Producing Flexible Nurses: How Institutional Texts Organize Nurses’ Experiences of Learning to Work on Redesigned Nursing Teams

Abstract

The purpose of this qualitative research was to utilize an institutional ethnographic (IE) lens to trace how various institutional (regulatory, educational, union, governmental, or health authority) texts and resources organize baccalaureate (RN) and diploma (vocational or practical) nurses’ experiences of learning to practice on acute care teams. Functional care models have been introduced in acute care, creating RN-LPN-health care aide (HCA) teams in conjunction with expanded practice scopes for LPNs. Questions arise as to how nurses (RNs and LPNs) learn to work together on these intra-professional teams. Beginning from the standpoint of front-line workers provides an entry-point into understanding how institutional priorities organize the everyday work of people. Ten RNs and ten LPNs were interviewed in two small community acute care hospitals on Vancouver Island. More specifically, in observations and interviews we looked for ways in which textually mediated work processes (such as regulatory, governmental, health authority, and educational documents) and other conceptual resources influenced nurses’ understandings of nursing education and professional practice. This analysis focused on how RNs and LPNs learn to work on re-designed nursing teams and traced the textually mediated discourses that are organizing this learning in the context of recent changes to LPN education and nursing teams. Our findings highlight unarticulated nursing knowledge/thinking, and the textual insertion of functional, skilled and flexible worker discourses, which organize to blur practice between RN and LPNs making them (potentially) interchangeable in complex acute care contexts. This study, situated as one analysis among a larger study, shows the invisibility of nursing disciplinary and professional goals and knowledge in nurses’ talk, as RNs and LPNs re-learn and sustain nursing practice in ways that fulfill other institutional and organizational goals. This realignment has significant implications for educators in nursing programs, who participate in teaching within educational silos. This research has shown that the absence of clarity in functional roles (perpetuating role confusion and ambiguity) is purposeful, with the goal of creating flexible workers.