Understanding nursing scope of practice in the acute environment

215 Pages·2010·0.54 MB·English

Delegate, undertake or negotiate:
Understanding nursing scope of practice
in the acute environment

by

Jessica Erin Schluter

RN, B Nursing

A thesis submitted in fulfilment of the requirements for the
Degree of Doctor of Philosophy in the
School of Nursing and Midwifery,
Faculty of Health, Griffith University

January 2009
Statement of Originality

This work has not been submitted for a degree or diploma at any other university. To
the best of my knowledge and belief, this thesis contains no material previously
published or written by another person except where due reference is made in the
thesis itself.

………………………………
Jessica Erin Schluter
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“The core of mans’ spirit comes from new experiences.”

~ Christopher McCandless (1992)
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Abstract
The past decade has seen increased patient acuity and shortened lengths of stays in
acute care hospitals (Australian Institute of Health and Welfare (AIHW), 2005),
resulting in an intensification of the work undertaken by nursing staff in hospitals.
Changes in nursing work have also been compounded by the proliferation of health
care roles, a blurring of skill boundaries (AIHW, 2001; Buchan & Dal Poz, 2002;
Hayman, Cioffi & Wilkes, 2006; Jones and Cheek, 2003) and an aging nursing
workforce that is predominantly working part-time (Creegan, Duffield & Forrester,
2003). Moreover, with increasing demand for acute care beds (ABS, 2005), there is
simply not enough licensed nursing staff to fill current vacancies (AIHW, 2005;
Duffield & O’Brien-Pallas, 2002).
Since 2003, the main response from the Australian government to the declining
numbers of nursing workers has been to recruit more people to the nursing profession.
However, it is becoming clear that recruitment alone is not enough, with shortages
growing even as nursing school enrolments are increasing; therefore, it was timely to
undertake a study to understand nurses’ perceptions of scope of practice to improve
future efficiency in the nursing workforce by using the information derived to provide
baseline data to guide workforce planning.
The specific aim of this study was to understand how medical and surgical nurses,
from two Queensland hospitals, conceive their scope of practice in response to the
available grade mix and skill mix of nurses—licensed and unlicensed—and other
health care professionals in the acute care setting. By exploring these meanings, this
study aimed to build an understanding of how nursing work patterns were shifting in
the face of changing patient acuity, patient profiles and nursing skill mix. To address
this aim, a constructivist methodology was used that allowed for exploration of
nursing role and scope of practice. While the notion of constructivism best describes
the main approach to this study, it was also naturalistic to the extent that participants
were reflecting on day-to-day experiences.
The method used in this study is situated around the Critical Incident Technique (CIT)
(Flanagan, 1954). CIT generates data representing experiences or perceptions of
aspects of best and worst practice (Byrne, 2001). The researcher asked 20 registered
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nurse (RN) and enrolled nurse (EN) participants to discuss up to two particular
significant events during which they were undertaking a patient care activity they
perceived they should be undertaking, and up to two events during which they
believed those activities should have either been delegated or undertaken by a higher
level of care provider. Using the CIT in this way, allowed the researcher to gain an
understanding of the nursing scope of practice and the interactions between nurses
and other clinicians (Byrne, 2001) while also minimising pre-interpretation of the
events by participants and focusing on a rich description of the chosen event
(Flanagan, 1954). Purposive sampling was used to assist with the discovery of
opposing points of view (Guba & Lincoln, 1989) with all RN and EN participants
being employed on selected medical and surgical wards within two large hospitals
based in South East Queensland.
Inductive analysis, a process for searching for themes within the data, rather than
imposing theories on the data (Guba & Lincoln, 1989), was used. Analysis revealed
that the nursing work environment was changing. This was causing nursing staff to
question what it meant to provide patient care given the increased numbers of health
care workers (HCWs) in the acute care setting, rising patient acuity, and increased
patient turnover. RNs were struggling with the notions that ‘hands-on’ care was
sometimes not the best use of their time, and delegation did not equate with laziness.
Five themes arose from the data: (1) good nurses work in proximity to patients
providing total patient care; (2) safeguarding patients; (3) privileging patients
without mental illness or cognitive impairment; (4) developing teamwork strategies;
and (5) picking up the slack to ensure patient safety.
Findings have shown that negotiation has become a fundamental aspect of nursing
practice given the variety of nursing care providers currently employed in acute care
settings. Previously, there wasn’t a need for nurses to negotiate care between licensed
and unlicensed staff because HCWs were not employed in these settings. Negotiation
has allowed nurses to redefine appropriate nurse–patient proximity, promote patient
safety and find innovative ways of working in nursing teams. Practice negotiation will
become a prominent topic over the coming years as hospital administrators struggle to
employ licensed nurses.
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Table of Contents
Statement of Originality .............................................................................................. 2
Abstract ......................................................................................................................... 4
Table of Contents ......................................................................................................... 6
List of Tables ................................................................................................................ 8
Abbreviations ............................................................................................................... 9
Acknowledgments ...................................................................................................... 11
Publications and presentations derived from this research ................................... 13
CHAPTER ONE ........................................................................................................ 14
Introduction ............................................................................................................ 14
Definitions ............................................................................................................... 14
Background ............................................................................................................ 15
Ageing population ................................................................................................ 16
Nursing workforce numbers and composition ..................................................... 17
Workforce planning ............................................................................................. 19
Nature of the nursing workforce .......................................................................... 21
Proliferation of health care roles .......................................................................... 21
Blurring of boundaries ......................................................................................... 22
Study aim ................................................................................................................ 24
Significance ............................................................................................................. 26
Staffing, grade mix and skill mix ......................................................................... 26
Patient outcomes .................................................................................................. 30
Job satisfaction ..................................................................................................... 33
Structure of thesis .................................................................................................. 34
Chapter One ......................................................................................................... 34
Chapter Two......................................................................................................... 34
Chapter Three....................................................................................................... 34
Chapter Four ........................................................................................................ 35
Chapter Five ......................................................................................................... 35
Chapter Six........................................................................................................... 35
CHAPTER TWO ....................................................................................................... 36
Introduction ............................................................................................................ 36
Search Methods ...................................................................................................... 36
Scope of practice regulation .................................................................................. 36
International Council of Nurses ........................................................................... 36
Australian Nursing and Midwifery Council ........................................................ 38
Queensland Nursing Council ............................................................................... 39
Research on nursing scope of practice ................................................................. 41
Nurses’ perceptions of regulation ........................................................................ 42
Enacting scope of practice ................................................................................... 43
Activities undertaken by nurses ........................................................................... 45
Role expansion ..................................................................................................... 48
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Role blurring ........................................................................................................ 52
Effects of HCWs on nursing roles ....................................................................... 54
Summary ................................................................................................................. 57
CHAPTER THREE ................................................................................................... 59
Introduction ............................................................................................................ 59
Methodology ........................................................................................................... 59
Method .................................................................................................................... 64
Researcher as instrument ...................................................................................... 67
Sample and Setting ................................................................................................ 68
Participants ................................................................. Error! Bookmark not defined.
Data collection ........................................................................................................ 69
Data analysis ........................................................................................................... 70
Rigour ...................................................................................................................... 72
Ethical considerations ............................................................................................ 74
Summary ................................................................................................................. 76
CHAPTER FOUR ...................................................................................................... 77
Introduction ............................................................................................................ 77
Overview of findings .............................................................................................. 77
Direct patient care .................................................................................................. 79
Good nurses work in proximity to patients providing total patient care .............. 79
Striving for close patient proximity ................................................................. 82
Proximity allows for control and builds trust and rapport with patients .......... 85
Recognising a new clinical reality ................................................................... 87
Renegotiating patient proximity ...................................................................... 89
Safeguarding patients ........................................................................................... 92
Synthesising cues and visual observations in assessment................................ 93
Tempering assessment with gut instinct .......................................................... 95
Ramping up critical thinking ........................................................................... 97
Piecing it all together ..................................................................................... 101
Privileging patients without mental illness or cognitive impairment ................ 103
Prioritising physical conditions...................................................................... 105
Disrupting ward routines................................................................................ 111
Decreasing quality of care ............................................................................. 112
Summary ............................................................................................................... 114
CHAPTER FIVE ..................................................................................................... 115
Introduction .......................................................................................................... 115
Developing teamwork strategies ........................................................................ 115
Delegating activities ....................................................................................... 116
Trading tasks .................................................................................................. 119
Valuing others ................................................................................................ 121
Picking up the slack to ensure patient safety ..................................................... 126
Role blurring .................................................................................................. 130
Nurses impeded by doctors’ omissions .......................................................... 133
Working beyond job description .................................................................... 135
Working below expertise level ...................................................................... 138
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Summary ............................................................................................................... 143
Chapter Six ............................................................................................................... 144
Introduction .......................................................................................................... 144
Overview of findings ............................................................................................ 144
Scope of practice .................................................................................................. 145
Negotiation ............................................................................................................ 146
Negotiated order ................................................................................................. 150
Negotiating nursing practice .............................................................................. 152
Negotiating patient safety .................................................................................. 160
Negotiating the nursing domain ......................................................................... 165
Negotiating patient proximity ............................................................................ 170
Recommendations ................................................................................................ 178
Recommendations for practice .......................................................................... 178
Recommendations for education........................................................................ 179
Recommendations for nursing management ...................................................... 180
Recommendations for research .......................................................................... 181
Limitations of findings ......................................................................................... 182
Conclusion ............................................................................................................ 183
References ............................................................................................................. 187
Appendix 1 ................................................................................................................ 207
Appendix 2 ................................................................................................................ 209
Appendix 3 ................................................................................................................ 211
Appendix 4 ................................................................................................................ 212
Appendix 5 ................................................................................................................ 213
Appendix 6 ................................................................................................................ 214

List of Tables
Table 4.1 Themes and sub-themes ........................................................................... 79
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Abbreviations
ABS Australian Bureau of Statistics
AHWAC Australian Health Workforce Advisory Committee
AHWAC Australian Health Workforce Advisory Committee
AIHW Australian Institute of Health and Welfare
AIN Assistant in Nursing
ANF Australian Nursing Federation
ANMC Australian Nursing and Midwifery Council
ARC Australian Research Council
ARCHI Australian Resource Centre for Hospital Innovations
ATNA Australasian Trained Nurses’ Association
AVCC Australian Vice Chancellors Committee
CIT Critical Incident Technique
CN Clinical Nurse
COAG Council of Australian Governments
DRG Diagnostic Related Groups
EEN Endorsed Enrolled Nurse
EN Enrolled Nurse
FTE Full Time Equivalent
GW Generic Worker
HCA Health Care Assistant
HCW Health care worker
I:R Interactive-Relational
ICN International Council of Nurses
IV Intravenous
LGA Local Government Area
LPN Licensed Practical Nurse
MODL Migration Occupations in Demand List
NHMRC National Health and Medical Research Council
NHPPD Nursing Hours Per Patient Per Day
NPDU Nursing Practice Development Unit
PAIS Patient Assessment and Information System
PCA Personal Care Attendant
QNC Queensland Nursing Council
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QNU Queensland Nursing Union
RMO Resident Medical Officer
RN Registered Nurse
UAP Unlicensed Assistive Personnel
UK United Kingdom
UKCC United Kingdom Central Council for Nursing, Midwifery and
Health Visiting
USA Untied States of America
WHO World Health Organization

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