Academic journal article The Qualitative Report

Understanding Hospital-Based Nurses' Experiences of Structurational Divergence

Academic journal article The Qualitative Report

Understanding Hospital-Based Nurses' Experiences of Structurational Divergence

Article excerpt

Nurses play multiple vital roles in the functioning of any healthcare facility. Nurses facilitate the physician-patient relationship; they are the conduit through which physician patient communication occurs (Apker, Propp, & Ford, 2009). Nurses experience extreme demands on their time and are often overworked and stressed (Lu, 2008; Ramanujam, Abrahamson, & Anderson, 2008; Shattell, 2004; Vivar, 2006). Moreover, as Nicotera and Clinkscales (2010) explained, nurses are institutionally positioned in such a way that they are often thrust into negative communication cycles with a host of individuals including physicians, patients, and their own peers. These conflicted cycles lead to an inability to accomplish goals which contributes then to fuel the conflicts that initiated the cycle (Nicotera & Clinkscales; Nicotera, Mahon, & Zhao, 2010). This negative cycle, rooted in incompatible rules and/or meaning systems placing simultaneous competing demands on the individual, has been termed structurational divergence (Nicotera & Clinkscales, 2003, 2010). This constant need to prioritize competing demands not only hinders goal achievement, it also complicates organizational relationships, pitting the nurse's loyalties to the patient, the attending physician, his/her fellow nurses, and nurse managers against one another. Conflicting expectations of nurses and the resulting inability to provide comprehensive care are the most important issues reported by nurses today (Forsyth & McKenzie, 2006). Further, in their study Davidson, Folacarelli, Crawford, Duprat, and Clifford (1997) found competing job duties and little time to perform required duties to be mitigating factors in nurses' decisions to leave their positions.

Given the important role that nurses play in caring for and providing interpersonal and physical support to patients, it is important to understand the factors that may lead to nursing turnover or dissatisfaction with duties. This study seeks a better understanding of nursing dilemmas created as a result of structurational divergence. Specifically, this study sheds light on structurational divergence and the resulting interpersonal, intrapersonal, and organizational conflicts that may impact patient care.

Literature Review

The overall ideology of teamwork amongst and between physicians and nurses is disrupted by an organizational focus on separation. A distinguishing feature of hospitals, notes Lammers, Barbour, and Duggan (2003), "is its dual hierarchy: physicians are organized in one hierarchical staff, and other hospital personnel--including nurses and other departments and staff--are organized in a second chain of command" (p. 327). The dynamics of role negotiation are therefore ongoing and complex.

According to a review of nursing organizations by Poole and Real (2003), leadership roles in hospitals are constantly negotiated. While it might be assumed that physicians maintain the primary leadership position, it is often the case that a nurse is asked to fill the role. Fountain (1993), however, explains that nurses are not adequately prepared to take on leadership positions because they are trained to assist physicians in a technical role. This inexperience coupled with the expectation of the physician to serve as group leader can lead to the nurse experiencing role ambiguity and uncertainty. This may in turn necessitate the physician reclaiming the leadership role (Fountain, 1993) despite the nurse having the most direct interaction with the patient (Forsyth & McKenzie, 2006). This shifting power balance is a key factor impeding collaborative efforts between physicians and nurses, and one that can ultimately impact the quality of patient health outcomes (Neale, 1999).

One form of structurational divergence, the constant negotiation of power between physician and nurse, is one of many factors that can lead to organizational and/or interpersonal conflict. …

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