The role of the Registered [Surgical] Nurse in the 21st century NHS acute trust hospital. An ethnographic study

Abstract

This study focused on Registered Nurses (RNs) working in Acute Trust surgical wards in the context of their role development, role expansion and role extension. The study originated from concerns raised by RNs undertaking the surgical pathway of the BSc Hons in clinical nursing practice, who alerted me to their dissatisfaction with their working conditions and their role. This revelation was made at a time when modernization was cascading into Acute Trusts as a result of the NHS plan (DOH 2000); simultaneously the European Working Time Directive (EWTD) was being implemented, sequentially reducing Junior Doctor’s hours of work. NHS modernization and the EWTD were the two initiatives which led the researcher to the assumption that RNs working in surgical wards were the labour force who would be absorbing the additional workload brought about by these changes, because RNs are the only health professionals in acute surgical wards with twenty-four hour contact with, and responsibility for, ward-based surgical patient care. The study was conducted in one clinical directorate of an Acute Trust hospital, comprising six in-patient surgical wards and five specialist nursing services. The methodology was ethnography, where the researcher worked as an RN for fifteen months, collecting data through Spradley’s (1980) descriptive, selective and focused phases of fieldwork. Data was analysed using what Miles and Huberman (1994) refer to as a set of ‘choreographed / custom built’ techniques. The descriptive phase of fieldwork revealed an apparent ‘staffing illusion’ on the surgical wards and RNs were found to be under tremendous pressure to manage ‘patient throughput’, and an ever increasingly dependent case mix of surgical patients, within the existing, or if possible diminishing Senior / experienced RN labour force due to the emergent evidence of a ‘cycle of staff change’ with non-clinical managers backfilling Senior RN posts with Junior RNs. For Senior RNs this backdrop meant additional support and supervision demands on their role. To get through the workload many RNs held ‘dual roles’ to enable maintenance of the surgical services within the directorate. The selective phase of fieldwork re-focused the ethnographic lens on the RNs in the context of their role development, role expansion and role extension, from which six perspectives were found: 1) role development from Junior to Senior RN, 2) role expansion dependent on shift of the day, day of the week – the co-ordinator role, 3) role extension confusion and boundary disputes, 4) hidden [role expansion and extension] talents of surgical nurses, 5) role contraction – a feeling Nursing is going backwards, and finally, 6) ‘if only I could’ – role expansion aspirations of surgical RNs. The third phase of fieldwork, described by Spradley (1980) as the focused phase, was spent validating the findings and conducting the ethnographic interviews. The findings are interpreted locally [from the perspective of RN’s working within Rodin] as ‘working to full capacity’ through ‘doing more for more with less’, as a result of the RN with the surgical directorate being sandwiched between two agendas, that of Junior Doctors EWTD and NHS modernisation. Braverman’s skill substitution / degradation of skilled work thesis is then used as an interpretative framework to conclude the thesis, the outcome of which reports a ‘triple substitution’ agenda.