School of Management

1
School of Management
SEMINAR
2
Jurisdictional Change and Nursings
Professionalization Liberating Nurses or Losing
the Plot?
Carole Doherty Lecturer in Healthcare Management
3
Structure of Presentation

• Introduction context of research, NHS Plan (DH,
  2000)
• Theory conceptual framework uses the sociology
  of professions and in particular Abbotts (1988)
  work on jurisdictional change
• Methods mixed methods, questionnaire data
  supported by in-depth interviews
• Findings nurses roles have altered with nurses
  now performing tasks traditionally carried out by
  doctors. This has resulted in intra-occupational
  differentiation. Specialist nurses have
  experienced greater clinical autonomy but ward
  sisters have experienced greater subordination
• Conclusion overall government intervention in
  the division of labour may have been detrimental
  to the quality of essential aspects of patient
  care such as assisting patients with feeding

4
Background

• NHS Modernization
• Break down the traditional, inflexible divides
  between occupational groups in the Service
• Challenge to the medical professions monopoly
• Opportunity for the professionalization of nursing

5
Research Questions

• Have changes to nursings jurisdiction aided its
  professionalization?
• What have been the intra-occupational
  consequences of jurisdictional change?
• Do nurses aspire towards the professionalization
  of their occupation?

6
Conceptual Framework

• Sociology of Professions
• The application of abstract knowledge to practice
  has both objective and subjective properties.
• Subjective properties are socially constructed,
  this creates dynamism in the system of
  professions (Abbott, 1988)
• Jurisdiction an area of practice over which an
  occupation has authority to act
• Three areas for competition
• The State including the legal system
• Public opinion
• The workplace

7
Jurisdictional Change

• Possible outcomes
• Full jurisdiction
• Subordination
• Intellectual jurisdiction
• Sharing of the jurisdiction
• Advisory control
• Client differentiation

8
Nursings History

• Modern form emerged in 1850s
• Occupational strategy based on practical not
  theoretical knowledge
• Broad and uncertain jurisdiction
• Attempts to professionalize
• 1900s, resulted in subordination
• 1990s, resulted in weakened labour market
  position

9
Study Design and Methods

• Mixed methods
• Quantitative data patterns and trends in
  nurses job attitudes, differences and
  similarities between the respective nursing jobs
• Qualitative data underlying processes and
  organizational structures that might account for
  differences in job attitudes, the effect of
  changes to nursings jurisdiction, factors
  influencing nurses job aspirations
• Data analysis
• Abbotts (1988) categorizations of professional
  work, descriptive statistics, t tests to compare
  differences in job attitudes, content analysis
  using matrix

10
Changes to Jurisdiction

• Key Tasks Staff
  Nurse Ward Sister Specialist
  Nurse Total
• N115
  N64 N62
  N241
• 
  
  
• Routine tasks
• Request x-rays
  18 27 39
  26
• Request blood tests
  55
  73 74 65
• Administer a range of medications using PGDs
  66 73
  68 69
• Admit patients with specific conditions within
  agreed Protocols 16
  20 34 22
• Discharge patients, with specific conditions
  within agreed protocols 17
  36 48
  30
• Diagnosis and inference
• Make referrals for doppler/ultrasound to confirm
  DVT 3 2
  6 4
• Make referrals for abdominal ultrasound
  3 4
  6
  4
• Make referrals directly to consultant medical
  staff 15 33
  77 36
• Inference and treatment
• Trained as a supplementary prescriber
  2 2
  19 6
• Diagnosis, inference and treatment
• Interpret x-rays and initiate treatment
  1 2
  18
  5
• Interpret blood test results and initiate
  treatment 24
  31 58 35
• Receive referrals directly from GPs10196827

11
Comparison of job related variables for ward
sisters and specialist nurses

• Ward
  Sisters (N64) Specialist Nurses (N 62)
• Item M
  SE M SE
  t (124)
• Qualifications 1.84 0.10
  2.34 0.10
  -3.59
• Skill variety 2.30 0.11
  2.60 0.12 -1.78
• Task identity 3.23 0.16
  3.98 0.11
  -3.81
• Job autonomy 3.43 0.10
  4.14 0.08
  -5.60
• Job complexity 3.92 0.08
  4.41 0.07
  -4.00
• Role expectations 3.58 0.10
  3.76 0.09
  -1.33
• Role clarity 3.44 0.11
  3.81 0.11
  -2.34
• Career prospects 3.02 0.10
  3.63 0.10 -4.16
• Decision-making 3.47 0.13
  3.12 0.14
  1.78
• Self-esteem 3.92 0.08
  4.22 0.08 -2.60
• Innovative work behaviour 3.47
  0.11 3.81 0.11
  -2.22
• Job satisfaction 3.40 0.09
  3.93 0.07 -4.65
• plt0.05 plt0.01 plt0.001

12
Effects of Jurisdictional Change

• Doing doctors work and losing nursing
• thats all they nurses do for the first two
  hours in the morning they do IV antibiotics then
  theyre doing another lot of taking bloods and
  Ive very sadly looked at whats going on in the
  rest of the ward in terms of patients are lying
  in wet beds, patients mouth care isnt being
  done..Bells are going everywhere patients are
  calling for the toilet and I just feel we have
  got to take a step back and look really at what
  nursing is about and go back to not basic nursing
  care but essential nursing care. I think weve
  really lost it. I really, really do I think
  weve lost the plot.
• Ward sister, 23 years experience

You can tend to neglect the patient because the
fundamental parts of nursing
seem to be missed a lot of the time now. .the
essence of nursing has been taken away from us
because weve got to take bloods, do ECGs, we
put venflons in. They are all things that the
doctors did at one time. Now we do it all.
Staff nurse, 7 years in nursing
13
Intellectual jurisdiction

• For us here the patient is our sole
  responsibility it doesnt go to anyone else. We
  see them we make a diagnosis and we decide upon a
  treatment thats lovely. Because thats your
  patient and you make all the decisions and youve
  administered it from a-z
• Ward sister 26 years experience who also
• practised as an emergency nurse practitioner

Its becoming more and more autonomous as things
have gone on. It used to be very doctor
orientated you used to do what the doctor said.
How nursing has progressed..it is definitely
developing towards more specialist type areas so
you become a practitioner in your own right
alongside the doctor side of it.
Staff nurse AE
14
Sharing the jurisdiction

• I see new patients in their consultants
  clinics new referrals from GPs... I can decide
  what Im going to do for that patient without
  having to go and feedback to the consultant. I
  have that amount of autonomy with the role. I
  work with the registrars in clinic so basically
  anything that the registrar sees I will see and
  go and feedback to the consultant in the same
  way
• Specialist nurse

Basically I work with the consultant surgeons
assisting them with patients during their
peri-operative period. It means that I can see
them pre-op, take consent in out-patients and
explain procedures to them, participate during
surgery either as a first or second assistant or
perform surgery depending on how big the surgery
is. I do my operations independently under local
anaesthetic.

Specialist nurse
15
Professionalization?

• Job aspirations
• Twenty-seven percent of ward sisters wished to
  become specialist nurses
• Not one of the specialist nurses were inclined to
  become ward sisters
• Aspirations among the staff nurse group were
  equally split between specialist nurse and ward
  sister jobs

16
Professionalization?

• Ward sister
• So where will I be in 5 years time, I probably
  still will be in the NHS but thats probably
  because my bank manager needs me to be here
  rather than I want to be here because I dont see
  nursing getting any better I just see it getting
  worse, it getting more and more stressful.
• Specialist nurse
• There is no limit to what can be done in this
  post. I wouldnt like to go back to being a ward
  sister there is no challenge, after a time every
  day is similareven now there are times that I
  look at something and think what do I do. Every
  day is different.
• Staff nurse
• .you dont deal with the patients as much and
  thats not what I came into nursing to do to be a
  nurse.

17
Conclusions

• Government intervention in the division of labour
  can have significant intra-occupational
  consequences for a subordinate occupation and
  impact on aspects of the dominant occupations
  monopoly
• Complex and multifaceted outcomes of change to
  the division of labour within a single occupation
  - suggesting a need to move beyond single
  occupational categories in studies of occupations
  
• Greater subordination has given rise to concerns
  that the work traditionally performed by nurses
  may become lost, opening the potential for
  further weakening of nursings labour market
  position
• The structure of the ward sisters job appears to
  constrain their opportunities. This finding adds
  to discussion about the role of structure and
  government policy in understanding changes to the
  division of labour (Bach et al., 2007)

18
School of Management
SEMINAR