Research on Clinical and Strategic Nursing Leadership

In the coming years the shortage of nurses and nurse managers in the Netherlands will increase (Klein Breteler, J.J.A.H., et al. 2009). Highly qualified staff will leave the hospital due to a sharp rise in aging population and due to cutback in healthcare costs. Retaining nurses and attracting new nurses are important issues for hospitals in both the United States of America as in the Netherlands. Nurse managers play an important role in creating a good work environment,retaining and attracting nurses for the wards and excellent patient care (Tomey 2009, McNeese-Smith 1999, Mintzberg 1994, Pearlin 1962).

Nurse Managers fields of work

This study focuses on what nurse managers do in daily work in relation to the different fields in the hospital organization and how they make sense of their organizational life. Research on this topic describes a hospital as a place where at least four ‘worlds’ or ‘fields’ (that is, care, cure, control and community) co-exist (Glouberman, Mintzberg 2001), with frictions between the professional (nursing or care and medical or cure) field and the managerial or control field in the focus of attention. In dealing with organizational issues, sensemaking (Weick 1995) requires us to look for explanations and answers in terms of how people see things rather than structures or systems. Sensemaking suggests that organizational issues - 'strategies', 'breakdowns', 'change', 'goals', 'plans', 'tasks', 'teams', and so on are not things that one can find out in the world or that exist in the organization. Rather, their source is people's way of thinking, which according to Bourdieu is influenced by their socialization process (education and entering the field) as members of an organizational field, in this particular case, the nurse managers. With Bourdieu’s methodology, we explore and break with the common understanding in the literature of nursing empowerment and socialization in the hospital field. Only a few have used Bourdieus theory for studying the different fields in the hospital organization (Rischel, Larsen & Jackson 2008, Rhynas 2005, Witman et al. 2011).

Shadowing at work

This study is based on a Bourdieusian perspective (Bourdieu, Wacquant 1992) and the Managerial Work and Behavior Approach (MWB) (Mintzberg 1994, Stewart 2008). It is an exploratory case study (Yin 1994) which draws data from non-structured participant observation and sensemaking as described by Weick of nurse managers in their organization (Weick 1995). Like Balogun we focus in particular on the importance of working with organizational members as research partners rather than passive informants (Balogun, Huff & Johnson 2003). We use a qualitative shadowing technique. The technique is developed to uncover not just the shape of a nurse manager’s day in terms of the actions performed, but also reveal the subtleties of perspective and purpose shaping those actions in the real-time context of a hospital (McDonald 2005). Weick says about shadowing: “shadowing has the ability to capture the brief, fragmented, varied, verbal and interrupted nature of organizational life” (Weick 1974). And this is exactly what we are looking for in the life of nurse mangers in daily work.

Bourdieu on practice and work

The late French sociologist Pierre Bourdieu offers an empirically founded theory of practice involving a relational perspective, saying that practice depends on structures and social relations. He argues that when acting in relations humans act according to a practical sense, and when asked to describe the rules by which they act, they are not able to do so. He bases this argument on observations, which are part of his methodological approach, and includes observations of both the spoken word and the human act. Bourdieu uses the word ‘agent’ to explain that a person’s practice is determined both by rational decisions and by embodied dispositions of habitus.

Habitus is the historical social-cultural background and embodied lens through which agents understand and interpret the social world and relations. Habitus as internalized history and experiences works as a structure which generates and organizes practices; it enables individuals to cope in unforeseen and ever-changing situations (Bourdieu 1977, Bourdieu 1990). The social world is explained by the concept of ‘field’. Numerous fields exist in parallel, each having a particular logic of practice, like the different field in a hospital organization. An agent’s (person’s) position in a field is structured by habitus and possession of capital and by this the relation to other agents in the field.

Capital has different forms: economic, social and cultural (Bourdieu 1997). In the field of medicine for example, the institutional form of cultural capital, including acknowledgement of the academic scientific discipline, is dominant according to Larsen (Larsen 2003). Others say that nowadays there is a shift from the dominance of the academic scientific disciple to the managerial discipline which gives frictions between the different fields. Many see these frictions as a power struggle (Keen, Malby 1992, Mintzberg 1997, Salhani, Coulter 2009). Some developments have intensified this struggle: escalating costs in health care, merging hospitals, pressure to control public spending, and a desire to improve the quality and efficiency of care. The managerial or control field seems to dominate these days.

With this study we want to describe what nurse mangers do and explain how they make sense of their daily work in dealing with these frictions between the different fields in the hospital organization given their own historical and social-cultural background as nurses.

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