Bingham_whole_thesis.pdf (24.63 MB)
Reshaping practice to get the job done : a constructivist grounded theory study of the ways of working in perioperative nursing
thesisposted on 2023-05-27, 11:28 authored by Bingham, SM
`Background:` Adverse events associated with surgical procedures can result in patient disability, death, or increased length of stay and reducing or eliminating adverse events is a top priority for patient safety. A major part of the perioperative nursing role is securing patient safety, yet adverse events continue to occur and patients continue to suffer harm. In the messy reality of the practice setting, perioperative nurses at times work in ways other than following the rules and standards that have been developed to support safe practice. This may have potential unintended consequences for patient safety. The way that perioperative nurses work and respond and adapt to the challenges in the workplace and the competing goals to 'get the job done', is the focus of this study. `Purpose:` The purpose of this study was to develop a substantive theory to explain the ways that perioperative nurses work to get the job done and the factors that influence their decisions to deviate from standards and rules. `Methods:` Between 2015 and 2016, a constructivist grounded theory study was conducted that included 56 hours of observation of practice and 10 hours of indepth semi-structured interviews. Five RNs and one EN working in operating theatres at a public and private hospital in Tasmania participated in the study. \\(Findings:\\) Emerging from my research was the substantive theory that perioperative nurses 'reshape their practice in response to being pressured and feeling pressured to get the job done'. Whilst the participants mostly complied with standards and rules and expressed a genuine desire to follow them, there were circumstances where they made a conscious decision to work in other ways. Factors within the context in which perioperative nurse's practice can both constrain and enable practicing in accordance with the rules and these constraining factors can lead to being pressured and feeling pressured which in turn constrains practicing in accordance with the rules. `Discussion:` Decision-making underpins practice and perioperative nurses employ experience and clinical judgment in making decisions about the way they work. Whilst working in ways other than following the rules is intentional it is not done with the intention to break the rules, rather it is for another purpose; that is to improve patient outcomes and team and organisational performance. The emergent theory adds to our understanding of the role that organisational, team, individual characteristics and the ambiguity/clarity of rules, tasks and responsibilities play in generating pressure and creating an environment more vulnerable to working in ways other than following the rules. `Implications:` Despite potential benefits to the patient, the team and organisation, decisions to deviate from standards and rules may result in unsafe practice and the potential for patient harm. Lack of documentation of the deviations and continuing absence of professional conversations around this issue inhibits our capacity to learn from work as done. Opportunities to improve systems and processes that enhance patient safety and to amend standards and rules to reflect the reality of practice is lost and the potential benefits remain hidden. Further research on capturing and scrutinising the potential benefits of deviating from rules and standards with the aim of keeping patients safe, meeting organisational demands and progressing professional practice will be a natural progression from this research study. `Conclusions:` This theory advances the perioperative nurse's perspective on responding to 'being pressured' and 'feeling pressured' in clinical practice. The theory is relevant to perioperative nurses, employing organisations, professional bodies, education providers and researchers who seek to better understand the messy reality of practice; develop and implement strategies to address factors that constrain following standards and rules; close the gap between work as imagined and work as done and ultimately make health care safer.
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