An ethnographic study of the role of frontline nurses in fostering a positive practice environment in hospitals

Abstract

Background: Modern healthcare continues to face the increasing challenges of short staffing, diluted skill mix, cost containment, rising public expectations, and constant changes associated with rapid advancements in medical science and technology. Its practice environment, which provides the context for care delivery, has been regarded as a pressure cooker environment, and has been gaining increasing attention in recent decades. A large body of evidence has pointed to an inseparable link between the features of the practice environment, and nurse and patient outcomes. While most studies have adopted surveys, standards and guidelines, and involved only management leaders' views in improving the practice environment, this study employed a field study approach to provide empirical evidence regarding the role of frontline nurses, and the dynamic processes involved in advancing a positive practice environment (PPE) in hospitals. Aim: This study intends to explicate the role of frontline nurses, and the underlying processes involved in fostering a PPE through an empirical analysis of the features of the practice environment in hospitals. Design: An ethnographic approach was adopted, and four medical units which resembled two pairs of magnet and stress units in two acute regional public hospitals in Hong Kong were involved. Empirical findings were generated from three sources: (a) individual interviews with 28 frontline nurses (i.e. frontline clinical nurses and first-line nurse managers), four ward stewards and 12 patients, (b) weekly field observations and informal conversations with healthcare members and care recipients, and (c) review of relevant documents, such as management meeting minutes and incident reports. The descriptive texts, including the field notes and verbatim transcripts, were analysed through a comparative analysis process. Findings: The examination of the features of the practice environment in the four medical units has pointed to a pressing need to improve the quality of the practice environment in local public hospitals, which has been challenged by a variety of unfavourable conditions. These include: understaffing situations involving a poor skill mix, which constrain the practice development of nurses and threaten patient safety; the material resource constraints associated with cost containment and escalating health service demands; and the complexity of team communication and collaboration in a multi-provider system, which undermines effective team functioning. Various workplace factors were noted to have a significant bearing on healthcare outcomes in terms of patient safety, nurse satisfaction and retention. These include: the aspects of workplace learning, non-blame culture, change management, professional update opportunities, equity in practice development, resource rationing, role transition and expertise development of nurses, and team communication and collaborative practices. Further analysis of the ethnographic findings revealed the frontline nurses' potential in confronting the workplace challenges to establish and sustain a PPE. These comprise their role in: (1) cultivating a positive learning climate conducive to practice development, (2) preserving ward functionality in turbulent times, (3) mitigating risk and preventing harm, and (4) building a cohesive and effective team. Integration of the findings with the previous literature further identified the four essential elements of a PPE, namely the aspects of practice development, resource management, patient safety advocacy, team cohesion and effectiveness, as well as the relevant skills (e.g. cognitive and psychosocial skills) and attitudes (e.g. accommodating and trusting) essential to the success in improving the practice environment in hospitals. The ethnographic findings, which are presented in the form of detailed delineations of the social processes and behaviours in the real clinical contexts, provide important operational data for guiding the advancement of a PPE, while also contributing to the theoretical understanding of the construct of PPE under study. Conclusion: This study serves as a springboard to generate insights into how to improve the quality of the practice environment in local public hospitals. The findings, which delineate the role of frontline nurses and the dynamic processes involved in fostering a PPE, have paved the road for improving work conditions, and nurse and patient outcomes. To succeed in confronting workplace challenges, there requires synergistic efforts among the different stakeholders to become engaged in the initiatives for advancing a PPE, and to put these initiatives into action through developing relevant healthcare policies and organisational programmes, and enhancing nursing education and training in the competencies required for directing the initiatives. Future research should take into account frontline nurses{174} views on their work conditions, and further examine the practice environment in different settings, and the influence of workplace culture on the features of the practice environment, which has been poorly conceptualised.