THE SOCIAL ORGANIZATION OF NURSING PRACTICE IN THE HOSPITAL SETTING AND THE INFLUENCE ON THE DEVELOPMENT OF CONFLICTING
WORKING RELATIONSHIPS BETWEEN REGISTERED NURSE PEERS
©Peggy A. Rauman
A Dissertation Submitted to the
School of Graduate Studies in partial fulfillment of the requirements of
Degree of Doctor of Philosophy in Medicine Memorial University
October 2020
St. John’s Newfoundland
ABSTRACT
The term conflicting working relationships (CWRs) is used in this research to represent working relationships between nurse peers that are non-collegial, uncaring, and non- supportive. These types of relationships have been reported in the research literature using many different labels including incivility, horizontal violence, and bullying and are known to be a source of job dissatisfaction, disengagement, and burnout. Despite efforts to limit the occurrences of CWRs between nurse peers, incidents of CWRs continue to occur. Using institutional ethnography, this research explored and made visible the relationship between the social organization of professional nursing practice in the hospital setting and the development of CWRs between Registered Nurse (RN) peers.
Three aspects of the social organization of professional nursing practice, should nursing, double domination, and the big picture were revealed as creating disjunctures,
frustrations, and tensions for nurses that were significant in the development of CWRs.
The findings of this research further illuminate how conflict has become institutionalized and how there is a need for strong nursing leadership to advocate for workplace processes and contexts that support healthy and productive working relationships between nurse peers. The results of this study offer important insights into the ways CWRs between RN peers are influenced by the extra-level processes and relations of ruling that govern professional nursing practice. Through increased clarity of these factors, it is hoped that this research can be used to open a dialogue for leaders to discuss how nursing practice could be organized in a way that supports more collegial practices between RNs.
Key words: nursing, institutional ethnography, conflict, relational practice
ACKNOWLEDGMENTS
Firstly, I would like to express my sincere gratitude and appreciation to my Supervisor Dr. Martha Traverso-Yepez, Co-Supervisor, Dr. Shirley Solberg, and
Supervisory member, Dr. Alice Gaudine for their guidance, feedback, and encouragement throughout this research process. I feel blessed to have had such a dedicated, supportive, and patient supervisory committee to assist me throughout this journey. Each committee member provided me with their unique expertise and insight, and I cannot thank them enough for everything that they have done for me.
Secondly, I would like to thank my colleagues from the Centre for Nursing Studies. They have supported me from day one of the PhD program, I will always be grateful for their love and support. Denise English, Natasha Fulford, and Robyn Noseworthy, we were most definitely the “dream team.” To my colleagues from the College of Registered Nurses of Newfoundland and Labrador, I thank each of you (and in one case, a significant other) for your consistent support and reassurance. Michelle Carpenter, I thank you for proof-reading, believing in me, and for always having my back.
Thirdly, I want to thank my family and extended family. My Mom and Dad,
Cindy, and Scott for always supporting my career goals and life pursuits. My husband
Ben for all his technical support, love, and encouragement, and my children, Tyler,
Logan, and Rowan for their understanding for the days when I was “busy.” I want to
thank my dearest friends, Kara, Kara, Kerry, and Tasha for always being there for me no
matter what. Kara Pender, your positive attitude, and contagious smile got me through
some tough days, thank you my friend. Thank you to the wonderful ladies of Seraka
Dance Company for making me take breaks and dance. I love you all. I also want to thank all the participants for sharing their stories and making this research possible.
Finally, I want to acknowledge how thankful I am for the scholarships I received
from the College of Registered Nurses of Newfoundland and Labrador, the Registered
Nurses Union of Newfoundland and Labrador, Eastern Health, and Memorial University
of Newfoundland for the Ellen Gillis Memorial Scholarship. The financial support
provided by such scholarships are invaluable in helping doctoral students achieve their
goals. I would also like to affirm that the work as presented, including the tables and
figures, is my own.
TABLE OF CONTENTS
ABSTRACT ... ii
ACKNOWLEDGMENTS ... iii
List of Tables ... xi
List of Figures ... xii
List of Appendices ... xiii
Chapter One – Introduction to Conflicting Working Relationships (CWRs) ... 1
1.1 Professional Nursing Practice ... 3
1.2 Research Background ... 4
1.3 Institutional Ethnography and the Research Problem Being Explored ... 6
1.4 Research Aim and Questions ... 8
1.5 Research Objectives ... 8
1.6 Research Contributions ... 9
1.7 Organization of Dissertation ... 10
1.8 Chapter Summary ... 11
Chapter Two – What is Known About CWRs Between RN Peers ... 12
2.1 Prevalence of CWRs between RN Peers ... 12
2.2 CWRs and the Emphasis on Personal and Interpersonal Explanations ... 16
2.3 A Closer Look at the Hospital Setting: Characteristics and Organization ... 18
2.4 Acute-Care Hospital Services in Canada: Extra-Local Influences ... 21
2.4.1 The Hospital Setting and Organization of Acute-Care Services ... 23
2.4.2 Health Care Changes and Influence on Professional Nursing Practice ... 25
2.4.3 Nurses Location in the Hierarchy of Medical Dominance ... 27
2.5 The Impact of CWRs for Nurses, the Health Care System, and the Public ... 28
2.6 Strategies Proposed to Address CWRs ... 33
2.6.1 Remedial/Corrective Strategies ... 33
2.6.2 Regulatory/Restorative Strategies ... 37
2.7 An Alternative Way to Investigate CWRs ... 42
2.8 Chapter Summary ... 42
Chapter Three - Institutional Ethnography ... 44
3.1 Introduction to IE ... 44
3.2 Theoretical Underpinnings of IE ... 46
3.3 Terms Fundamental to Understanding IE ... 48
3.3.1 Standpoint, Work and Work Knowledge ... 48
3.3.2 Texts, Text-Mediation, and Ideology ... 50
3.3.3 Ruling Relations ... 52
3.3.4 Disjunctures and the Problematic ... 53
3.4 Institutional Ethnography Points of Departure... 54
3.5 Positioning Myself as a Researcher ... 55
3.6 Description of the Research Process ... 58
3.6.1 Formal, Semi-Structured Interviews ... 59
3.6.2 Text Analysis ... 61
3.6.3 The Process of Mapping ... 63
3.7 Measures to Ensure Rigour, Trustworthiness, and Authenticity ... 64
3.7.1 Ethical Integrity ... 65
3.8 Chapter Summary ... 67
Chapter Four - Data Analysis and Findings ... 68
4.1 Description of the Participants ... 69
4.2 Participants’ Reactions to Being Interviewed and to their CWR Experiences ... 72
4.3 How Institutional Language Provides Insight into How Nursing Practice is Organized ... 74
4.4 Writing Accounts of the Participants’ CWR Experiences ... 76
4.4.1 Participants’ Accounts Arising from Novice Nurses Practice... 78
4.4.1.1 Accounts of CWRs from RNs Working on a “New” Nursing Unit ... 81
4.4.1.2 Accounts of CWRs from Casual and Float Nurses... 85
4.4.1.3 Being Set-Up to Fail ... 88
4.4.1.4 Summary of the CWR Experiences from Novice RNs, RNs New to a Unit, and Casual/Float RNs ... 91
4.4.2 Participants’ Accounts of CWRs Related to Working in the Hospital Setting: Documentation, Text, and Text-Mediated Discourse ... 93
4.4.2.1 The Use of Documents and Documentation ... 94
4.4.2.2 Hitting the Ground Running ... 99
4.4.2.3 Being Left to Your Own Devices: Demonstrating Competence in the Hospital Setting... 104
4.4.2.4 Workload, Workplace Atmosphere, the Development of Burnout, and the Relationship to CWRs ... 109
4.4.2.5 The Politics of Nursing Practice: Participants’ Accounts of CWRs
Related to Expectations for Equality in the Workplace ... 112
4.4.2.6 Summary of CWRs Related to the Organization of the Hospital Setting
... 118
4.4.3 Participants’ Accounts of CWRs Related to Working Within an Evolving Health Care System ... 120
4.4.3.1 CWR Accounts Related to Organizational Change and Lack of Consultation Regarding Changes to Nursing Practice ... 121
4.4.3.2 CWR Accounts Related to the Disruption of Routine Nursing Practice ... 124
4.4.3.3 CWR Accounts Related to the Use of Over Capacity Protocol ... 127
4.4.3.4 Summary of CWRs as Influenced by the Evolving Health Care System ... 134
4.5 Analysis of Texts Referenced by Participants ... 136
4.5.1 Setting the Expectations: Analysis of Texts Governing Professional Nursing Practice ... 136
4.5.1.1 The Standards of Practice for RNs ... 137
4.5.1.2 Code of Ethics for RNs ... 139
4.5.1.3 Registered Nurses Union Newfoundland Labrador (RNUNL) Collective Agreement 2014 ... 141
4.5.1.4 Summary of Texts Broadly Governing Professional Nursing Practice . 144 4.5.2 Analysis of Texts Organizing Nursing Practice in the Hospital Setting ... 145
4.5.2.1 Eastern Health Model of Acute Nursing Clinical Practice ... 145
4.5.2.2 Lean Process Improvement ... 148
4.5.2.3 Over Capacity Protocol (OCP) ... 148
4.5.3 Hospital Policies on Conflict Resolution ... 150
4.5.3.1 Conflict Management ... 151
4.5.3.2 Prevention and Resolution of Harassment in the Workplace ... 153
4.5.3.4 Summary of Policies on Conflict Resolution ... 154
4.6 Using the Data Analysis Tool Indexing ... 154
4.7 Mapping the Connections... 165
4.7.1 Mapping the Socialization Processes of Becoming an RN ... 166
4.7.2 Mapping the Influence of the Hospital Setting on the Development of CWRs between Nurse Peers ... 170
4.7.3 Mapping the Influence of the Evolving Health Care System on the Development of CWRs between Nurse Peers ... 173
4.8 Chapter Summary ... 181
Chapter Five - Discussions, Key Contributions, and Future Directions ... 182
5.1 A Discussion of Should Nursing, Double Domination, and the Big Picture ... 183
5.1.1 Discussion of the Should Nursing Thread ... 183
5.1.2 Discussion of the Double Domination Thread ... 186
5.1.3 Discussion of the Big Picture Thread ... 190
5.2 Discussion of Key Findings ... 195
5.2.1 When the Organization of Professional Nursing Practice Creates Struggles for Nurses ... 196
5.2.2 The Institutionalization of Conflict ... 200
5.2.3 The Importance of Leadership ... 202
5.2.4. Supporting Relational Practices and a More Collegial Workplace Culture . 204
5.3 Recommendations for Future Directions ... 205
5.3.1 Complementing Existing Work ... 208
5.4 Contributions and Limitations of Institutional Ethnography ... 210
5.4.1. Limitations of My Research Using IE ... 213
5.5 Dissemination of Findings ... 216
5.6 Conclusion ... 217
References ... 219
Appendix A: Recruitment Flyer ... 235
Appendix B: Interview Guide ... 236
Appendix C: List of Texts ... 240
Appendix D: Consent to Take Part in Research ... 241
Appendix E: HREA Approval Letter ... 247
Appendix F: RPAC Approval ... 248
List of Tables
Table 1: Indexing the Should Nursing Thread: The Additional Work of Proving Yourself
as a Good Nurse ... 157
Table 2: Indexing the Double Domination Thread: Being a Good Nurse in the Hospital
Setting……… ... ………....….………...……...…159
Table 3: Indexing the Big Picture Thread: Practicing Nursing Within an Evolving Health
Care System ... 164
List of Figures
Figure 1: Mapping the socialization processes of becoming an RN ... 167 Figure 2: Mapping the influence of the hospital setting on the development of CWRs between nurse peers ... 171 Figure 3: Mapping the influence of the evolving health care system on the development of CWRs between nurse peers ... 175 Figure 4: A map of the interconnections and generalizing relations influential to the development of CWRs between nurse peers ... 177 Figure 5: A map of the social organization of nursing practice in the hospital setting and its relationship to the development of CWRs between Registered Nurse (RN)
peers……….179
List of Appendices
Appendix A: Recruitment Flyer ... 235
Appendix B: Interview Guide ... 236
Appendix C: List of Text ... 240
Appendix D: Consent to Take Part in Research ... 241
Appendix E: HREA Approval Letter ... 247
Appendix F: RPAC Approval ... 248
Chapter One – Introduction to Conflicting Working Relationships (CWRs)
When I first became employed as a nurse
1, I was surprised by how difficult it was to adjust to the busyness of an acute care hospital setting and the multitude of demands placed upon me as a registered nurse (RN). I found that by the end of a set of twelve- hour shifts, I was physically and mentally exhausted, and I needed my days off to recover.
I did not like being that tired. However, I accepted the busyness of nursing practice as a requirement of the profession. What was harder to accept was that in this hectic
environment, it was also common for me to witness a variety of behaviours among nurses that were unexpected. Some of these behaviours were non-collegial and often resulted in conflict between nurse peers.
I experienced a conflict with a nursing peer shortly after I completed my orientation to a new unit. Orientation is an employment requirement in the health care setting, and my orientation consisted of some classroom instruction, followed by a specified amount of time co-signed with a senior nurse. The goal of being co-signed is to provide a new nurse with enough knowledge to provide patient care independently, competently, and safely. However, unit orientation is not standardized, and it differs between units. On a night shift after my orientation was complete, I received a report on a challenging patient assignment, so I prepared a priority list of tasks to complete. Caring for this patient would require the coordination of many complex nursing skills including the simultaneous administration of a variety of blood products, the use of new equipment, and the navigation of care obstacles such as securing intravenous access.
1 The use of the term nurse refers to a registered nurse unless otherwise specified.