By Diane Butcher, RN PhD
How are RNs and LPNs learning to work together amidst siloed educational programs, shifting LPN scopes of practice, role ambiguity, and expectations to work within functionally-orientated teams in acute care? Adopting a methodologically plural approach, my dissertation (Butcher, 2017) work focused on exploring how these learning experiences were being organized by educational and work contexts. I utilized multiple angles of vision (Thorne, 2016) to create and reflect upon knowledge revealed from a Joanna Briggs Institute (JBI) qualitative systematic review and an institutional ethnographic (IE) – informed analysis. Knitted together by philosophical inquiry, my disorientation while walking along this unsettling path led to deepened understandings of how these approaches to inquiry pulled my gaze in divergent directions, resulting in various (and somewhat disparate) implications for nursing education.
My JBI systematic review (Butcher, MacKinnon, Bruce, Gordon, & Koning, 2017) explored what was currently known about intra-professional learning (experiences of pre-licensure diploma and baccalaureate students under one disciplinary domain – such as nursing –learning together). Although eight studies’ findings were aggregated for this review (including studies from occupational therapy, dentistry, nursing, and occupational therapy), only one study was from nursing (exploring baccalaureate and practical nursing students learning together). The aggregated findings revealed how various intra-professional learning activities were valued by students; helped them develop various team-building, trust, and leadership skills; enhanced role clarity; and assisted with negotiating scopes of practice. However, intra-professional learning was impeded (creating tension and frustration) by hierarchical and exclusionary educator and staff attitudes and practices; poor communication between nursing groups; and lack of role clarity.
My second methodological focus involved an institutional ethnographic (IE) analysis, revealing how RNs and LPNs experiences of learning to work together are socially organized (Butcher, MacKinnon, & Bruce, under review). Interviews were conducted with RNs and LPNs working in acute care, in addition to limited observations of their practice, which provided entry-points into exploring social relations mediated by regulatory, educational, union, governmental, and health authority texts. This analytic thread was part of a larger research study exploring changing work relationships between RNs and LPNs in acute care (MacKinnon, Butcher, & Bruce, forthcoming).
My IE-based analysis revealed how the complexities of professional nursing practice were simplified and categorized within talk of functional roles (what each nurse would be doing); task/skill proficiency and job-readiness (be finished products at graduation); and absence of talk of their multi-specialist role (facilitating nurse
flexibility). The fourth finding of the absence of talk of nursing knowledge was significant, as both RNs and LPNs struggled to articulate nursing knowledge. Instead, nurses talked of differences in biomedical knowledge, critical thinking, length of educational programming, or knowledge depth.
Nurse Flexibility and Neglect of Professional Development: Implications for Nursing Education Nurses’ learning to work together was found to be reorganized as nurses ‘learn’ categories of RN/LPN related to tasks and scope; subsuming disciplinary knowledge and goals, and simplifying the complexity and fluidity of nursing practice. Further, various institutional discourses purposefully blur nurse roles and categories, sustaining non-specialist, flexible workers with transferable tasks. The invisibility of nursing disciplinary knowledge and goals, purposeful role ambiguity, and expectations for work-readiness, raise educational concerns. How might
the development of professional nursing practice be disrupted by functional orientations (and narrowed scopes for RNs)?
The answers may reside in where educators choose to gaze, and the future questions that arise. Most profound for me was reflecting on the competing knowledge systems created by my research approaches. While the JBI review focused on creating generalized recommendations to inform nursing education, the IE work disrupted the generalizing effects of texts. Herein lies the tension – the JBI recommendations (while weak – especially for nursing) encourage educators to consider introducing intra-professional learning experiences and competencies (in addition to exploring attitudinal, cultural, and educational silos, hierarchies, and discourses). However, it is also worth noting that role clarity is needed as a component of successful intra-professional learning.
Profoundly, my IE exploration highlighted how role blurriness, not clarity, is intentional, as revealed by tracing nurses’ talk to the various boss texts that transcend their local working environment. Further, I realized that without an appreciation for explicating the generalizing effects of texts (and on how RNs and LPNs are organized to learn how to work together), I could have possibly (and uncritically) taken up the generalized JBI recommendations (supporting intra-professional learning recommendations) without realizing how these recommendations might very well be part of the ‘organizing texts’ that re-organize and mediate educator practice.
Ultimately, where I focus my gaze can impact where I focus my further work. If I had only completed the JBI systematic review, my gaze would perhaps have been sustained on educational research focused on the development of intra-professional learning. However, the IE gaze pulls me toward the potential (and concerning) perceived irrelevancy of professional nursing practice support in the workplace due to the ways in which practising nurses are being socially organized to learn (or re-learn) how to work together in acute care. I continue to appreciate the inherently political nature of research and teaching. For educators, it is significant to reflect upon how teaching work is being reorganized by predominating, discursive resources from afar.
Educators are often positioned on the ‘fault line’ between professional education and practice realities, and being able to see, reflect upon, and push back against institutional texts offers one strategy to perhaps raise different questions in different places.
Butcher, D.L. (2017). Walking on unstable ground: Exploring registered nurses’ and licensed practical nurses’ experiences of learning to work together using a methodologically plural approach [dissertation]. Victoria, BC: University of Victoria. https://dspace.library.uvic.ca/handle/1828/8508
Butcher, D.L., MacKinnon, K.A., & Bruce, A. Producing flexible nurses: How institutional texts organize nurses’ experiences of learning to work on redesigned nursing teams.[forthcoming]. Quality Advancement in Nursing Education.
Butcher, D.L., MacKinnon, K.A., Bruce, A., Gordon, C., & Koning, C. (2017). The experiences of pre-licensure or pre-registration health professional students and their educators in working with intra-professional teams: A systematic review of qualitative evidence. JBI Database of Systematic Reviews and Implementation Reports, 15(4), 1011-1056.
MacKinnon, K.A., Butcher, D., & Bruce, A. (forthcoming). Working to full scope: the reorganization of nursing work in two Canadian community hospitals. Global Qualitative Nursing Research.
Thorne, S. (2016). Interpretive description: Qualitative research for applied practice (2nd ed.). New York: Rutledge.