A Grounded Theory of Directors' of Nursing Perceptions on Caring

Purpose:

This study explores the perceptions of Directors of Nursing from NHS acute Trusts in England, on caring practices. The aspiration of the NHS is to deliver good care to patients and their families. However, recent inquiries into poor care have created a searching debate regarding standards of nursing care, leadership, culture and practice. Directors of Nursing play a significant role in influencing care, as they are charged with responsibilities relating to providing assurance of standards of care within NHS Trusts. However, little is known about the perceptions of Directors of Nursing in NHS acute Trusts, on caring practices.

Methods:

The study aimed to construct a grounded theory of the perceptions of Directors of Nursing from NHS acute Trusts, on caring practices. The study also sought to understand the social, political, professional and organisational challenges facing Directors of Nursing. Twelve Directors of Nursing from NHS acute Trusts in England were interviewed between July 2013 and January 2014 using semi-structured questions. A constructivist grounded theory approach was adopted to support the co-construction of the theory by exploring how the participants construct their worlds or reality.  In the constructivist grounded theory approach, underlines that the researcher is not neutral in the research process, as data are co-constructed between the researcher and the participants. I believe it is important to make my identity as the researcher visible, so as to create a transparent co-construction of data in this research study.

Results:

Through the co-construction approach a theory of ‘Directors of Nursing Perceptions on Caring: Post Francis Paradoxes’ revealed that the participants are working within a paradoxical NHS system in response to findings from the Mid Staffordshire NHS Foundation Trust inquiry. The theory is supported by three categories of: ‘trusting my senses’; ‘avoiding becoming collateral damage’; and ‘being in a different place’.

The three paradoxes that emerged were: the need to produce reliable high-quality assurance about standards of care in the NHS which detracted from and impacted on the Directors of Nursing roles in supporting internal assurances processes. Secondly, external monitoring standards did not capture the ‘real’ warning signals of care failings as intended. Thirdly, the reliance on intuitive skills to give assurances of caring practices was considered necessary to support the demanding monitoring and assurance processes. This study captures a challenge, as perceived by Directors of Nursing, regarding how external regulatory demands can be accommodated alongside the internal organisational requirements to lead the improvement agenda of patient care standards. Directors of Nursing need then to balance the competing priorities in their roles whilst supporting and leading a nursing workforce to deliver ethical caring practices.

Conclusion:

The study confirms that experienced senior nurses such as Directors of Nursing relied on their skills of intuition when assessing the quality and standards of caring practices on the ward. However, this research would suggest that there is also a reliance on intuition when seeking reassurance about caring practices more broadly on the wards. This was particularly so when the Directors of Nursing attended and observed the nursing staff on the wards to seek assurances about the standards of nursing care, by observing staff’s interactions with patients. Senses were relied upon as well as intuitive feelings and instincts about good or uncaring practices. Notably, there appeared to be more reliance on instincts than on measurable ward clinical metrics. In a hierarchy of ranges of information about standards of care on the wards, ‘intuition’ was seemingly the default position adopted by the Directors of Nursing.

It is suggested that there are several distinct contributions that this research offers. Firstly, it notes the creation of paradoxes in the post-Francis era, because of the contradictory impact of additional regulation and monitoring on the role of Directors of Nursing, whereby the intention is through regulation to create and safeguard the quality of care and try and prevent future failing. The contradiction has arisen in that there was an increased insatiable requirement for documentary evidence to be presented to the numerous regulatory parties. This is contested as having the effect of over-burdening the role of Directors of Nursing, which has impacted on their operational and strategic roles of leading improvements to patient care. This positivist approach to monitoring and regulating care is opposed to the interpretative approach of intuition applied by the Directors of Nursing.

A second contribution is the Directors of Nursing’s identification of a continuum of kindness in their staff, which is perceived as an indicator of staff more likely to be kind to the patients. This is important in understanding more about what influence the Directors of Nursing can have on caring practices at the ward level if kindness is nurtured and supported to flourish. Equally, they can make an impact by putting in support mechanisms and monitoring staff that are perceived to be demonstrating less kind behaviours, to help prevent uncaring behaviours from developing.

Finally, this research proposes that the Directors of Nursing experience feelings of anxiety about the security of their own roles, in anticipation that caring practices might fall below standards in the organisation. The research also suggests that the Directors of Nursing use their skills and relationships at the Trust Board to try and mitigate against this perilous situation by securing additional investment in the nursing workforce.