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Posts tagged ‘Ethnography’

The “As-if” World of Nursing Practice: Nurses, Marketing and Decision-Making

We are currently featuring the article titled “The “As-If” World of Nursing Practice: Nurses, Marketing, and Decision-Making” by Quinn Grundy, PhD, RN and Ruth E. Malone, PhD, RN, FAAN. Based on an ethnographic study, the authors conclude that “nursing must deconstruct the “as-if” nondecisional myth by confronting conflicts of interest and owning fully its rightful clinical and advocacy roles.” This article is available to download at no cost while it is featured; I join the authors in inviting you to return here to share your responses and comments!  Dr. Grundy shared this background about her work:

The Physician Payments Sunshine Act, passed as part of the Affordable Care Act, came into effect just at the time I was selecting an area of focus for my PhD dissertation. This legislation required pharmaceutical and medical device companies to publicly report all payments made to physicians and teaching hospitals and issued in a new era of transparency in United States healthcare. What surprised me, however, was that nurses were omitted from the mandate. This caused me to question whether nurses did not have these types of relationships with industry? Or, whether policymakers did not believe they warranted the same level of scrutiny?

Under the supervision of Dr. Ruth Malone, my co-author on this week’s featured article, I conducted an ethnographic investigation into the ways that registered nurses interact with industry in their day-to-day clinical practice at 4 hospitals in the western United States. What we found couldn’t have been more different than what the policy climate suggested.

Often on a daily basis, nurses interacted with industry representatives from multiple medically-related industries including

Quinn Grundy

pharmaceutical, medical device, information technology and infant formula companies. These interactions including attending drug company-sponsored dinners, receiving payments for speaking or consulting, and receiving gifts at conferences or other sponsored events. Among physicians, these types of relationships have been associated with negative changes in prescribing habits including increased prescribing of brand-name, heavily marketed medicines with lower safety profiles.

However, to our surprise, nurses were mystified at the attention of sales representatives and wondered at their inclusion in marketing activities like drug dinners. They explained that as health professionals who cannot prescribe medicines, there was no decision-making for marketing to attempt to sway. Yet, these same nurses described their roles on hospital purchasing committees, narrated multiple instances where they had recommended treatments to providers, and described powerful influence over patient care within the hospital.

This article explores the conditions under which nurses’ considerable influence and power to affect change within clinical practice becomes invisible, even at times to nurses themselves. We call this the “as-if” world of nursing practice — a well-constructed, institutionally-preserved myth that nurses do not make decisions in the absence of doctor’s orders.

We hope this article will stimulate a conversation in the profession about the nature of conflict of interest in nursing practice and the need to recognize, and safeguard, nurses’ considerable decision-making power from marketing influence.


Shadowing Nurse Middle Managers

Our current featured article is titled “Nurse Middle Managers’ Dispositions of Habitus: A Bourdieusian Analysis of Supporting Role Behaviors in Dutch and American Hospitals” by P. C. B. Lalleman, MA; G. A. C. Smid, PhD; M. D. Lagerwey, PhD; L. Oldenhof, PhD and M. J. Schuurmans, PhD. While it is featured, you can access this article at no charge on the ANS website, and welcome your comments here! Pieterbass Lalleman has prepared this video, followed by a blog message about this work:

The current featured article in ANS focuses on supporting roles of nurse middle managers. The paper is part of a larger Dutch study on nurse middle managers daily work. The main goal is to better understand the role of nurse middle managers in hospitals and their leadership. We wondered: What gives these nurse managers authority in their daily

work? Most literature on nurse managers advocate American nurse managers work within Magnet hospitals as the best practice model.

The study has been initiated by the Dutch HU University of Applied Sciences and the Dutch Nurses Association. We decided to investigate practices of nurse middle managers in Magnet, Magnet-related and non-Magnet hospitals in both the Netherlands and the United states. Our grant proposal has been awarded $300.000. This allowed us to have a close look at the work of nurse managers in both the Netherlands and the United States This funding made it possible to conduct research and shadow nurse managers in New York and Michigan for one year.

Based on this ethnographic work (560 hours shadowing), we made an interpretation of the work of nurse middle managers using Bourdieu’s tools of dispositions and habitus (or second nature), field and capital. In this ANS article we describe first describe some essential findings: the eight dispositions of habitus of nurse middle managers. A caring, clinical and scientific disposition seemed vital. In the next part we describe how a different configuration of dispositions of habitus of nurse middle managers influenced their authority in each of the four participating hospitals. In forthcoming articles, we will analyze how these configurations influence the emergence of nurse middle manager’s leadership.

In this blog we zoom in on two aspects of our research that were more on the background: 1) living and doing research in the U.S. and 2) the importance of doing research together.

Big Friendly Giant

I used to work as a nurse and manager in a hospital, and now I work as a lecturer and researcher in an University of Applied Sciences in The Netherlands. We choose to move with my family to the U.S. for one year and take our time to understand living and working in the U.S. from a Dutch perspective (and not fly alone to the U.S. for 4-5 times and conduct the shadowing in slots of 2-3 weeks). This was a lucky choice. Doing ethnography demands a deep and robust understanding of the world you are investigating. Living in New York, walking my two youngest daughters to PS 8, the Robert Fulton School in the morning, followed by a bike trip across the Brooklyn Bridge to drop-off my eldest daughter at the Lower Manhattan Community Middle School at 26 Broadway , helped me in understanding and comprehending what I saw during my days shadowing the nurse managers. Although every hospital looks alike on first sight, especially during quick visits or tours, deeper insight is created by ‘hanging around’ for a longer time. Both shadowing as a research method for ethnography and moving to the U.S. were crucial for describing the habitus or second nature of these nurse managers. As a shadower I literally have been in the shadow of these, mostly women, that I followed during work. I am 6 feet and 5 inches tall a rather large shadow for these nurse managers. On a particular day a staff nurse of the hospital in Queens came to me smiling and said: ‘there you have the Big Friendly Giant again’. This reference to Roald Dahl expressed exactly how I felt in the strange new world that I thought I knew so well (both the hospital world and the U.S from the hundreds of articles, movies and TV shows). These kinds of encounters and also the experiences of my children and my partner helped me with making sense of the work of nurse managers in their hospitals and reflect on my own presence and interpretations. My work would not have been possible if I just have been visiting for a couple of weeks.

Reflection on wheels: the importance of ‘member check’ and collaborative research

This research project was an ethnography inspired by action research. The grant money gave us the opportunity to organize member check sessions with the nurse managers to report on the preliminary findings and discuss the meaning of these. The first session was organized in The Netherlands after we finished shadowing at the two Dutch sites. A very interesting finding of that session was that the nurse managers from the two sites requested to shadow each other. Their main motivation was that being shadowed helped them with the recognition of habitus as a second nature, their routine behavioral repertoire became exposed during shadowing. Shadowing someone else who was doing the same job enhanced their understanding of their daily work and habitus. The objects of this study, the nurse managers, became researchers (or subjects) of their own work. This movement became even more visible when the eight Dutch nurse managers (and my Dutch PhD supervisors) joined me in the U.S. for a one-week research trip to the two American hospitals. The 6-day trip started on a Sunday at NYU’s Institute of Public Knowledge were I met these Dutch managers and discussed the program with them. On Monday and Tuesday, we would visit the partner university and the hospital I shadowed in New York. On Wednesday we had a 733 miles’ bus trip from New York to Western Michigan. On Thursday and Friday, we visited the hospital and university in the Mid-West.

For me, as a researcher it was great to finally share all my observations with the nurse managers of the Netherlands, show them the U.S. system in full color. It also, helped me reflect on my findings and putting them in perspective. After two full days of New York, (Live in New York City once, but leave before it makes you hard) the 10 hour coach ride was one of the greatest reflective experiences I had during this PhD project. The drive through the state of New York, Pennsylvania, Ohio, Indiana and Michigan was superb. It gave us a change to reflect on all the impressions of New York and prepared us ready for the friendly Mid-West. I had the chance to talk the Dutch managers, interview them, record their experiences and illustrations. They did not only talk about the U.S., they also talked about home, how nursing and nurse management is organized in their own institutions. Travels like these can be very inspirational and valuable. Travelling enhances reflection. It creates new insights and helps both researcher and participants in making sense of the phenomenon under investigation.

In sum, PhD research tracks like these are like journeys in which both researcher and participants of the study collaborate to find the answers to complex challenges. To accomplish this the researcher, have to be close to the subject, live and work with them to fully grasp and comprehend the essence of what is seen. Both shadowing, member checking sessions and an international research trip contribute to these outcomes.

I would like to thank all the nurse managers and my supervisors for realizing this first publication on nurse middle managers daily work.

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