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Delegate, undertake or negotiate : understanding nursing scope of practice in the acute environment.

The past decade has seen increased patient acuity and shortened lengths of stays in acute care hospitals (Australian Institute of Health and Welfare (AIHW), 2005), resulting in an intensification of the work undertaken by nursing staff in hospitals. Changes in nursing work have also been compounded by the proliferation of health care roles, a blurring of skill boundaries (AIHW, 2001; Buchan & Dal Poz, 2002; Hayman, Cioffi & Wilkes, 2006; Jones and Cheek, 2003) and an aging nursing workforce that is predominantly working part-time (Creegan, Duffield & Forrester, 2003). Moreover, with increasing demand for acute care beds (ABS, 2005), there is simply not enough licensed nursing staff to fill current vacancies (AIHW, 2005; Duffield & O’Brien-Pallas, 2002). 
Since 2003, the main response from the Australian government to the declining numbers of nursing workers has been to recruit more people to the nursing profession. However, it is becoming clear that recruitment alone is not enough, with shortages growing even as nursing school enrolments are increasing; therefore, it was timely to undertake a study to understand nurses’ perceptions of scope of practice to improve future efficiency in the nursing workforce by using the information derived to provide baseline data to guide workforce planning.
The specific aim of this study was to understand how medical and surgical nurses, from two Queensland hospitals, conceive their scope of practice in response to the available grade mix and skill mix of nurses—licensed and unlicensed—and other health care professionals in the acute care setting. By exploring these meanings, this study aimed to build an understanding of how nursing work patterns were shifting in the face of changing patient acuity, patient profiles and nursing skill mix. To address this aim, a constructivist methodology was used that allowed for exploration of nursing role and scope of practice. While the notion of constructivism best describes the main approach to this study, it was also naturalistic to the extent that participants were reflecting on day-to-day experiences.
The method used in this study is situated around the Critical Incident Technique (CIT) (Flanagan, 1954). CIT generates data representing experiences or perceptions of aspects of best and worst practice (Byrne, 2001). The researcher asked 20 registered nurse (RN) and enrolled nurse (EN) participants to discuss up to two particular significant events during which they were undertaking a patient care activity they perceived they should be undertaking, and up to two events during which they believed those activities should have either been delegated or undertaken by a higher level of care provider. Using the CIT in this way, allowed the researcher to gain an understanding of the nursing scope of practice and the interactions between nurses and other clinicians (Byrne, 2001) while also minimising pre-interpretation of the events by participants and focusing on a rich description of the chosen event (Flanagan, 1954). Purposive sampling was used to assist with the discovery of opposing points of view (Guba & Lincoln, 1989) with all RN and EN participants being employed on selected medical and surgical wards within two large hospitals based in South East Queensland. 
Inductive analysis, a process for searching for themes within the data, rather than imposing theories on the data (Guba & Lincoln, 1989), was used. Analysis revealed that the nursing work environment was changing. This was causing nursing staff to question what it meant to provide patient care given the increased numbers of health care workers (HCWs) in the acute care setting, rising patient acuity, and increased patient turnover. RNs were struggling with the notions that ‘hands-on’ care was sometimes not the best use of their time, and delegation did not equate with laziness. Five themes arose from the data: (1) good nurses work in proximity to patients providing total patient care; (2) safeguarding patients; (3) privileging patients without mental illness or cognitive impairment; (4) developing teamwork strategies; and (5) picking up the slack to ensure patient safety.
Findings have shown that negotiation has become a fundamental aspect of nursing practice given the variety of nursing care providers currently employed in acute care settings. Previously, there wasn’t a need for nurses to negotiate care between licensed and unlicensed staff because HCWs were not employed in these settings. Negotiation has allowed nurses to redefine appropriate nurse–patient proximity, promote patient safety and find innovative ways of working in nursing teams. Practice negotiation will become a prominent topic over the coming years as hospital administrators struggle to employ licensed nurses.