Transcript Slides - Royal Holloway

School of Management
SEMINAR
Jurisdictional Change and Nursing’s
Professionalization: Liberating Nurses or Losing
the Plot?
Carole Doherty
Lecturer in Healthcare Management
Structure of Presentation
• Introduction – context of research, NHS Plan (DH, 2000)
• Theory – conceptual framework uses the sociology of professions and in
particular Abbott’s (1988) work on jurisdictional change
• Methods – mixed methods, questionnaire data supported by in-depth
interviews
• Findings – nurses’ roles have altered with nurses now performing tasks
traditionally carried out by doctors. This has resulted in intra-occupational
differentiation. Specialist nurses have experienced greater clinical
autonomy but ward sisters have experienced greater subordination
• Conclusion – overall government intervention in the division of labour may
have been detrimental to the quality of essential aspects of patient care
such as assisting patients with feeding
Background
• NHS Modernization
◦ Break down the traditional, inflexible divides between
occupational groups in the Service
◦ Challenge to the medical profession’s monopoly
◦ Opportunity for the professionalization of nursing
Research Questions
• Have changes to nursing’s jurisdiction aided its
professionalization?
• What have been the intra-occupational consequences of
jurisdictional change?
• Do nurses aspire towards the professionalization of their
occupation?
Conceptual Framework
• Sociology of Professions
• The application of abstract knowledge to practice has both objective and
subjective properties.
• Subjective properties are socially constructed, this creates dynamism in ‘the
system of professions’ (Abbott, 1988)
• Jurisdiction – an area of practice over which an occupation has authority to
act
• Three areas for competition:
◦ The State including the legal system
◦ Public opinion
◦ The workplace
Jurisdictional Change
• Possible outcomes:
◦
◦
◦
◦
◦
◦
Full jurisdiction
Subordination
Intellectual jurisdiction
Sharing of the jurisdiction
Advisory control
Client differentiation
Nursing’s History
• Modern form emerged in 1850s
◦ Occupational strategy based on practical not theoretical
knowledge
◦ Broad and uncertain jurisdiction
• Attempts to professionalize
◦ 1900s, resulted in subordination
◦ 1990s, resulted in weakened labour market position
Study Design and Methods
• Mixed methods
◦ Quantitative data – patterns and trends in nurses’ job attitudes,
differences and similarities between the respective nursing
jobs
◦ Qualitative data – underlying processes and organizational
structures that might account for differences in job attitudes,
the effect of changes to nursing’s jurisdiction, factors
influencing nurses’ job aspirations
• Data analysis
◦ Abbott’s (1988) categorizations of professional work,
descriptive statistics, t tests to compare differences in job
attitudes, content analysis using matrix
Changes to Jurisdiction
Key Tasks
Staff Nurse
N=115
%
Routine tasks
Request x-rays
Request blood tests
Administer a range of medications using PGDs
Admit patients with specific conditions within agreed Protocols
Discharge patients, with specific conditions within agreed protocols
Diagnosis and inference
Make referrals for doppler/ultrasound to confirm DVT
Make referrals for abdominal ultrasound
Make referrals directly to consultant medical staff
Inference and treatment
Trained as a supplementary prescriber
Diagnosis, inference and treatment
Interpret x-rays and initiate treatment
Interpret blood test results and initiate treatment
Receive referrals directly from GPs10196827
Receive referrals directly from hospital consultants or
junior doctors acting on their behalf
Prescribe medicines from the nurse prescribers' formulary
Initiate and administer thrombolysis under PGDs
Make 'do not resuscitate' decisions
Take written consent from patients for procedures you perform
Perform minor surgery
Perform out patient procedures that require written consent
Run a nurse led clinic
Ward Sister
N=64
%
Specialist Nurse
N=62
%
Total
N=241
%
18
55
66
16
17
27
73
73
20
36
39
74
68
34
48
26
65
69
22
30
3
3
15
2
4
33
6
6
77
4
4
36
2
2
19
6
1
24
2
31
18
58
5
35
25
11
4
0
8
1
2
6
33
9
3
0
5
2
3
8
81
23
2
2
27
13
16
50
41
14
3
<1
12
4
6
19
Comparison of job related variables for ward sisters
and specialist nurses
Item
Ward Sisters (N=64)
M
SE
Qualifications
Skill variety
Task identity
Job autonomy
Job complexity
Role expectations
Role clarity
Career prospects
Decision-making
Self-esteem
Innovative work behaviour
Job satisfaction
1.84
2.30
3.23
3.43
3.92
3.58
3.44
3.02
3.47
3.92
3.47
3.40
*p<0.05 **p<0.01 ***p<0.001
0.10
0.11
0.16
0.10
0.08
0.10
0.11
0.10
0.13
0.08
0.11
0.09
Specialist Nurses (N= 62)
M
SE
t (124)
2.34
2.60
3.98
4.14
4.41
3.76
3.81
3.63
3.12
4.22
3.81
3.93
0.10
0.12
0.11
0.08
0.07
0.09
0.11
0.10
0.14
0.08
0.11
0.07
-3.59***
-1.78
-3.81***
-5.60***
-4.00***
-1.33
-2.34*
-4.16***
1.78
-2.60*
-2.22*
-4.65***
Effects of Jurisdictional Change
• Doing doctors’ work and losing nursing
‘…that’s all they [nurses] do for the first two hours in the morning they do IV
antibiotics then they’re doing another lot of taking bloods and I’ve very sadly
looked at what’s going on in the rest of the ward in terms of patients are lying
in wet beds, patients’ mouth care isn’t being done…..Bells are going
everywhere patients are calling for the toilet and I just feel we have got to
take a step back and look really at what nursing is about and go back to not
basic nursing care but essential nursing care. I think we’ve really lost it. I
really, really do I think we’ve lost the plot.”
Ward sister, 23 years experience
‘You can tend to neglect the patient because the fundamental parts of nursing
seem to be missed a lot of the time now. ….the essence of nursing has been taken
away from us because we’ve got to take bloods, do ECG’s, we put venflons in.
They are all things that the doctors did at one time. Now we do it all.
Staff nurse, 7 years in nursing
Intellectual jurisdiction
‘For us here the patient is our sole responsibility it doesn’t go to
anyone else. We see them we make a diagnosis and we decide upon
a treatment that’s lovely. Because that’s your patient and you make all
the decisions and you’ve administered it from a-z’
Ward sister – 26 years experience who also
practised as an emergency nurse practitioner
‘Its becoming more and more autonomous as things have gone on. It
used to be very doctor orientated you used to do what the doctor said.
How nursing has progressed…..it is definitely developing towards more
specialist type areas so you become a practitioner in your own right
alongside the doctor side of it.’
Staff nurse A&E
Sharing the jurisdiction
‘I see new patients in their [consultants’] clinics …new referrals from
GPs... I can decide what I’m going to do for that patient without having
to go and feedback to the consultant. I have that amount of autonomy
with the role……. I work with the registrars in clinic so basically
anything that the registrar sees I will see and go and feedback to the
consultant in the same way’
Specialist nurse
‘Basically I work with the consultant surgeons assisting them with
patients during their peri-operative period. It means that I can see them
pre-op, take consent in out-patients and explain procedures to them,
participate during surgery either as a first or second assistant or
perform surgery depending on how big the surgery is. I do my
operations independently under local anaesthetic.’
Specialist nurse
Professionalization?
• Job aspirations
◦ Twenty-seven percent of ward sisters wished to become
specialist nurses
◦ Not one of the specialist nurses were inclined to become ward
sisters
◦ Aspirations among the staff nurse group were equally split
between specialist nurse and ward sister jobs
Professionalization?
• Ward sister
◦ ‘So where will I be in 5 years time, I probably still will be in the NHS but
that’s probably because my bank manager needs me to be here rather
than I want to be here because I don’t see nursing getting any better I
just see it getting worse, it getting more and more stressful.’
• Specialist nurse
◦ ‘There is no limit to what can be done in this post. I wouldn’t like to go
back to being a ward sister there is no challenge, after a time every
day is similar…even now there are times that I look at something and
think what do I do. Every day is different.’
• Staff nurse
◦ ‘….you don’t deal with the patients as much and that’s not what I came
into nursing to do to be a nurse.’
Conclusions
• Government intervention in the division of labour can have significant intraoccupational consequences for a subordinate occupation and impact on aspects
of the dominant occupation’s monopoly
• Complex and multifaceted outcomes of change to the division of labour within a
single occupation - suggesting a need to move beyond single occupational
categories in studies of occupations
• Greater subordination has given rise to concerns that the work traditionally
performed by nurses may become lost, opening the potential for further weakening
of nursing’s labour market position
• The structure of the ward sisters’ job appears to constrain their opportunities. This
finding adds to discussion about the role of structure and government policy in
understanding changes to the division of labour (Bach et al., 2007)
School of Management
SEMINAR