from a contingency approach makes sense.

CONCLUSIONS

The results provide insights about the structural design of nurse-intensive primary care teams. Non-physicians' professional autonomy is likely to be higher in smaller teams. Likewise, a primary care team that aims to increase nurses' and other non-physicians' professional autonomy should be careful about the extent to which it formalises its processes.

Bedside nurses' roles in discharge collaboration in general internal medicine: Disconnected, disempowered and devalued?

Collaboration among nurses and other healthcare professionals is needed for effective hospital discharge planning. However, interprofessional interactions and practices related to discharge vary within and across hospitals. These interactions are influenced by the ways in which healthcare professionals' roles are being shaped by hospital discharge priorities. This study explored the experience of bedside nurses' interprofessional collaboration in relation to discharge in a general medicine unit. An ethnographic approach was employed to obtain an in-depth insight into the perceptions and practices of nurses and other healthcare professionals regarding collaborative practices around discharge. Sixty-five hours of observations was undertaken, and 23 interviews were conducted with nurses and other healthcare professionals. According to our results, bedside nurses had limited engagement in interprofessional collaboration and discharge planning. This was apparent by bedside nurses' absence from morning rounds, one-way flow of information from rounds to the bedside nurses following rounds, and limited opportunities for interaction with other healthcare professionals and decision-making during the day. The disconnection, disempowerment and devaluing of bedside nurses in patient discharge planning has implications for quality of care and nursing work. Study findings are positioned within previous work on nurse-physician interactions and the current context of nursing care.

Examining the implementation of collaborative competencies in a critical care setting: Key challenges for enacting competency-based education

Interprofessional collaboration is recognised as an important factor in improving patient care in intensive care units (ICUs). Competency frameworks, and more specifically interprofessional competency frameworks, are a key strategy being used to support the development of attitudes, knowledge, skills, and behaviours needed for an interprofessional approach to care. However, evidence for the application of competencies is limited. This study aimed to extend our empirically based understanding of the significance of interprofessional competencies to actual clinical practice in an ICU. An ethnographic approach was employed to obtain an in-depth insight into healthcare providers' perspectives, behaviours, and interactions of interprofessional collaboration in a medical surgical ICU in a community teaching hospital in Canada. Approximately 160 hours of observations were undertaken and 24 semi-structured interviews with healthcare workers were conducted over a period of 6 months. Data were analysed using a directed content approach where two national competency frameworks were used to help generate an understanding of the practice of interprofessional collaboration. Healthcare professionals demonstrated numerous instances of interprofessional communication, role understandings, and teamwork in the ICU setting, which supported a number of key collaborative competencies. However, organisational factors such as pressures for discharge and patient flow, staffing, and lack of prioritisation for interprofessional learning undermined competencies designed to improve collaboration and teamwork. The findings demonstrate that interprofessional competencies can play an important role in promoting knowledge, attitudes, skills, and behaviours needed. However, competencies that promote interprofessional collaboration are dependent on a range of contextual factors that enable (or impede) individuals to actually enact these competencies.