This article is a report of a study of boundary work following the introduction of an acute care nurse practitioner role in healthcare teams.
Acute care nurse practitioners enacting their roles in healthcare teams have faced a number of challenges including a mix of positive and negative views of the acute care nurse practitioner role from healthcare team members and acute care nurse practitioner roles crossing the boundaries between the medical and nursing professions. Understanding the process by which the boundaries between professions changed following the introduction of an acute care nurse practitioner role was important since this could affect scope of practice and the team's ability to give patient care.
The study was conducted in two university-affiliated teaching hospitals in Canada. A descriptive multiple case study design was used. Data were collected from March to May 2009.
Participants (N = 59) described boundary work as a process that included: (1) creating space; (2) loss of a valued function; (3) trust; (4) interpersonal dynamics; and (5) time. The development of trust among team members was essential. The co-location of team members working on common projects, and medical and nursing leadership facilitated boundary work.
The micro-level processes of boundary work in healthcare teams have important implications for the development of full scope of practice for acute care nurse practitioners, effective inter-professional teamwork and the integration of new roles in healthcare systems. Future research needs to be undertaken in different contexts, and with patients and families.
Author Affiliations: 1School of Nursing, Queen's University, 2Bloomberg Faculty of Nursing, Nursing Health Services Research Unit, University of Toronto, 3Corporate Health Care, Ministry of Community Safety and Correctional Services, Government of Ontario, 4Toronto Jail, 5Hamilton Wentworth Detention Centre, 6Toronto Public Health, 7Daphne Cockwell School of Nursing, Ryerson University, 8Kingston General Hospital, 9School of Nursing, University of California, Irvine, 10School of Nursing, McMaster University.
Correctional nurses hold a unique position within the nursing profession as their work environment combines the demands of two systems, corrections and health care. Nurses working within these settings must be constantly aware of security issues while ensuring that quality care is provided. The primary role of nurses in correctional health care underscores the importance of understanding nurses' perceptions about their work. The purpose of this study was to examine the work environment of nurses working in provincial correctional facilities. A mixed-methods design was used. Interviews were conducted with 13 nurses and healthcare managers (HCMs) from five facilities. Surveys were distributed to 511 nurses and HCMs in all provincial facilities across the province of Ontario, Canada. The final sample consisted of 270 nurses and 27 HCMs with completed surveys. Participants identified several key issues in their work environments, including inadequate staffing and heavy workloads, limited control over practice and scope of practice, limited resources, and challenging workplace relationships. Work environment interventions are needed to address these issues and subsequently improve the recruitment and retention of correctional nurses.
To examine factors within the nursing work environment that may affect nurse outcomes.
Primary data were acquired from unit managers and staff nurses on the study units. Secondary data were collected from health records administrative databases. The sample included adult medical and surgical units within all 19 teaching hospitals in Ontario, Canada.
A cross-sectional study design was employed in this study. A random sampling process was used to recruit the number of nurses (n = 1,116) required to provide a statistically adequate sample for the survey.
Perceptions of the quality of care at the unit level were found to have a statistically significant positive influence on nurses' job satisfaction, and a statistically significant negative influence on nurses' job pressure and job threat.
The results of this study underscore the importance of examining the environment in which nurses' work as a potential factor that influences outcomes experienced by patients and nurses.
Little research has been conducted examining the linkages between nurse staffing and care delivery models in relation to patient care quality. Nurses in this study perceive that an all-RN staffing model is associated with better quality outcomes for patients, and that staffing models that include professional and unregulated staff may pose a challenge for unit-based communication and the coordination of care. Patient care delivery models were also important predictors of the quality outcomes studied.
This study describes the views of multidisciplinary teams on work-related empowerment in a transitional organization.
The data were collected between September 2003 and January 2004 (n=115) and one year later (n=112) using a self-administered questionnaire consisting of verbal and behavioural items, empowerment outcomes, and factors promoting and impeding empowerment. The target population consisted of all members working in multidisciplinary teams at the Rheumatism Foundation Hospital in Finland. The response rate was 58% at both data collections. The data were analysed statistically using SPSS software.
The multidisciplinary teams rated their work empowerment quite highly. The number of empowerment promoting factors was lowest for the category of future orientedness, consisting of continuity of work, opportunities for advancement, and access to information. The number of impeding factors was also highest for the same category of future orientedness, consisting here of organizational bureaucracy and hierarchy, authoritarian leadership, poor access to information, and short working periods.
It is important not to underestimate the impacts of organizational changes: they have a direct effect on the work environment and may contribute to higher rates of dissatisfaction, burnout and absenteeism among health care workers.
The impact of interventions designed to improve the nursing work environment on patient and nurse outcomes was examined.
Nursing work environments have been characterized as contributing to patient outcomes as a result of organizational management practices, workforce deployment, work design, and organizational culture.
This quasi-experimental study involved 16 unit managers, 1,137 patients, and 296 observations from registered nurses over time.
After participation in the intervention, study nurses reported higher perceptions of their work and work environment. Demographic nurse, unit, and hospital characteristics also had an impact on the work environment and outcomes.
Findings in this study highlight the importance of understanding factors in the work environment that influence patient and nurse outcomes.
Canadian nursing leadership is called to advance a national patient safety agenda for the delivery of safe, quality care in professional practice environments. Yet, the nursing discipline is burdened by issues and challenges related to clinical practice and workplace dilemmas that contribute to barriers and obstacles to safe, quality and humane care. We propose that the many clinical challenges faced by nurses in Canada can be more fully understood when framed by a patient safety perspective. Nurse executive leaders and nurse scientists are called to reform clinical practice and conduct research to reconcile patient care safety issues. This paper applies findings obtained from nurses via focus groups led by the Academy of Canadian Executive Nurses (ACEN) and integrates these findings into a patient safety perspective via a conceptual framework.
The purpose of this study was to compare the processes of care (performance of role functions, provision of comprehensive care, coordination of services) of acute care nurse practitioners (ACNPs) and physician residents (PRs) assigned to various medical and surgical programs in acute care settings. A cross-sectional comparative design was used. ACNPs (n = 31) and PRs (n = 10) completed the study questionnaire within two weeks of consenting. Patients who received ACNP care (n = 320) and those who received PR care (n = 46) completed the questionnaire within one week of discharge. The results indicate that ACNPs engaged in management and informal coordination activities more than PRs did, while PRs engaged in more formal coordination activities compared to ACNPs. ACNPs encouraged more patient participation in care and provided more patient education than PRs. These findings, which reflect differences in the processes used by ACNPs and PRs to provide care to patients, could influence the quality and cost outcomes expected of these two groups of healthcare providers.
The objective of this study was to investigate the relationship between the characteristics of home-care contracts, as indicators of employment relationships, and nurses'job satisfaction and perceived job security. A cross-sectional design was used to collect data on the study variables.The setting was 11 Community Care Access Centres and 11 nursing provider agencies in the Canadian province of Ontario. The sample included 700 nurses. A mailed survey was used to collect data from CCACs on length of contract awarded to provider agencies, potential for renewal, volume of service awarded, and profit status of the agency. Data were collected, via a mailed survey, on nurses' age, gender, work status, and years of employment in the community and at the current agency. The Nursing Job Satisfaction Scale was used to collect data on nurses'job satisfaction. Perceived job security was assessed using a single item measured on a 5-point Likert scale. Significant differences were found among provider agencies in nurses' perception of the quality of care, work enjoyment, satisfaction with time for care, and job security. Older nurses rated work enjoyment higher than younger nurses. Nurses paid on an hourly basis were more satisfied with their time for care than those paid on a per-visit basis. Nurses employed on a casual basis were less satisfied with job security than those employed on a full-time basis. Differences in nurse outcomes were observed among nursing provider agencies, but these were not related to the profit status of the agency. Further research is needed on the best practices within agencies that result in more satisfied staff.
Communication among healthcare professionals is a focus for research and policy interventions designed to improve patient safety, but the challenges of changing interprofessional communication patterns are rarely described. We present an analysis of 756 preoperative briefings conducted by general surgery teams (anesthesiologists, nurses, and surgeons) at four urban Canadian hospitals in the context of two research studies conducted between August 2004 and December 2007. We ask the questions: how and why did briefings succeed, how and why did they fail, and what did they mean for different participants? Ethnographic fieldnotes documenting the coordination and performance of team briefings were analyzed using Kenneth Burke's concepts of motive and attitude. The language and behaviour of participants were interpreted as purposive and situated actions which reveal perceptions, beliefs and values. Motives and attitudes varied both within and across sites, professions, individuals, and briefings. They were contingent on the organizational, medical and social scenes in which the briefings took place and on participants' multiple perceived purposes for participating (protecting patient safety, exchanging information, engaging with the team, fulfilling professional commitments, participating in research, and meeting social expectations). Participants' attitudes reflected their recognition (or rejection) of specific purposes, the briefings' perceived effectiveness in serving these purposes, and the briefings' perceived alignment (or conflict) with other priorities. Our findings illustrate the intrinsically rhetorical and variable nature of change.