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

Liberati, Elisa Giulia

doi:10.1016/j.socscimed.2016.11.008

Cited by 45 publications

(50 citation statements)

References 29 publications

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“…organizational) factors such as timely discharges and limited resources for interprofessional learning. The variability in our findings reflects research demonstrating both collaboration and conflict in ICU settings (Xyrichis et al, 2017), and that interprofessional interactions are not solely about individuals' competencies; rather, the clinical contexts in which they work shape the nature of these interactions (Liberati, 2017).…”

Section: Discussionmentioning

confidence: 62%

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

Goldman

Kitto

Reeves

2017

Journal of Interprofessional Care

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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.

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Section: Discussionmentioning

confidence: 62%

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

Goldman

Kitto

Reeves

2017

Journal of Interprofessional Care

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“…Thus, in contrast to other findings that inter-professional relations are characterised by conflict and differing viewpoints (cf. , I observed a more collaborative work setting, aligning with Carmel (2006b) and Liberati (2017). As members of this integrated community of practice, nurses could continue to develop their clinical knowledge, which in turn supported boundary-blurring work in triage and other nursing roles in the EPCC.…”

Section: Collegial Interactiona Community Of Practicementioning

confidence: 99%

“…work that obscures formal jurisdictional boundaries. Most such studies have centred on healthcare organisations, with particular emphasis on 'the nursing-medical boundary' Annandale et al, 1999;Apesoa-Varano, 2013;Carmel, 2006a;Liberati, 2017;Porter, 1991;Prowse and Allen, 2002;Salhani and Coulter, 2009;Snelgrove and Hughes, 2000;Stein, 1967;Stein et al, 1990;Svensson, 1996;. For instance, did participant observation in a casualty clinic and discovered that nurses frequently found themselves "moving close to areas of judgment for which the doctor takes legal responsibility" (Hughes, 1988, p. 5).…”

Section: Introductionmentioning

confidence: 99%

Between standardisation and discretion: the priority setting of triage nurses

Johannessen¹

2018

Preprint

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This dissertation explores the relationship between standardisation and discretion in professional work at street level, using the priority setting of triage nurses as its case. Triage nurses are employed at the frontline of emergency medical services, where they work to assess the urgency of patients’ complaints. This work can be very challenging, requiring rapid assessments of a large group of unknown and unsorted patients, some of whom may be critically ill. To aid these assessments, emergency services have increasingly introduced standardised triage systems that specify how nurses should proceed in interpreting and prioritising cases. Triage systems reflects a broader trend in healthcare, which has seen a widespread introduction of clinical practice guidelines, all seeking to generate uniformity and quality control by streamlining clinical decision making. The introduction of these guidelines has been described as an unprecedented form of standardisation of professional clinical work, but there is little consensus regarding their effects. While proponents argue that clinical practice guidelines are an important means of improving quality and efficiency, critics denounce them for promoting bureaucratisation, homogenisation and so-called ‘cookbook medicine’. Observing this impasse, there have been calls for an empirically grounded ‘sociology of standardisation’ to acknowledge that guidelines can have different effects in different settings and to explore standardisation on a case-by-case basis. Informed by that proposal, this dissertation explores the relationship between standardisation and discretion in triage nurses’ priority setting. The dissertation is based on nine months of fieldwork in a Norwegian emergency primary care clinic (EPCC), where nurses were required to assess patients using the Manchester Triage System (MTS). Observations revealed that nurses regularly departed from the MTS while also seeming to be influenced by the system in a number of ways. On this basis, the dissertation addresses the question of how and why nurses departed from the MTS and, conversely, how the MTS influenced their assessments. The introduction and the four associated articles show how nurses supplemented the MTS with additional skills and knowledge, and how this led them to adjust or override the priorities formally prescribed by the system. While they had several reasons for so doing, their primary concern was to ‘correct’ the MTS and to ensure more precise prioritisation of patients. However, the MTS also played a significant role in their assessments by restricting, enabling and supporting priority setting.Beyond shedding light on discretionary practices among triage nurses, the dissertation makes three more general contributions to the sociology of standardisation. First, it helps to bridge the gaps between the sociology of standardisation and the literatures on street-level bureaucracy and categorisation. In so doing, it identifies fruitful theoretical linkages for future studies of standardisation and discretion in street-level categorisation of clients.Secondly, the in-depth exploration of nurses’ use of the MTS provides a rich account of the difficulties of streamlining clinical practice. Despite its elaborate design, the MTS was too ‘thin’ to match the complexity of triage nurses’ work, and to follow it unreflectively would be to the detriment of both patients and staff. For that reason, nurses found it necessary to render the guidelines ‘thicker’ by making situated judgments, illustrating the crucial role of additional skills and knowledge in making standards work.Finally, the dissertation shows how the MTS (despite its shortcomings) affected nurses’ work in multiple ways, illustrating how guidelines interact with professional practice. In so doing, the dissertation transcends the either/or language that characterises much of the debate around standardisation, instead providing a nuanced account of the interplay between prescribed and discretionary aspects of triage nursing.

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“…These study findings provide insights into one GIM unit in Canada, but illuminate the importance of such in-depth studies across clinical units and hospitals nationally and internationally to better understand how interprofessional collaboration and, more specifically, nurse-physician interactions in discharge vary across care settings. These in-depth and comparison studies would allow deeper insights into the contextual factors that shape interprofessional negotiations (Liberati, 2017). In addition, further research 2 Interprofessional education has been defined as 'occasions when two or more health/ social care professions learn with, from and about each other to improve collaboration and the quality of care' (CAIPE, 2002).…”

Section: Con Cluding Commentsmentioning

confidence: 99%

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

et al. 2018

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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.

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

Cited by 45 publications

References 29 publications

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

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

Between standardisation and discretion: the priority setting of triage nurses

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

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