- Email: [email protected]
Conflicts of practiceconfronting second line nurse managers in an Accident and Emergency department. Part 2
Conflicts of practice confronting second line nurse managers in an Accident and
Emergency department. Part 2
THE RESEARCH FINDINGS Following from the aim of the study to 'examine the practice of the Associate Charge Nurse (ACN) in the Accident and Emergency (A & E) department' the group members decided a good place to start their reconnaissance would be to document their responsibilities. By comparing these responsibilities with their role as outlined in the A & E d e p a r t m e n t ' A C N Job Description', they hoped to establish the degree of congruence between the two. In other words, they aimed to establish the degree of 'fit' between what they thought they should be doing, and the organisation's expectations of them. T h r o u g h this process they hoped to develop a picture of what the 'ideatised' vision of the ACNs' practice in the A & E department would look like.
U n c o v e r i n g an idealised vision o f ACN practice
A. L. Robinson and C. M. O'Connell
Andrew L. RobinsonRN. Rid, BASANC(Ed), MNS, Phd.
student,SchoolorNursing,~ TrobeUniversity,Helbour:ne, Australia.
Cathryn M. O'Connell RN,
In order to construct an 'idealised vision' of the A C N practice, each group member contributed
In recent times in Australia, there has been a proliferation of nursing career structures which aim to address the historical neglect of a career path for clinical nurses. A m o n g these developments has been the formulation of a new and exciting nursing role, that of the second line nurse manager. This role was designed to give experienced nurses who traditionally worked 'in charge' formal recognition of their knowledge and skill, and sought to construct a role that encompassed both clinical and managerial responsibilities. However, the reality of these nurses' practice is fraught with problems and difficulties as they a t t e m p t to negotiate a new and uncharted domain. This paper recounts an action research study conducted by a group of second line nurse managers in an Accident and Emergency d e p a r t m e n t , who sought to explore the dimensions of their practice. T h e study identifies problems with combining clinical and managerial responsibilities in the one role, within a context marked by a high level of
Dip. ENT, Cer~ Emerg,, B.Fd,
unpredictability,
UnitManager, Neurosciences,
values clinical practice over other forms
Melbourne Private Hospital RHH, PO Box 2150
Parkville,Victoria,
Australia 3050.
Requests for offprintsto Cathryn M. O ' C o n n e l L
of
and a culture
nursing practice.
The
which
paper
concludes with a n u m b e r of recommendations to overcome these
problems.
Accident ond Emergency Nursing (t 995) 3, 129-135 © PearsonProfessionalLtd 1995
to a ' b r a i n s t o r m i n g ' session w h e r e they documented what they believed were their responsibilities. The results were then collated into a schema which contained four distinct domains. These domains covered the areas of clinical, m a n a g e m e n t , education, and research responsibilities. For example, clinical responsibilities included areas of practice such as the p r o v i s i o n o f ~hands o n ' patient care, the supervision of medical and nursing staff, and acting as a clinical resource person. Managerial responsibilities included d e v e l o p m e n t o f individual p o r t f o l i o s * , allocation of P~N daily duties, liaison with the multi-disciplinary team, and a number o f p u r e l y administrative functions such as fostering and d e p a r t m e n t a l budgeting. Educational responsibilities included the provision of informal (clinical) and formal (tutorials) education to nursing staff, as well as p a r t i c i p a t i o n in education, such as tertiary studies, for personal professional development. Research responsibilities included p a r t i c i p a t i o n in research projects w h i c h p r o m o t e d the d e v e l o p m e n t of quality o f nursing care. When they compared this schema with the A C N Job Description they found a good degree of congruence between the two, indicating that the group members' understanding of their role was generally consistent with organisational expectations. *Specific projects, pursued by individual ACNS, which aim co develop the effectiveness and ei~ciency of nursing practice and improve the quality of patient care.
130 Accident and Emergency Nursing
Reconceptualising A C N practice Reflecting on these findings highlighted that in practice the delineation between these domains of the ACN's practice in A & E, as represented in the schema, was not so clear. It became obvious that these domains intersected, or crossed over each other on many levels. For e x a m p l e , the s u p e r v i s i o n o f staff is an administrative responsibility which takes place in the arena of clinical practice; informal chnical education comes under the rubic of education, yet it is situated as a component o f the ACN's clinical practice. Responsibility for facihtating positive communication, as described by the ACN's job description, traverses and intersects with every domain of responsibility described above. In order to deal with this complexity, and the p r o b l e m s that arise f r o m a t t e m p t i n g to c a t e g o r i s e a b r o a d range o f i n t e r s e c t i n g responsibilities into a number o f specific and discrete domains, the ACN's decided it would be more useful to employ a different conceptual framework. T h e framework they developed delineated their responsibilities in terms o f a different conceptual framework, comprising two broad categories. The first category included those activities directly related to the ongoing provision of patient care and staff supervision, which are geographically located in the clinical arena - their clinical practice. T h e second category included those activities which either support clinical nursing practice or work to improve it, but do not involve the provision of ongoing patient care. The latter generally takes place in a different geographical location, such as an office or seminar room - what we called the ACN's managerial practice. This conceptual framework made it clear that as second line nurse managers, A C N s in A & E had two sets o f responsibilities: those related to support/development, and those related to the provision of direct patient care, both o f which are pursued in different geographical locations. However, it soon became clear that the ACNs had a number of reservations about the degree of congruence between this idealised vision, and the reality that was their practice in the department. In o r d e r to expose the conflicts and contradictions that existed between the idealised vision of their practice, with the reality that was their practice, they began the next phase of the project. This phase a i m e d to explore and articulate what it was actually like to practice as a second hne nurse manager in A & E.
Exploring the practice of second line nurse managers in A & E Investigating the A C N role in practice revealed that the ACNs experienced difficulty dividing
time between the responsibilities associated with their clinical and managerial practice. Their reconnaissance showed that these difficulties arose d i r e c t l y f r o m the p r o b l e m s t h e y experienced getting time out of their primary geographical location, the clinical context, to devote time to their managerial practice. These problems arose from a number of sources, which are summarised below.
' W i l l I or will I not leave?' T h e influence of contextual unpredictability As the n a m e ' A c c i d e n t and E m e r g e n c y department' implies, an emergency situation can occur at any time. This means that the practice contingencies for second line nurse managers are g r e a t l y i n f l u e n c e d by ' c o n t e x t u a l unpredictabihty', that is, by the ebb and flow of clients into and out of the department, and the seriousness o f the conditions with which these clients present. The contextual unpredictability meant that the group members experienced varying degrees of ambivalence about leaving the department at all. Their ambivalence arose out of a fear that some emergency would occur; an emergency which the A C N would not be on hand to deal with. Also, in those circumstances where they judged the department as being busy, the A C N w o u l d cancel any p r e v i o u s l y a r r a n g e d m a n a g e r i a l c o m m i t m e n t s , no m a t t e r h o w pressing, and stay on the floor. These sentiments are reflected in the following comments: ...the first priority for me is to stay (in the clinical context) if it is really busy,.., or if there was a ' r e s u s ' (a child n e e d i n g resuscitation) expected or something like that, I would stay in there .... ...if things are a little bit busy, or perhaps there's a potential for things to become busy, you think 'will I go (leave the clinic area) or won't I go? and I end up deciding I better be here because I shouldn't be there (out o f the clinical area)'. In m a n y respects these s e n t i m e n t s are understandable. As second line nurse managers, the A C N position is not supernumerary. Rather, they make up one o f the numbers o f nurses rostered on a particular shift, with a delegated clinical role. Consequently, when they are absent f r o m the clinical c o n t e x t , the n u m b e r o f experienced staffavailable to provide patient care is r e d u c e d , p o t e n t i a l l y c o m p r o m i s i n g the department's function, especially during busy periods. Similarly, as the most experienced nurses in A & E, their absence deprives the department o f an important clinical resource
Conflicts of practice confronting second line nurse managers in an A & E department. Part 2 13 1
person. These concerns arising from contextual unpredictability, and the resource implications o f their absence, effectively u n d e r m i n e d their ability to plan activities, and meet specific targets and deadlines o f their projects.
W h a t does it mean to be 'busy'? Competing interpretations This contextual unpredictability, and concern for the viability o f the department during the ACN's absence, also contributed to the conflict that was generated between Registered Nurses (RNs) and ACNs. It became evident that the R N s ' and ACNs' understanding of the meaning of'busy', was subject to some contestation. That is, they had differing interpretation~about what busy meant, and these differing interpretations often resulted in conflict. The following account highlights this point. ...they (the RNs) gave rne a hard time about going (to the meeting) because it was busy. But I felt it wasn't busy .... T h e pressure ( f r o m t h e R N s ) c a m e b a c k o n me. Emotional pressure put on me that I shouldn't be at a meeting. The above account illustrates the kind o f conflict that arises when there are competing interpretations as regards resource requirements. It also illustrates that the A C N s ' interpretation of being busy often conflicted with their less e x p e r i e n c e d R N colleagues. R e f l e c t i n g o n this f i n d i n g t h e A C N s c a m e to t h e conclusion that such interpretations o f being busy were made o n t h e basis o f subjective judgements; judgements based on an individual nurse's confidence and experience in t h e d e p a r t m e n t , as o n e g r o u p m e m b e r commented: It's a very subjective individual interpretation the term too busy.., what ACNs and R N s think is busy are often two different things. It all depends on people's confidence, their abilities, their willingness to accept a c h a l l e n g e as w e l l . . . (If) t h e y d o n ' t feel c o m f o r t a b l e w i t h it (responsibility), they're going to think it's busy even if there are o n l y 6 p a t i e n t s in the d e p a r t m e n t , whereas someone else might think it's busy w h e n there's 14 (patients), banked up to the ceiling. The findings showed that these disputes in interpretation over what it means to be busy, made a significant contribution to the conflict generated between R N s and ACNs when the latter attempted to leave the clinical context to pursue their managerial practice. This conflict added a further disincentive for A C N s to leave the clinical context at all.
' W h e n are you going to do some real work?' The A & E d e p a r t m e n t as a site of conflict The A C N group shared many accounts which highlighted the fact that their R N colleagues did not have a clear understanding o f the diverse r e s p o n s i b i l i t i e s associated w i t h the A C N s ' practice. These accounts showed that the registered nurses believed the A C N s ' primary p r a c t i c e r e s p o n s i b i l i t i e s r e s i d e d in t h e supervision o f activities in the department and the provision o f direct patient care. That is,.the RNs did not acknowledge the ACNs' managerial responsibilities. Consequently, those A C N activities n o t g e o g r a p h i c a l l y l o c a t e d within the clinical context had limited legitimacy. This point was highlighted w h e n one group m e m b e r reported 'the R N s believe t h a t w h a t w e do w h e n w e l e a v e t h e department.., doesn't constitute workL In the light o f the above attitudes, it was not surprising to find that the ACNs received various forms o f censure from their Registered Nurse colleagues w h e n they were absent from the clinical context. This censure took many forms, from overt comments such as °...oh you're back [in the clinical area], I wondered when you were going to do some work', to more discrete forms o f disapproval described by one group member, w h o r e p o r t e d that ' y o u can feel the chilly atmosphere w h e n you come back in the unit, although you often don't k n o w exactly what they've said'. Once again, the lack o f legitimacy o f the ACNs' managerial work is mirrored in the above comments. According to group members, the continual and sustained nature o f this censure represented a significant disincentive for them to leave the clinical context to pursue their other activities.
Conflicting values: the dilemmas of being a second line nurse manager in an A & E d e p a r t m e n t T h e s t u d y s h o w e d t h a t t h e R N s in t h e department were not alone in valuing clinical practice over other forms o f practice. As the A C N group members' discussions evolved, it soon became apparent that they too held similar values; values which highlighted a belief that clinical practice was the central interest o f their w o r k . This value p o s i t i o n is i l l u s t r a t e d in comments like: To m e it's ( a d m i n i s t r a t i v e a c t i v i t i e s ) something that I had to get used to (as an A C N ) 0 b u t p r i m a r i l y I w a n t to b e a clinician .... If you want to be 'hands on' that's what a clinical nurse ... is about, so you stay in the clinical area .... These discussions also highlighted that, like t h e i r R N c o l l e a g u e s , t h e A C N s also
132 Accident and Emergency Nursing
experienced some difficulty acknowledging the legitimacy of the managerial, or administrative, aspect of their practice; difficulties reflected in comments like: ...part o f the difficulty for us is that we believe that (as ACNs) the clinical part o f our role is m o r e l e g i t i m a t e t h a n the administrative part. These sentiments highlight the problems second line nurse managers experience as they grapple with the competing and conflicting values systems. O n the one hand they must meet organisational expectations which demand they construct their practice in ways that involve more than the provision of direct clinical care and supervision. O n the other hand, they are located in a cultural c o n t e x t w h i c h values clinical practice over all else, and has difficulty a c c e p t i n g the l e g i t i m a c y o f the diverse managerial responsibilities that comprise the ACN's practice. The problem is made all the more difficult by the fact that, as members of this culture, the ACNs actively subscribe to the latter view.
The changing conditions of nursing work: problems with 24-hour rotating rosters The ACNs' research also uncovered a number o f structural and organisational issues which contributed to the problems. The first of these issues related to their roster. The fact that ACNs must work a 24-hour roster meant that each A C N had to frequently rotate onto night duty. These frequent rotations upset their biological clocks, resulting in what was described as 'a constant state o f tiredness' - a situation where many claimed that they '...simply did not have the energy' to attempt to resolve the conflict that arose as a direct result of having responsibilities in two domains of practice. At the same time, the reduced numbers of nursing staff on night duty made it virtually impossible to leave the clinical context at all during these shifts. This latter point meant that on night shift, the A C N had to suspend work on various projects. This made it all the more difficult to pick up work on these projects on return to day shift, further limiting the ability to make concrete achievements in managerial aspects of their practice. The ACNs' subjective impression was that they seldom worked on the same day, on either a day or evening shift, between Monday and Friday. These subjective impressions were confirmed from data collected relating to the patterns o f A C N ' s rosters. These patterns showed that for a number of reasons, primarily because the charge nurse assumed responsibility for r u n n i n g the d e p a r t m e n t on day shifts between Monday and Friday, they only worked
on the same day, on opposite shifts, 31% o f the time. This arrangement worked to restrict their ability to engage in managerial practice because they could rarely arrange with a colleague (who was rostered on the same day but on an opposite shift) to supervise the activities in the clinical arena during the double staff time, a period of 272 hours. This organisational a r r a n g e m e n t contributed to their difficulties because they were unable to cover each other's absence in the d e p a r t m e n t , and t h e r e b y a c c o u n t for the contextual unpredictability discussed previously.
W h a t are we really doing? The implications of an unfulfilled practice As a result of the constraints we have outlined, it became evident that there was a chain reaction of events that took place as the ACNs attempted to balance so many divergent and competing demands. In order to meet their 'portfolio' and other managerial practice obligations, most o f the ACNs reported that they found it necessary to do a great deal of work at home, in their own time, thereby impacting on family and social commitments. Evidence also emerged that even with a substantial effort to devote personal time to work commitments, few of them had made any progress in developing their portfolios. They believed this was a direct result o f their inability to take regular planned time out of the clinical context. T h e difficulties they e x p e r i e n c e d participating in the study, alluded to previously, supported this contention. All these difficulties h e i g h t e n e d a sense o f frustration, lack o f concrete achievement and in the context o f ongoing confrontation and conflict, resulted in a high level o f stress. As one group member noted: It is extremely difficult to be all things to all people, yet that is what I feel is expected o f me... I feel I have two full time jobs in keeping up with my portfolio and the rest of the place (my clinical practice).
DISCUSSION This action research project was set up to explore the practice o f a group o f second line nurse managers in an A & E department o f a large city hospital. C o n s i s t e n t w i t h the values underpinning this methodology, the study was predicated on a collaborative agenda, where all g r o u p m e m b e r s p a r t i c i p a t e d in e x p l o r i n g concerns they identified with their practice in the department. This extended dialogic engagement provided a rare o p p o r t u n i t y to share views, express concerns, and break d o w n isolation through exposure o f a c o m m o n experience
Conflicts of practice confronting second line nurse managers in an A & E department. Part 2 133
of struggle. Participation in the study worked to foster a new found solidarity within the A C N group, and brought to light a host of issues which previously had been submerged beneath the hectic day to day operations of the department; issues which had previously only been spoken of in the context of 'tea room chatter'. B e g i n n i n g the study by e x a m i n i n g the ACN's theoretical understanding o f what was labelled an 'idealised vision' of practice provided a referent to c o m p a r e this vision with the organisation's expectations and the reality that is their practice. W h i l e this 'idealised vision' p r o v e d g e n e r a l l y c o n g r u e n t w i t h the organisational expectations, they recognised the need to reconceptualise their role in schema which more clearly represented their practice. This schema demarked A C N practice into two domains, distinguished in terms of the nature of w o r k p u r s u e d - clinical versus managerial practice - and in terms of geographical location, in or out o f the clinical context. While this reconceptualisation o f their practice helped them better to understand the dimensions o f their role, it soon became apparent that the reality o f their practice made the 'idealised vision' little more than a fantasy. The findings of the group's research articulated the dimensions of this fantasy, and located organisational and c u t t u r a l f o r m a t i o n s w h i c h c o n s p i r e d to p e r p e t u a t e it. These formations traverse a spectrum of issues ranging from the particular issues associated with an A & E department, to the way that values and attitudes o f nurses who work in such departments reflect the values and attitudes o f the wider nursing culture. If we look first to the peculiarities o f A & E, we must acknowledge the impact of contextual unpredictability. The research showed that the contextual unpredictability of A & E emergency presentations at any time with little or no warning - combined with the A C N s ' status as the most experienced practitioners, heightened their fear that nurses remaining in the department would be unable to manage unforeseen events that occurred in their absence. C o n s e q u e n t l y , as the m o s t s e n i o r and e x p e r i e n c e d nurse on duty, they saw their primary responsibility as maintaining a clinical presence in order to be on hand to deal with the inevitable emergency presentation. In many respects, the unpredictability o f A & E demands that the optimal amount of nursing resources be readily and immediately available at all times. In this sense, the very nature o f A & E undermines the ability o f nurses to fulfil the responsibilities associated with a practice that takes them out of the immediate clinical context. However, the degree to which an ACN's absence actually compromised the department's function raised a spectre o f conflict. Disputes
between P,.Ns and ACNs over interpretations of the relative 'business' of the department, or the ability to deal with unpredictability, led to disputes over appropriate times for ACNs to be absent or not. These disputes resulted in l:LNs engaging in various forms o f censure which worked to contest the legitimacy of the ACNs' managerial practice and dissuade them from leaving the clinical context. Not surprisingly, these disputes provided a further incentive for ACNs to defer the pursuit o f their managerial responsibilities and stay in the clinical arena. In o n e sense, the process o f deferral can be understood as a strategy adopted by the ACNs to diffuse conflict and avoid censure. However, the study showed that while these issues are i m p o r t a n t c o n t r i b u t o r s to the problems these A & E second line managers experienced, they do not represent the complete picture. The study also highlighted the strong cultural imperatives in nursing which constrain clinical nurses from expanding the dimensions o f their practice out o f traditional and historical confines. Through engaging in reflective and p a r t i c i p a t o r y research practice, the nurses involved in this study uncovered a number o f cultural forces which worked to compromise their ability to meet their practice responsibilities as second line nurse managers. This engagement highlighted the way that nurses' participation in critical reflective processes helps them to see past the immediate functional and organisational constraints, and to uncover the ways that culture exerts its influence. In many respects, the findings o f the study illustrate the powerful way nursing culture works to influence nurses' values and beliefs. The P..Ns' and ACNs' strong bias toward clinical practice reflects the interests of the wider clinical nursing culture; an interest supported by strong historical imperatives w h i c h value clinical practice over other forms of nursing practice. It is apparent from the findings that this cultural valuing of clinical practice influences the ACNs' situation in a number of ways. Firstly, despite the fact that the A C N s recognise the diversity of their responsibilities, by their actions they devalue the importance of their managerial practice, and remain captive to the dominant clinical culture embedded in the department. In many respects, their ambivalence toward their managerial responsibilities reflects their historical membership within this culture clinical practice is what nursing is all about. The group members subsequently acknowledged this belief during the course o f their reflections. In this situation, it is not surprising to find that their managerial practice is relegated to the status of something o f an 'add on' to their primary clinical role - p r a c t i c e p u r s u e d o n l y at t h o s e times -
134 Accident and EmergencyNursing
when the situation in the department permits. Secondly, like the ACNs, the R N s ' inability to a c c e p t the l e g i t i m a c y o f the A C N s ' m a n a g e r i a l p r a c t i c e reflects their clinical priorities and focus. Yet in the context of the wider nursing culture, this lack of acceptance is not so strange. After all, the ACNs' clinical role is highly visible, and well understood, having strong historical associations with the practice of nurses who traditionally acted in charge of the shift - nurses whose priorities were firn~y located in clinical practice. In contrast, the construction of the ACNs' managerial practice lacks clarity, has no historical precedent, being a relatively recent development, and comes to life away f r o m the clinical world, u n s e e n and unknown by 1KNs. Finally, the lack o f institutional support p r o v i d e d to the A C N s , in the f o r m o f sympathetic rosters and the like, gives insights into the way that health care institutions do not always consider h o w clinical nurses can be supported in a process o f diversifying their practice out o f the traditional clinical realm. O n e is left to p o n d e r h o w m u c h these institutions, and indeed nursing professional bodies w h o devised the V i c t o r i a n career structure, understand the powerful imperatives that drive nursing culture. It seems they do not, for if they did, why would they assign these nurses a broad array o f new responsibilities, while at the same time offering few institutional supports to assist them? That the ACNs make little progress in their managerial endeavours should come as no surprise, considering the circumstances. It seems that w i t h o u t clearly defined institutional supports, second line nurse managers are doomed to remain marginalised and frustrated nurses, caught between a rock and a hard place. In many respects these second line nurse managers in A & E are caught in a nexus o f competing values. O n the one hand they are faced with an organisational expectation that their responsibilities traverse a field far beyond the clinical arena. This expectation is supported in the literature (Harris & Martin-Hylwa •992; Williams •992; Atha et al, 1989; Silver 1986; C a r d w e l l 1984) w h i c h the p a r t i c i p a n t s in the study acknowledge, and attempt to fulfil. O n the other hand the majority of their work is located within an unpredictable context, and a culture which devalues the legitimacy o f these aspects o f their practice. In this respect, the difficulties t h e y face m i r r o r the difficulties r e p o r t e d in the f a c u l t y practice - joint appointment literature (Mobily 1991; Langemo 1988 in Mobily 1991; Lambert & Lambert 1988; deTornay 1987; McClure 1987; Morrison 1985). This is their catch-22; a situation reflected in their
angst at their circumstances, and their inability to make concrete progress in their various projects.
RECOMMENDATIONS T h e w o r k o f this s t u d y h i g h l i g h t s the importance of clearly articulating the dimensions of second line nurse managers' practice and of communicating the expectations associated with that practice to all relevant parties. In other words, second line nurse managers need to engage in extensive discussions to f u r t h e r explore the dimensions of their practice, and to work together to legitimise the centrality o f their managerial practice. T h e y also need to work with their 1KN colleagues to articulate and clarify the expectations associated with such a complex and demanding role in order to foster a m o r e s u p p o r t i v e and u n d e r s t a n d i n g relationship. This would open the channels of communication, advocated by Nettles-Carlson & F r i e d m a n (1985) and t h e r e b y assist in addressing a significant source of cultural conflict that emerges out o f competing interpretations as to w h a t the p r a c t i c e o f these nurses legitimately entails. As the A & E department is characterised by an ever present contextual unpredictability, and b e c a u s e s e c o n d line nurse m a n a g e r s are e x p e r i e n c e d and skillful p r a c t i t i o n e r s , organisational arrangements have to be put in place to support ongoing departmental activities d u r i n g their absence. A r e v i e w o f these arrangements should include the rostering practices, the mix of experience a m o n g staff rostered on particular shifts, the tangible support s t r u c t u r e s available to s e c o n d line nurse managers to assist them to meet their managerial responsibilities, such as allocating specific regular periods o f time when they can freely leave the clinical context. O t h e r s u p p o r t strategies c o u l d i n c l u d e scrutinising the relevance of their responsibilities for the provision o f direct patient care. T h e competing interests o f these two domains o f responsibility must be creatively resolved if the practice of these nurses is not to be marginalised. All the above r e c o m m e n d a t i o n s c o u l d be successfully addressed within an action research f r a m e w o r k , w h i c h p r o m o t e s collaborative participation, sustained engagements in critical reflection, and taking action to transform the social and material conditions of the participants and concerned others. This research process is ideally suited for nurses who wish to undertake a future project w h i c h aims to address the dilemmas and difficulties exposed within the confines of this study.
Conflicts of practice confronting second line nurse managers in an A & E department. Part 2 135
REFERENCES
Atha C, Salkovskis P, Storer D 1989 More questions than answers Nursing Times 85(15): 28-31 Cardwell S 1984 Violence in accident and emergency departments. Nursing Times April: 32-34 de Tornay P, 1987 Coping with amxiety and tension. Journal of Nursing Education 26:181 Harris A Martin-Hylwa E M 1992 'Assistant Head Nurse: today's catalytic manager. Nursing Management 23(1): 40-43 Lambert C, Lambert V 1988 A review and synthesis of the research on role conflict and its impact on nurses involved in faculty practice programs. Journal of Nursing Education 27(2): 54-60 McClure M 1987 Faculty practice: new definitions, new opportunities. Nursing Outlook 35(40:162-166
Mobily P IK 1991 An examination of role strain for university nurse faculty, and its relation to socialization experiences and personal characteristics. Journal of Nursing Education 30(2): 73-80 Morrison E 1985 Faculty Practice in an Urban Academic Community in Barnard K Smith G (eds) Faculty Practice in Action. Kansas City, American Academy of Nursing: 67-73 Nettles-Carlson B, Friedman B 1985 Group faculty practice. Nursing Outlook 33(4): 170-174 Silver M 1986 A vision becomes reality. The Australian Nurses Journal. 16(2): 44-47 Williams G ] 992 'Sorting out triage.' Nursing Times 88(30): 34-36
Emergency department. Part 2
THE RESEARCH FINDINGS Following from the aim of the study to 'examine the practice of the Associate Charge Nurse (ACN) in the Accident and Emergency (A & E) department' the group members decided a good place to start their reconnaissance would be to document their responsibilities. By comparing these responsibilities with their role as outlined in the A & E d e p a r t m e n t ' A C N Job Description', they hoped to establish the degree of congruence between the two. In other words, they aimed to establish the degree of 'fit' between what they thought they should be doing, and the organisation's expectations of them. T h r o u g h this process they hoped to develop a picture of what the 'ideatised' vision of the ACNs' practice in the A & E department would look like.
U n c o v e r i n g an idealised vision o f ACN practice
A. L. Robinson and C. M. O'Connell
Andrew L. RobinsonRN. Rid, BASANC(Ed), MNS, Phd.
student,SchoolorNursing,~ TrobeUniversity,Helbour:ne, Australia.
Cathryn M. O'Connell RN,
In order to construct an 'idealised vision' of the A C N practice, each group member contributed
In recent times in Australia, there has been a proliferation of nursing career structures which aim to address the historical neglect of a career path for clinical nurses. A m o n g these developments has been the formulation of a new and exciting nursing role, that of the second line nurse manager. This role was designed to give experienced nurses who traditionally worked 'in charge' formal recognition of their knowledge and skill, and sought to construct a role that encompassed both clinical and managerial responsibilities. However, the reality of these nurses' practice is fraught with problems and difficulties as they a t t e m p t to negotiate a new and uncharted domain. This paper recounts an action research study conducted by a group of second line nurse managers in an Accident and Emergency d e p a r t m e n t , who sought to explore the dimensions of their practice. T h e study identifies problems with combining clinical and managerial responsibilities in the one role, within a context marked by a high level of
Dip. ENT, Cer~ Emerg,, B.Fd,
unpredictability,
UnitManager, Neurosciences,
values clinical practice over other forms
Melbourne Private Hospital RHH, PO Box 2150
Parkville,Victoria,
Australia 3050.
Requests for offprintsto Cathryn M. O ' C o n n e l L
of
and a culture
nursing practice.
The
which
paper
concludes with a n u m b e r of recommendations to overcome these
problems.
Accident ond Emergency Nursing (t 995) 3, 129-135 © PearsonProfessionalLtd 1995
to a ' b r a i n s t o r m i n g ' session w h e r e they documented what they believed were their responsibilities. The results were then collated into a schema which contained four distinct domains. These domains covered the areas of clinical, m a n a g e m e n t , education, and research responsibilities. For example, clinical responsibilities included areas of practice such as the p r o v i s i o n o f ~hands o n ' patient care, the supervision of medical and nursing staff, and acting as a clinical resource person. Managerial responsibilities included d e v e l o p m e n t o f individual p o r t f o l i o s * , allocation of P~N daily duties, liaison with the multi-disciplinary team, and a number o f p u r e l y administrative functions such as fostering and d e p a r t m e n t a l budgeting. Educational responsibilities included the provision of informal (clinical) and formal (tutorials) education to nursing staff, as well as p a r t i c i p a t i o n in education, such as tertiary studies, for personal professional development. Research responsibilities included p a r t i c i p a t i o n in research projects w h i c h p r o m o t e d the d e v e l o p m e n t of quality o f nursing care. When they compared this schema with the A C N Job Description they found a good degree of congruence between the two, indicating that the group members' understanding of their role was generally consistent with organisational expectations. *Specific projects, pursued by individual ACNS, which aim co develop the effectiveness and ei~ciency of nursing practice and improve the quality of patient care.
130 Accident and Emergency Nursing
Reconceptualising A C N practice Reflecting on these findings highlighted that in practice the delineation between these domains of the ACN's practice in A & E, as represented in the schema, was not so clear. It became obvious that these domains intersected, or crossed over each other on many levels. For e x a m p l e , the s u p e r v i s i o n o f staff is an administrative responsibility which takes place in the arena of clinical practice; informal chnical education comes under the rubic of education, yet it is situated as a component o f the ACN's clinical practice. Responsibility for facihtating positive communication, as described by the ACN's job description, traverses and intersects with every domain of responsibility described above. In order to deal with this complexity, and the p r o b l e m s that arise f r o m a t t e m p t i n g to c a t e g o r i s e a b r o a d range o f i n t e r s e c t i n g responsibilities into a number o f specific and discrete domains, the ACN's decided it would be more useful to employ a different conceptual framework. T h e framework they developed delineated their responsibilities in terms o f a different conceptual framework, comprising two broad categories. The first category included those activities directly related to the ongoing provision of patient care and staff supervision, which are geographically located in the clinical arena - their clinical practice. T h e second category included those activities which either support clinical nursing practice or work to improve it, but do not involve the provision of ongoing patient care. The latter generally takes place in a different geographical location, such as an office or seminar room - what we called the ACN's managerial practice. This conceptual framework made it clear that as second line nurse managers, A C N s in A & E had two sets o f responsibilities: those related to support/development, and those related to the provision of direct patient care, both o f which are pursued in different geographical locations. However, it soon became clear that the ACNs had a number of reservations about the degree of congruence between this idealised vision, and the reality that was their practice in the department. In o r d e r to expose the conflicts and contradictions that existed between the idealised vision of their practice, with the reality that was their practice, they began the next phase of the project. This phase a i m e d to explore and articulate what it was actually like to practice as a second hne nurse manager in A & E.
Exploring the practice of second line nurse managers in A & E Investigating the A C N role in practice revealed that the ACNs experienced difficulty dividing
time between the responsibilities associated with their clinical and managerial practice. Their reconnaissance showed that these difficulties arose d i r e c t l y f r o m the p r o b l e m s t h e y experienced getting time out of their primary geographical location, the clinical context, to devote time to their managerial practice. These problems arose from a number of sources, which are summarised below.
' W i l l I or will I not leave?' T h e influence of contextual unpredictability As the n a m e ' A c c i d e n t and E m e r g e n c y department' implies, an emergency situation can occur at any time. This means that the practice contingencies for second line nurse managers are g r e a t l y i n f l u e n c e d by ' c o n t e x t u a l unpredictabihty', that is, by the ebb and flow of clients into and out of the department, and the seriousness o f the conditions with which these clients present. The contextual unpredictability meant that the group members experienced varying degrees of ambivalence about leaving the department at all. Their ambivalence arose out of a fear that some emergency would occur; an emergency which the A C N would not be on hand to deal with. Also, in those circumstances where they judged the department as being busy, the A C N w o u l d cancel any p r e v i o u s l y a r r a n g e d m a n a g e r i a l c o m m i t m e n t s , no m a t t e r h o w pressing, and stay on the floor. These sentiments are reflected in the following comments: ...the first priority for me is to stay (in the clinical context) if it is really busy,.., or if there was a ' r e s u s ' (a child n e e d i n g resuscitation) expected or something like that, I would stay in there .... ...if things are a little bit busy, or perhaps there's a potential for things to become busy, you think 'will I go (leave the clinic area) or won't I go? and I end up deciding I better be here because I shouldn't be there (out o f the clinical area)'. In m a n y respects these s e n t i m e n t s are understandable. As second line nurse managers, the A C N position is not supernumerary. Rather, they make up one o f the numbers o f nurses rostered on a particular shift, with a delegated clinical role. Consequently, when they are absent f r o m the clinical c o n t e x t , the n u m b e r o f experienced staffavailable to provide patient care is r e d u c e d , p o t e n t i a l l y c o m p r o m i s i n g the department's function, especially during busy periods. Similarly, as the most experienced nurses in A & E, their absence deprives the department o f an important clinical resource
Conflicts of practice confronting second line nurse managers in an A & E department. Part 2 13 1
person. These concerns arising from contextual unpredictability, and the resource implications o f their absence, effectively u n d e r m i n e d their ability to plan activities, and meet specific targets and deadlines o f their projects.
W h a t does it mean to be 'busy'? Competing interpretations This contextual unpredictability, and concern for the viability o f the department during the ACN's absence, also contributed to the conflict that was generated between Registered Nurses (RNs) and ACNs. It became evident that the R N s ' and ACNs' understanding of the meaning of'busy', was subject to some contestation. That is, they had differing interpretation~about what busy meant, and these differing interpretations often resulted in conflict. The following account highlights this point. ...they (the RNs) gave rne a hard time about going (to the meeting) because it was busy. But I felt it wasn't busy .... T h e pressure ( f r o m t h e R N s ) c a m e b a c k o n me. Emotional pressure put on me that I shouldn't be at a meeting. The above account illustrates the kind o f conflict that arises when there are competing interpretations as regards resource requirements. It also illustrates that the A C N s ' interpretation of being busy often conflicted with their less e x p e r i e n c e d R N colleagues. R e f l e c t i n g o n this f i n d i n g t h e A C N s c a m e to t h e conclusion that such interpretations o f being busy were made o n t h e basis o f subjective judgements; judgements based on an individual nurse's confidence and experience in t h e d e p a r t m e n t , as o n e g r o u p m e m b e r commented: It's a very subjective individual interpretation the term too busy.., what ACNs and R N s think is busy are often two different things. It all depends on people's confidence, their abilities, their willingness to accept a c h a l l e n g e as w e l l . . . (If) t h e y d o n ' t feel c o m f o r t a b l e w i t h it (responsibility), they're going to think it's busy even if there are o n l y 6 p a t i e n t s in the d e p a r t m e n t , whereas someone else might think it's busy w h e n there's 14 (patients), banked up to the ceiling. The findings showed that these disputes in interpretation over what it means to be busy, made a significant contribution to the conflict generated between R N s and ACNs when the latter attempted to leave the clinical context to pursue their managerial practice. This conflict added a further disincentive for A C N s to leave the clinical context at all.
' W h e n are you going to do some real work?' The A & E d e p a r t m e n t as a site of conflict The A C N group shared many accounts which highlighted the fact that their R N colleagues did not have a clear understanding o f the diverse r e s p o n s i b i l i t i e s associated w i t h the A C N s ' practice. These accounts showed that the registered nurses believed the A C N s ' primary p r a c t i c e r e s p o n s i b i l i t i e s r e s i d e d in t h e supervision o f activities in the department and the provision o f direct patient care. That is,.the RNs did not acknowledge the ACNs' managerial responsibilities. Consequently, those A C N activities n o t g e o g r a p h i c a l l y l o c a t e d within the clinical context had limited legitimacy. This point was highlighted w h e n one group m e m b e r reported 'the R N s believe t h a t w h a t w e do w h e n w e l e a v e t h e department.., doesn't constitute workL In the light o f the above attitudes, it was not surprising to find that the ACNs received various forms o f censure from their Registered Nurse colleagues w h e n they were absent from the clinical context. This censure took many forms, from overt comments such as °...oh you're back [in the clinical area], I wondered when you were going to do some work', to more discrete forms o f disapproval described by one group member, w h o r e p o r t e d that ' y o u can feel the chilly atmosphere w h e n you come back in the unit, although you often don't k n o w exactly what they've said'. Once again, the lack o f legitimacy o f the ACNs' managerial work is mirrored in the above comments. According to group members, the continual and sustained nature o f this censure represented a significant disincentive for them to leave the clinical context to pursue their other activities.
Conflicting values: the dilemmas of being a second line nurse manager in an A & E d e p a r t m e n t T h e s t u d y s h o w e d t h a t t h e R N s in t h e department were not alone in valuing clinical practice over other forms o f practice. As the A C N group members' discussions evolved, it soon became apparent that they too held similar values; values which highlighted a belief that clinical practice was the central interest o f their w o r k . This value p o s i t i o n is i l l u s t r a t e d in comments like: To m e it's ( a d m i n i s t r a t i v e a c t i v i t i e s ) something that I had to get used to (as an A C N ) 0 b u t p r i m a r i l y I w a n t to b e a clinician .... If you want to be 'hands on' that's what a clinical nurse ... is about, so you stay in the clinical area .... These discussions also highlighted that, like t h e i r R N c o l l e a g u e s , t h e A C N s also
132 Accident and Emergency Nursing
experienced some difficulty acknowledging the legitimacy of the managerial, or administrative, aspect of their practice; difficulties reflected in comments like: ...part o f the difficulty for us is that we believe that (as ACNs) the clinical part o f our role is m o r e l e g i t i m a t e t h a n the administrative part. These sentiments highlight the problems second line nurse managers experience as they grapple with the competing and conflicting values systems. O n the one hand they must meet organisational expectations which demand they construct their practice in ways that involve more than the provision of direct clinical care and supervision. O n the other hand, they are located in a cultural c o n t e x t w h i c h values clinical practice over all else, and has difficulty a c c e p t i n g the l e g i t i m a c y o f the diverse managerial responsibilities that comprise the ACN's practice. The problem is made all the more difficult by the fact that, as members of this culture, the ACNs actively subscribe to the latter view.
The changing conditions of nursing work: problems with 24-hour rotating rosters The ACNs' research also uncovered a number o f structural and organisational issues which contributed to the problems. The first of these issues related to their roster. The fact that ACNs must work a 24-hour roster meant that each A C N had to frequently rotate onto night duty. These frequent rotations upset their biological clocks, resulting in what was described as 'a constant state o f tiredness' - a situation where many claimed that they '...simply did not have the energy' to attempt to resolve the conflict that arose as a direct result of having responsibilities in two domains of practice. At the same time, the reduced numbers of nursing staff on night duty made it virtually impossible to leave the clinical context at all during these shifts. This latter point meant that on night shift, the A C N had to suspend work on various projects. This made it all the more difficult to pick up work on these projects on return to day shift, further limiting the ability to make concrete achievements in managerial aspects of their practice. The ACNs' subjective impression was that they seldom worked on the same day, on either a day or evening shift, between Monday and Friday. These subjective impressions were confirmed from data collected relating to the patterns o f A C N ' s rosters. These patterns showed that for a number of reasons, primarily because the charge nurse assumed responsibility for r u n n i n g the d e p a r t m e n t on day shifts between Monday and Friday, they only worked
on the same day, on opposite shifts, 31% o f the time. This arrangement worked to restrict their ability to engage in managerial practice because they could rarely arrange with a colleague (who was rostered on the same day but on an opposite shift) to supervise the activities in the clinical arena during the double staff time, a period of 272 hours. This organisational a r r a n g e m e n t contributed to their difficulties because they were unable to cover each other's absence in the d e p a r t m e n t , and t h e r e b y a c c o u n t for the contextual unpredictability discussed previously.
W h a t are we really doing? The implications of an unfulfilled practice As a result of the constraints we have outlined, it became evident that there was a chain reaction of events that took place as the ACNs attempted to balance so many divergent and competing demands. In order to meet their 'portfolio' and other managerial practice obligations, most o f the ACNs reported that they found it necessary to do a great deal of work at home, in their own time, thereby impacting on family and social commitments. Evidence also emerged that even with a substantial effort to devote personal time to work commitments, few of them had made any progress in developing their portfolios. They believed this was a direct result o f their inability to take regular planned time out of the clinical context. T h e difficulties they e x p e r i e n c e d participating in the study, alluded to previously, supported this contention. All these difficulties h e i g h t e n e d a sense o f frustration, lack o f concrete achievement and in the context o f ongoing confrontation and conflict, resulted in a high level o f stress. As one group member noted: It is extremely difficult to be all things to all people, yet that is what I feel is expected o f me... I feel I have two full time jobs in keeping up with my portfolio and the rest of the place (my clinical practice).
DISCUSSION This action research project was set up to explore the practice o f a group o f second line nurse managers in an A & E department o f a large city hospital. C o n s i s t e n t w i t h the values underpinning this methodology, the study was predicated on a collaborative agenda, where all g r o u p m e m b e r s p a r t i c i p a t e d in e x p l o r i n g concerns they identified with their practice in the department. This extended dialogic engagement provided a rare o p p o r t u n i t y to share views, express concerns, and break d o w n isolation through exposure o f a c o m m o n experience
Conflicts of practice confronting second line nurse managers in an A & E department. Part 2 133
of struggle. Participation in the study worked to foster a new found solidarity within the A C N group, and brought to light a host of issues which previously had been submerged beneath the hectic day to day operations of the department; issues which had previously only been spoken of in the context of 'tea room chatter'. B e g i n n i n g the study by e x a m i n i n g the ACN's theoretical understanding o f what was labelled an 'idealised vision' of practice provided a referent to c o m p a r e this vision with the organisation's expectations and the reality that is their practice. W h i l e this 'idealised vision' p r o v e d g e n e r a l l y c o n g r u e n t w i t h the organisational expectations, they recognised the need to reconceptualise their role in schema which more clearly represented their practice. This schema demarked A C N practice into two domains, distinguished in terms of the nature of w o r k p u r s u e d - clinical versus managerial practice - and in terms of geographical location, in or out o f the clinical context. While this reconceptualisation o f their practice helped them better to understand the dimensions o f their role, it soon became apparent that the reality o f their practice made the 'idealised vision' little more than a fantasy. The findings of the group's research articulated the dimensions of this fantasy, and located organisational and c u t t u r a l f o r m a t i o n s w h i c h c o n s p i r e d to p e r p e t u a t e it. These formations traverse a spectrum of issues ranging from the particular issues associated with an A & E department, to the way that values and attitudes o f nurses who work in such departments reflect the values and attitudes o f the wider nursing culture. If we look first to the peculiarities o f A & E, we must acknowledge the impact of contextual unpredictability. The research showed that the contextual unpredictability of A & E emergency presentations at any time with little or no warning - combined with the A C N s ' status as the most experienced practitioners, heightened their fear that nurses remaining in the department would be unable to manage unforeseen events that occurred in their absence. C o n s e q u e n t l y , as the m o s t s e n i o r and e x p e r i e n c e d nurse on duty, they saw their primary responsibility as maintaining a clinical presence in order to be on hand to deal with the inevitable emergency presentation. In many respects, the unpredictability o f A & E demands that the optimal amount of nursing resources be readily and immediately available at all times. In this sense, the very nature o f A & E undermines the ability o f nurses to fulfil the responsibilities associated with a practice that takes them out of the immediate clinical context. However, the degree to which an ACN's absence actually compromised the department's function raised a spectre o f conflict. Disputes
between P,.Ns and ACNs over interpretations of the relative 'business' of the department, or the ability to deal with unpredictability, led to disputes over appropriate times for ACNs to be absent or not. These disputes resulted in l:LNs engaging in various forms o f censure which worked to contest the legitimacy of the ACNs' managerial practice and dissuade them from leaving the clinical context. Not surprisingly, these disputes provided a further incentive for ACNs to defer the pursuit o f their managerial responsibilities and stay in the clinical arena. In o n e sense, the process o f deferral can be understood as a strategy adopted by the ACNs to diffuse conflict and avoid censure. However, the study showed that while these issues are i m p o r t a n t c o n t r i b u t o r s to the problems these A & E second line managers experienced, they do not represent the complete picture. The study also highlighted the strong cultural imperatives in nursing which constrain clinical nurses from expanding the dimensions o f their practice out o f traditional and historical confines. Through engaging in reflective and p a r t i c i p a t o r y research practice, the nurses involved in this study uncovered a number o f cultural forces which worked to compromise their ability to meet their practice responsibilities as second line nurse managers. This engagement highlighted the way that nurses' participation in critical reflective processes helps them to see past the immediate functional and organisational constraints, and to uncover the ways that culture exerts its influence. In many respects, the findings o f the study illustrate the powerful way nursing culture works to influence nurses' values and beliefs. The P..Ns' and ACNs' strong bias toward clinical practice reflects the interests of the wider clinical nursing culture; an interest supported by strong historical imperatives w h i c h value clinical practice over other forms of nursing practice. It is apparent from the findings that this cultural valuing of clinical practice influences the ACNs' situation in a number of ways. Firstly, despite the fact that the A C N s recognise the diversity of their responsibilities, by their actions they devalue the importance of their managerial practice, and remain captive to the dominant clinical culture embedded in the department. In many respects, their ambivalence toward their managerial responsibilities reflects their historical membership within this culture clinical practice is what nursing is all about. The group members subsequently acknowledged this belief during the course o f their reflections. In this situation, it is not surprising to find that their managerial practice is relegated to the status of something o f an 'add on' to their primary clinical role - p r a c t i c e p u r s u e d o n l y at t h o s e times -
134 Accident and EmergencyNursing
when the situation in the department permits. Secondly, like the ACNs, the R N s ' inability to a c c e p t the l e g i t i m a c y o f the A C N s ' m a n a g e r i a l p r a c t i c e reflects their clinical priorities and focus. Yet in the context of the wider nursing culture, this lack of acceptance is not so strange. After all, the ACNs' clinical role is highly visible, and well understood, having strong historical associations with the practice of nurses who traditionally acted in charge of the shift - nurses whose priorities were firn~y located in clinical practice. In contrast, the construction of the ACNs' managerial practice lacks clarity, has no historical precedent, being a relatively recent development, and comes to life away f r o m the clinical world, u n s e e n and unknown by 1KNs. Finally, the lack o f institutional support p r o v i d e d to the A C N s , in the f o r m o f sympathetic rosters and the like, gives insights into the way that health care institutions do not always consider h o w clinical nurses can be supported in a process o f diversifying their practice out o f the traditional clinical realm. O n e is left to p o n d e r h o w m u c h these institutions, and indeed nursing professional bodies w h o devised the V i c t o r i a n career structure, understand the powerful imperatives that drive nursing culture. It seems they do not, for if they did, why would they assign these nurses a broad array o f new responsibilities, while at the same time offering few institutional supports to assist them? That the ACNs make little progress in their managerial endeavours should come as no surprise, considering the circumstances. It seems that w i t h o u t clearly defined institutional supports, second line nurse managers are doomed to remain marginalised and frustrated nurses, caught between a rock and a hard place. In many respects these second line nurse managers in A & E are caught in a nexus o f competing values. O n the one hand they are faced with an organisational expectation that their responsibilities traverse a field far beyond the clinical arena. This expectation is supported in the literature (Harris & Martin-Hylwa •992; Williams •992; Atha et al, 1989; Silver 1986; C a r d w e l l 1984) w h i c h the p a r t i c i p a n t s in the study acknowledge, and attempt to fulfil. O n the other hand the majority of their work is located within an unpredictable context, and a culture which devalues the legitimacy o f these aspects o f their practice. In this respect, the difficulties t h e y face m i r r o r the difficulties r e p o r t e d in the f a c u l t y practice - joint appointment literature (Mobily 1991; Langemo 1988 in Mobily 1991; Lambert & Lambert 1988; deTornay 1987; McClure 1987; Morrison 1985). This is their catch-22; a situation reflected in their
angst at their circumstances, and their inability to make concrete progress in their various projects.
RECOMMENDATIONS T h e w o r k o f this s t u d y h i g h l i g h t s the importance of clearly articulating the dimensions of second line nurse managers' practice and of communicating the expectations associated with that practice to all relevant parties. In other words, second line nurse managers need to engage in extensive discussions to f u r t h e r explore the dimensions of their practice, and to work together to legitimise the centrality o f their managerial practice. T h e y also need to work with their 1KN colleagues to articulate and clarify the expectations associated with such a complex and demanding role in order to foster a m o r e s u p p o r t i v e and u n d e r s t a n d i n g relationship. This would open the channels of communication, advocated by Nettles-Carlson & F r i e d m a n (1985) and t h e r e b y assist in addressing a significant source of cultural conflict that emerges out o f competing interpretations as to w h a t the p r a c t i c e o f these nurses legitimately entails. As the A & E department is characterised by an ever present contextual unpredictability, and b e c a u s e s e c o n d line nurse m a n a g e r s are e x p e r i e n c e d and skillful p r a c t i t i o n e r s , organisational arrangements have to be put in place to support ongoing departmental activities d u r i n g their absence. A r e v i e w o f these arrangements should include the rostering practices, the mix of experience a m o n g staff rostered on particular shifts, the tangible support s t r u c t u r e s available to s e c o n d line nurse managers to assist them to meet their managerial responsibilities, such as allocating specific regular periods o f time when they can freely leave the clinical context. O t h e r s u p p o r t strategies c o u l d i n c l u d e scrutinising the relevance of their responsibilities for the provision o f direct patient care. T h e competing interests o f these two domains o f responsibility must be creatively resolved if the practice of these nurses is not to be marginalised. All the above r e c o m m e n d a t i o n s c o u l d be successfully addressed within an action research f r a m e w o r k , w h i c h p r o m o t e s collaborative participation, sustained engagements in critical reflection, and taking action to transform the social and material conditions of the participants and concerned others. This research process is ideally suited for nurses who wish to undertake a future project w h i c h aims to address the dilemmas and difficulties exposed within the confines of this study.
Conflicts of practice confronting second line nurse managers in an A & E department. Part 2 135
REFERENCES
Atha C, Salkovskis P, Storer D 1989 More questions than answers Nursing Times 85(15): 28-31 Cardwell S 1984 Violence in accident and emergency departments. Nursing Times April: 32-34 de Tornay P, 1987 Coping with amxiety and tension. Journal of Nursing Education 26:181 Harris A Martin-Hylwa E M 1992 'Assistant Head Nurse: today's catalytic manager. Nursing Management 23(1): 40-43 Lambert C, Lambert V 1988 A review and synthesis of the research on role conflict and its impact on nurses involved in faculty practice programs. Journal of Nursing Education 27(2): 54-60 McClure M 1987 Faculty practice: new definitions, new opportunities. Nursing Outlook 35(40:162-166
Mobily P IK 1991 An examination of role strain for university nurse faculty, and its relation to socialization experiences and personal characteristics. Journal of Nursing Education 30(2): 73-80 Morrison E 1985 Faculty Practice in an Urban Academic Community in Barnard K Smith G (eds) Faculty Practice in Action. Kansas City, American Academy of Nursing: 67-73 Nettles-Carlson B, Friedman B 1985 Group faculty practice. Nursing Outlook 33(4): 170-174 Silver M 1986 A vision becomes reality. The Australian Nurses Journal. 16(2): 44-47 Williams G ] 992 'Sorting out triage.' Nursing Times 88(30): 34-36