Writing ourselves into a web of obedience: a nursing policy analysis

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Writing ourselves into a web of obedience: A nursing policy analysis

Kasia Bail a,*, Robert Cook b, Anne Gardner c, Laurie Grealish a

a Faculty of Health, University of Canberra, Australiab Royal Brisbane and Women’s Hospital, Australiac James Cook University and Townsville Health Service District, Australia

What is already known about this topic?

� The registered nurse is required to think critically and toautonomously exercise professional judgement.� The effectiveness of organisational policy in guiding

practice has been questioned.� Gaps between theory and practice, and between proce-

dural policy and clinical practice, have been identified.

International Journal of Nursing Studies 46 (2009) 1457–1466

A R T I C L E I N F O

Article history:

Received 13 November 2008

Received in revised form 11 March 2009

Accepted 16 April 2009

Keywords:

Policy analysis

Procedure

Guideline

Newly qualified nurse

New graduate nurse

Bureaucracy

Clinical governance

Tradition

Discourse analysis

A B S T R A C T

Background: Nursing work is governed by a web of overarching documents from

professional bodies, registration bodies, and individual health care organisations. The

focus for these documents is to maintain high standards and protect patients and

organisations from unnecessary risk. The presentation of the nurse within these

documents has important implications for the ability of nurses to function as autonomous

professionals.

Objectives: How the role of the nurse is situated in hospital procedural policy, and more

specifically how these presentations of the nurse define, limit, and enable nursing practice

is the focus of this paper.

Design: A combination of random and purposive sampling of the nursing policies of one

tertiary level hospital was utilised to collect policy documents for thematic content

analysis.

Setting: The study was completed in a tertiary level health institution, in one Australian

jurisdiction with a population of approximately 500,000 people. This health institution

employs over 4000 people and admitted 49,000 patients in the 2004–2005 financial year.

Methods: An inductive approach, which utilised theoretical and contextual comprehen-

sion of the nursing policies, informed the collation of coded data which determined the

themes of the study.

Findings: Analysis consisted of coding of particular words, textual structure and theory

content. Practice was presented in the nursing procedural policies in two themes, called

‘lingering tradition’ and ‘bureaucratic template’.

Conclusions: The discourse of hospital procedural policy situates the nurse as obedient to

organisational requirements by limiting practice to a performance of actions without

explicit recognition of professional autonomy. This sets up a puzzling contradiction

between performance expectations from the employing organisation and the nursing

profession. Writing hospital policy in the discourse of procedural directives reduces

nurses’ ability to act as autonomous, critically thinking professionals, with implications for

patient safety, nurse autonomy and the professional status of nursing.

� 2009 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +61 02 6201 2930.

E-mail address: [email protected] (K. Bail).

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

0020-7489/$ – see front matter � 2009 Elsevier Ltd. All rights reserved.

doi:10.1016/j.ijnurstu.2009.04.005


What this paper adds

� When hospital policy is written in the discourse ofprocedural directives, nurses’ ability to act as autono-mous, critically thinking professionals is reduced, withimplications for patient safety and the professionalstatus of nursing.� A theory–practice contradiction, rather than gap, is

created for nurses when the procedural policy doesnot explicitly value the clinical judgement of autono-mous professionals.

1. Introduction

Descriptions of nursing practice in Australia can befound in a web of governance documents, including theAustralian Nursing and Midwifery Council (ANMC) Code of

Conduct (2008), Code of Ethics (2008), and Competency

Standards for the Registered Nurse (2006), State andTerritory legislative requirements, and individual healthcare organisations’ procedural policies. There are multipledocuments, variously called ‘standards’, ‘guidelines’, ‘pro-tocols’ and ‘policies’, that govern the work of nurses withinthe boundaries of everyday clinical practice.

The catalyst for this study was the personal experience ofthe first author (KB) as a newly qualified nurse. Nursingstudents are introduced to national and state or territorystandards and regulations, and learn about local governancestructures while in the classroom and on clinical placementsin a variety of health care institutions. Familiarity with suchdocuments was encouraged to assist in a smooth transitionfrom student to registered nurse. The consistent differencesbetween the descriptions of nursing practice found in theorganisation’s procedural policies and how nurses wereactually practising was puzzling. Further, when the puzzling‘gap’ was raised with colleagues, this newly qualified nursewas advised to follow the procedural policies rather thancollegial practices. The ‘gap’ between procedural policy andpractice has been highlighted in the recent nursing practiceliterature (Boogaerts et al., 2008).

The focus of this paper is on health care organisationalprocedural policies developed to guide nursing practice.More specifically, this paper focuses on how nurses aresituated in organisational procedural policy and how thesediscursive presentations define, limit and enable nursingpractice. Using a combination of random and purposivesampling of the nursing procedural policies in one tertiarylevel health agency, policy documents were collected forthematic analysis. The two dominant themes revealedwere ‘lingering tradition’ and ‘bureaucratic template’.Through the discourse of policy, organisational legal andfiscal liability dominates to the detriment of individualprofessional expectations of autonomy and critical think-ing in context-specific situations. This study raisesimplications for nurses, nursing decisions and the pro-cesses of policy development and review.

2. Literature review

The regulation of nursing is achieved through a focus onthe individual. As a professional, the registered nurse is

required to think critically and autonomously exerciseprofessional judgement (ANMC Competency Standards,2006). The necessary and integral role that professionaljudgement plays in the application of evidence-basedpractice has been identified by nurses (Haynes et al., 1996;Stetler, 2001) and the role is reified in the nationalcompetency standards (ANMC Competency Standards forthe Registered Nurse, 2006). Nationally established stan-dards for nurses are used by state and territory regulatoryauthorities to monitor and discipline nurses in the publicinterest. These national standards and legislation informpre-registration nursing curricula, and are reinforced inyearly registration renewals, so that nurses are well awareof their professional, regulatory and legal obligations. Butin the clinical setting the focus shifts from the regulatorycontrol of nurses to the governance of their clinicalpractices.

Clinical governance is where ‘‘accountability for thequality of clinical care delivered by clinicians. . . is extendedthroughout the organisation’’ (Swage, 2000, p. 4). Thegovernance of clinical processes and practices is an essentialaspect of organisational management to ensure efficiency,quality, and effectiveness of health services. One of the mainelements of clinical governance is a policy framework tomanage institutional and consumer risk (Swage, 2000).Given that nurses constitute over 50% of the healthworkforce (AIHW, 2004), nursing procedural policy is animportant tool to achieve effective clinical governance.

Nursing procedural policies have emerged from thereform of health services led by Nightingale in the late 19thcentury, with nursing work often codified in hospitalpolicies or standards. This approach to governing practicewas probably introduced with the original nursing schoolsfrom about 1860 (Francis et al., 2001). The policydocuments were used by Sisters (senior nurses) to prepareprobationers (nursing students) for nursing practice aspart of hospital-based vocational education. The Sisters,working with Nurse Educators, would have prepared thesedocuments with the probationer as a learner in mind. Theauthorised descriptions of nursing practice found inprocedural policies continue to be the most immediatedescriptions of practice for busy nurses. Some authorsargue that explicit descriptions of nursing practices cancontribute to the development of nursing knowledge(McCloskey and Bulechek, 1994; Barnes, 2000). Forexample, Manias and Street (2000) found that nursescould use policy documents to dispute medical dominancein clinical decision-making, indicating that nurse auton-omy can be validated with policy. Whereas, Noak et al.(2002) in analysis of policies in the area of ‘management ofviolence’, found that policy documentation varied widelybetween institutions and question the usefulness of thepolicies to guide practice. The value of procedural policy toguide nursing practice is not clearly established in theresearch to date.

Other researchers have found that localised policies areinadequate representations of nursing knowledge. Horsfalland Cleary (2000) undertook a discourse analysis of anursing policy on ‘observation levels’ in mental healthpractice. They found that significant theoretical nursingconcepts such as patient rights, therapeutic processes and

K. Bail et al. / International Journal of Nursing Studies 46 (2009) 1457–14661458


ethical dilemmas were noticeably absent in the localisedpolicy (Horsfall and Cleary, 2000), therefore, questioningthe adequacy of policy to represent nursing knowledge.Thomas et al. (1999) in a systematic review of theeffectiveness of 18 clinical guidelines in the UnitedKingdom found that the policies and guidelines theyexamined were limited in their evidence base. Noak et al.(2002) had similar concerns, again highlighting whetherpolicy content offers validity and currency to informnursing practice.

A number of nurse researchers have investigated theways that policy works to influence nursing practice andhave concluded that rather than support practice, policyworks to control and limit nursing practice. For example, inHorsfall and Cleary’s (2000) study, when essential nursingconcepts related to professional and ethical theory wereomitted from the nursing procedural policy, the remainingmedical focus of health care reinforced the traditionalmedical control found in hospitals. In a study of nursingprocedural policy related to medication administration,Cheek and Gibson (1996) found that procedural steps orrules for practice had a reductive and ritualising effect onnursing work. The findings from these two studies indicatethat procedural policy could have a restrictive effect on theautonomous professional judgement of nurses.

The use of procedural policy, even those policiesinformed by research evidence, has the potential to limitrather than support nursing practice (DiCenso et al., 1998;Thompson et al., 2004). In a clinical example, Boogaertset al. (2008) highlight the limiting effect of proceduralpolicy on nursing judgement. In this case, the experiencedclinician is confronted by a dilemma between what shejudges to be in the best interests of the patient and whatthe policy dictates. The contradiction between policy andprofessional judgement in specific cases requires the nurseto exercise professional autonomy, to work outside of thepolicy framework incurring possible personal risk. Inanother example, Larsen (2005) highlighted the risk forthe public when procedural nursing policies written toguide practice in a health call centre limited nursingpractice. Procedural policies can be strict algorithms fornursing care delivery that limit nursing autonomy.Although clinical governance offers a framework forimproved health services, health service organisationsthat seek to manage and control the work processes ofprofessionals, including nurses, will have an impact onautonomous professional judgement (Kermode, 1994).

The effectiveness of policy to guide practice is notclearly established. In an investigation of nurses’ use ofresearch findings present in nursing policy, Brett (1987)found only weak or non-existent relationships betweennurses’ perceptions of the existence of hospital nursingpolicies and the actual existence of those policies. This lackof awareness of what policies exist challenged theeffectiveness of policy to guide nursing practice. Morerecently, Alley (2001) examined the influence of anorganisational pain management policy on the painmanagement practices of registered nurses. Althoughknowledge of the policy related to higher standards ofpain management practice, overall correlations betweenpolicy and practice were much lower than expected (Alley,

2001) challenging the effectiveness of pain managementpolicy to guide nursing practice. Nurses’ experience ofpractice/s appears to be inconsistent with policy, bringingthe effectiveness of policy to guide practice into question.

In summary, procedural policies for nursing practiceemerged with the Nightingale-led health reforms of theindustrial age. Unlike state-based regulatory control ofnurses, procedural policy controls nursing practice. Whilstdesigned to reduce organisational risk by applying aconsistent standard to patient services, the effectiveness ofprocedural policy is questioned. How nurses are presentedin procedural policy may contribute to how those policiesare used. This study seeks to describe the presentation ofnurses in procedural policy and how such policies define,limit and enable nursing practice.

3. Method

A qualitative approach was adopted to investigate hownursing was presented in the policy texts and how thesepresentations define, enable, and limit nursing practice. Adescriptive analysis of the institution’s nursing proceduralpolicies was undertaken. The analysis was informed byconstructivist ontology. In the paradigm of constructivistontology, people both shape and are shaped by socio-political as well as cultural arrangements (Clare, 2003). Inthis approach, the knowledge of the researcher is valuedand informed interpretation of the data.

The study was completed in a tertiary level hospital, inone Australian jurisdiction with a population of approxi-mately 500,000 people. This health institution employsover 4000 people and admitted 49,000 patients in the2004–2005 financial year. The collected organisationalnursing policies are referred to as the Nursing PracticeStandards (NPS). They are available to all nurses (theintended audience for the documents) via the hospitalintranet on computer terminals in the wards and units.Using a standard template, the NPS provide organisationalpolicy statements and procedural details for a range ofnursing care practices, and are maintained and reviewedby a committee comprising members of hospital nursingstaff representing newly qualified nurses, enrolled nurses,Clinical Nurse Consultants and Directors of Nursing. Atemplate is available for general nursing staff to create oramend nursing policies, which the committee reviews.

Two of the authors had worked in a clinical capacitywithin the hospital, and had been representative membersof the NPS committee for a brief period. This familiaritywith the policy context (Lloyd-Jones, 2003) informed thedata analysis process. In the qualitative approach, thissubjectivity is not considered a hindrance to the research,but rather is valued in that the analysis is richer because ofit (Ryan and Bernard, 2000).

The institution’s NPS comprised the data for this study.These documents, while copyrighted, are in the publicdomain and do not contain personal information of anykind. Consequently there was no requirement for ethicalclearance for this study.

At time of data collection (October 2003) the NPSincluded 129 individual policies collated into eightcategories of practice called Units, and ranged from three

K. Bail et al. / International Journal of Nursing Studies 46 (2009) 1457–1466 1459


to 33 policies per Unit (see Table 1). A preliminaryexamination of the documents confirmed data wererelatively homogenous, in terms of the tone of language,content elements, and format.

To manage the large number of policies initially, astratified sampling technique was used to provide 10% of thepolicies. Each Unit was thus represented as a single stratum,to then be randomly sampled from, so that each Unit isproportionally represented according to the number ofpolicies within (Roberts & Taylor, 2002). Consequently 1policy was randomly selected for every 5 per Unit. Thisprovides a total sample of 28 policies for analysis.

Purposive sampling was utilised in later stages ofanalysis by selecting policies included in the stratifiedrandom sample above for deeper analysis to confirmthemes (see Table 2). The policies were collected with afocus on those more likely to be accessed more frequently,hence a decreased focus on those in ‘special procedures’.Consistent with discourse analysis techniques (Wodak andMeyer, 2001), this allows for a selection of policies fromeach Unit with the aim of analysing a representativesample of the policy documents.

A general inductive approach for qualitative data(Thomas, 2003) was used to analyse the text of thepolicies, and included the processes of examining andcoding language, format and content. The analysis was aniterative process, working through multiple readings andsuccessive codings of a text in order to identify majorthemes for interpretation (Lupton, 1992; Powers, 1996;Denzin and Lincoln, 2000). The procedural steps areoutlined in Table 3.

These steps were performed individually and thendiscussed as a team, thereby providing both internalvalidity and analytical range (Denzin, 1989). The perspec-tives in this study were from a newly qualified nurse (KB),an experienced nurse clinician (RC), and an experiencednurse clinician and researcher (AG). Collation of the codeddata revealed dominant themes, which were analysedinductively using theoretical and contextual knowledge(Thomas, 2003).

4. Results

Twenty-eight (of 129) policies found in the NursingPractice Standards (NPS) were subjected to reading and

rereading. Of these, eight were chosen for in-depthanalysis, and to enable greater familiarity with specificexamples of the NPS. They were chosen for their richness indata representative of the NPS as a whole, and promotedthe deep understanding required.

Following review of selected documents, and multiplediscussions among the research team, two dominantthemes emerged:

(1) lingering traditions of nursing subservience; and(2) working to the bureaucratic template.

These themes are discussed with supporting evidencefrom the policy text. The names of the policies are providedin parenthesis following verbatim quotations.

4.1. Lingering traditions of nursing subservience

Within this theme, the policy texts revealed sub-servient relationships between the nurse and the doctorand the organisation, and focussed on the ‘doing’ and‘assisting’ role of the registered nurse. In the NPS, nurseswere consistently portrayed as ‘doers’, which is expectedgiven that these were procedural standards. However,the critical nursing activities of assessment, monitoring,and decision-making were absent in the policy text. Toillustrate, in one example for recording vital signs,there is a literal directive that any temperature outsideof the normal range should be reported to the medicalofficer:

. . .Normal range (36–37.2 8C. . .)Record the temperature in the patient’s clinical file.If the temperature is abnormally high or low. . .reportthe reading to the medical officer.[NPS: Temperature, Pulse, Respirations, Blood Pressure]

A literal interpretation of this policy standard wouldresult in notification of a medical officer of everytemperature outside the stated range. But nurses arerequired to assess patients’ physical condition in thecontext of each individual’s medical situation and theresources that are readily available (Kramer et al., 2004;MacLellan et al., 2002; Gooch, 1999). Practically, whennurses assess temperature and it is outside the normalrange, they check local conditions (hot sun, warm room),consider a different measuring tool, analyse the finding inlight of the patient’s medical condition, and then decidewhether interventions such as nurse initiated panadol,cold face washes, blankets, and other medications arerequired. Nurses formulate a prognosis to determinewhether the temperature may be going down or up,whether the occurrence of rigors or other unpleasantsymptoms are likely, the degree of suffering the patientexperiences with any of these symptoms, and createprovisional diagnoses about what the temperature maymean clinically.

In undertaking an assessment of temperature, the nursealso consults with the patient and/or family to determinetheir concerns and address questions, consults thepatient’s medical record, recalls handover informationand uses this information to collaboratively negotiate a

Table 1

Stratified sampling of nursing practice standards.

NPS units Number of

policies in

the unit

Number of

policies

sampled

per unit

Unit 1 - Professional/practice standards 14 3

Unit 2 - Patient safety 8 2

Unit 3 - Nursing interventions 25 5

Unit 4 - Diagnostic tests/procedures 14 3

Unit 5 - Medication administration 24 5

Unit 6 - Intravenous therapy 8 2

Unit 7 - General surgical procedures 3 1

Unit 8 - Special procedures 33 7

Total 129 28



treatment plan with the health care team. In the instanceof a febrile episode, nurses would negotiate with otherteam members regarding appropriate intervention, bothnursing and medical, for this specific patient. This work isrendered invisible in the NPS for recording vital signs. Theterms, ‘‘record’’ and ‘‘report’’ undermine the nursingknowledge that is required to assess temperature, as wellas other vital signs such as heart rate, respiratory rate, andblood pressure. The nursing work associated with assess-ment of vital signs is reduced to the ‘doing’ actions, thoseaspects of assessment that are visible to the casualobserver. This codification of nursing work to a simpleconstruction as ‘doing’ procedures hides the embodiedknowledge of anatomy, physiology, pathophysiology,sociology, and psychology that is drawn upon to ‘do’assessment work.

There were examples where language showed nursedecision-making. However, the decision is often qualifiedas in the following example.

Initial decision may be made by a registered nurse, butmust later be authorised by a medical officer [NPS;Restraint].

Examples of qualification of nursing decisions weremost commonly evident in policies dealing with invasiveclinical procedures, such as biopsies or examinations ofvarious patient orifices, where nurses make decisionsrelated to ‘assisting’. For example:

Assist the medical officer with gowning, open furtherrequired sterile equipment such as the catheter pack,local anaesthetic, water for balloon, suture material.[NPS: Suprapubic catheter management]A medical officer assisted by a nurse may only perform arectal examination for diagnostic purposes. [NPS:Rectal examination]

In these cases, nurses can decide but only with theauthorisation of the doctor. In some standards, the

Table 2

Random and purposive sampling of nursing practice standards.

Random sampling Purposive sampling

The stratified random sample from each unit Chosen from the 28 randomly sampled

Unit 1 - Professional/practice standards

1.1.1 Code of professional conduct for nurses 1.1.1 Code of professional conduct for nurses

1.5:002 Valuables and personal property

1.7 Preceptorship

Unit 2 - Patient safety

2.3:002 Heat & cold applications

2.6 Restraining patients 2.6 Restraining patients

Unit 3 - Nursing interventions

3.1 Patient admission, discharge and transfer 3.2.1 Temperature, pulse, respiration, blood pressure

3.2.1 Temperature, pulse, respiration, blood pressure

3.2.3 Neurological observations

3.3 Nursing interview and clinical assessment

3.7.6 Suture and staple removal

Unit 4 - Diagnostic tests/procedures

4.2.2 Midstream urine specimen

4.2.3 24 Hour urine specimen

4.3.5 Liver biopsy 4.3.5 Liver biopsy

Unit 5 - Medication administration

5.2 Patient medication administration 5.2 Patient medication administration

5.4.2 Subcutaneous insulin administration 5.4.2 Subcutaneous insulin administration

5.4.5:002 Guidelines for the management of an

insulin infusion

5.5:002 Oral medication

5.7.5:001 Entonox administration management 5.7.5:001 Entonox administration management

Unit 6 - Intravenous therapy

6.10 Peripherally inserted central catheter (PICC). . . 6.10 PICC & midline catheter management. . .

6.9 Subcutaneous fluid replacement (hyodermoclysis)

Unit 7 - General surgical procedures

7.1 Pre-operative care

Unit 8 - Special procedures

8.1.1 Ear examination

8.1.2 Eye examination

8.1.4 Nasal examination

8.2.6 Rectal examination

8.2.9 Percutaneous endoscopic gastrostomy tube - PEG

8.5.4 Peak flow spirometry

8.7.3 Suprapubic catheter management



assistance of the nurse is written as a requirement for theprocedure itself:

Ear/eye/nasal examination is performed by a medicalofficer and assisted by a nurse if required [NPS: Ear/eye/nasal examination – three separate policies].A liver biopsy is performed by a medical officer andassisted by a registered nurse [NPS: Liver biopsy].

In these examples, the medical procedure itselfbecomes paramount and the text is directive in ananthropomorphic fashion of the actions whereby, theprimary performance is medical and secondary assistanceis nursing. One analogy would be the performance of amagic act, where the doctor is the magician in centre stageand the nurse is on the side, quiet and demure, assistingwith the equipment required to ‘do’ the act. Further, inthese examples, the patient is invisible; the patient hasbeen reduced to an eye, ear, nose or liver. The discursivepower of the language of ‘doing to’ organs reflects thedominance of the biomedical discourse in nursingprocedural policies.

The traditional hierarchy born in the Nightingale eraof nursing continues. In these texts, the nurse ispositioned solely as the doctor’s assistant, focusing onthe procedural requirements. The work of the nurse inproviding emotional support to the patient during theseoften traumatic procedures is not acknowledged in thepolicy text, effectively devaluing the caring aspect ofnursing (and medical) work. This limited representationof nursing work codifies the traditional socio-politicalpower relationship that privileges medical judgementand practice over nursing judgement and practice.Without more complex textual representations withinference to the depth of participation and knowledgerequired when performing these roles, nursing assis-tance is limited to a passive, subordinate form ofassistance.

Not only are nurses situated as the doctor’s assistantwithin the nursing policy standards, but they are expectedto monitor aspects of the doctor’s performance on behalf ofthe organisation, as in the following examples.

A consent form signed by the patient and witnessed bythe medical officer is required [NPS: Liver Biopsy].

Nursing Alert: The medical staff responsible should. . .

[NPS: Restraint].

The manifest meaning is that the doctor is responsiblefor consent, with latent implications of nurses asresponsible for ensuring medical officers are fulfillingtheir own duties. This may be interpreted as influence onmedical practice, as suggested by Manias and Street(2000). However, we argue that the discourse of providingassistance is extended from ‘doing’ to monitoring theperformance of doctors, making the nurse subservient tothe organisational needs for ‘monitoring’ as well asassisting the doctor.

In summary, while the nurse is held accountable for thecompletion of procedures, including medically conductedprocedures, such accountability is discursively presentedin relation to medical authority. The simple textualrepresentation in this set of the NPS render the embodiedknowledge of the nurse invisible, represented only asobservable actions.

4.2. Working to the bureaucratic template

Within this second theme, nursing policy text reinforcedorganisational interests in governing autonomous profes-sionals through risk management. Working to the bureau-cratic template comprised of two components: ‘Prioritising

legal liability’, and ‘Negative and authoritative tone’.

4.2.1. Legal liability as a priority

Often in the policy texts, the priority given to certainrisks often privileged the organisation over the patient. Toillustrate this, an example of the policy text for medicationadministration is presented. A significant portion of thedaily duties of a hospital-employed registered nurse iscentred on medication administration. As with tempera-ture assessment, the administration of medication is acomplex activity, requiring a multifaceted knowledgebase. Unlike some of the other policy standards, thislengthy policy standard has a formal introduction, outlinedbelow.

Medication errors can result in a loss of confidence inthe health care system, increased health care costs,cause harm and even death to patients. . .

Table 3

Procedural steps in data analysis.

Step Description

Reading Sampled policy texts were read and re-read to acquire a detailed view of how nursing practice was presented. Some of these

readings focused on the:

Language (e.g. words, phrases, grammatical constructions);

Content (e.g. policy and procedure statements, information source citations, explication of protocols or guidelines), and;

Format (e.g. length, labelling and ordering of different types of information, placement of sources of authority) of the texts.

Coding Following the multiple readings, segments of text (ranging from single phrases to whole policy sections) were systematically

coded into initial thematic groupings.

Collation Initial thematic labels were collated and subjected to frequency generation within and across the selected policies, enabling

the data to be linked in a convergent fashion and organised into broader themes.

Interpretation These broader themes were interpreted contextually and theoretically (Lupton, 1992; Powers, 1996). This stage is akin to a

creative act, employing the researchers’ ‘sociological imagination’ (Denzin and Lincoln, 2000; Mills, 1959) to create links between

the data, the literature, and the researchers’ contextual knowledge.



The hospital is also faced with the risk of legal liabilityfrom medication administration errors. Therefore it isessential for the hospital to have a policy which guidesstaff and that aims to prevent medication errors andmethods to prevent these errors that are discussed inthe current literature. [NPS: Patient medication admin-istration]

The risk of the procedure of medication administrationto ‘‘cause harm and even death to patients’’ is last in the listof concern, following ‘‘loss of confidence in the healthsystem’’ and ‘‘increased health care costs’’, both organisa-tional priorities. Later in Section 1, the stated reason for themedication policy standard is to ‘‘guide staff’’ [in theirmedication administration work] and ‘‘to prevent medica-tion errors’’. However, the associated rationale for suchguidance and prevention is ‘‘the risk of [vicarious] legalliability’’ for the hospital. In following the introductorytext, there is no further reference to potential patientharm—it is implied within legal liability. While it is presentin the policy text through implication, the nursing focus ofprotecting the patient from harm is subordinate to theorganisational focus on reducing legal liability. In thiswritten form, the medication policy standard becomes anorganisational instrument or tool to govern nursingpractice.

In order to ‘do’ certain procedures, nurses wererequired to be deemed competent. The discursive textmakes the assessment of competence essential for theprocedure by not only stating that competence is requiredbut also by describing the process for being deemedcompetent.

Competency:

Registered nurse who has been assessed as competentto perform the procedure.

(A registered nurse is assessed as competent when:

- the nurse has observed the procedure,- practised, at least once under the supervision of a

registered nurse,- assessed as competent by another registered nurse

nominated by the clinical nurse consultant). [NPS:Peripherally inserted central catheter (PICC) and midlinecatheter management.

The underlying theme of competence throughout theNPS continues the historical uses of the NPS—to provideguidance for probationers or students. Continuity of thislevel of surveillance within the discursive texts of adocument that purports to govern the practice of qualifiednurses, could seriously undermine the profession’s argu-ments for autonomy. The subjection of nursing work tomedical control and to regular competence assessmentwas consistent in the policy texts reviewed. The continua-tion of explicit behavioural descriptions of competencewithin the policy text, provide organisational control ofnursing work through surveillance.

As will be demonstrated in the next sub-themes, thesubordination of the nurse to the organisation is further

established in the negative and authoritative tone of thetext.

4.2.2. Negative and authoritative tone

The tone of many of the NPS reviewed was negative,with an apparent focus on avoiding error by informing thereader (the nurse) of what not to do. Continuing with theprevious example of the policy standard for medicationadministration, the word ‘‘error’’ appears twelve times.While language with a positive tone, such ‘‘right’’ and‘‘correct’’ are present, they are dichotomous terms that byimplication carry negative tone such as ‘‘wrong’’ and‘‘incorrect’’. It is expected that a medication policystandard should focus on the prevention of adverseincidents, but the overuse of language that focuses onerror rather than on good or best practice can be read aslitigation avoidance rather than guidance.

As with the earlier example of assessment of vital signs,the text in the medication policy reduces the administra-tion of medication to a series of steps.

� Unlock the medication trolley.� Remove medication from patient’s drawer. . .[NPS:

Patient medication administration].

The instructional nature of this policy standard impliesthat the nurse requires guidance for every step of theprocedure, disregarding years of education and experience.Another example of the instructional tendency in NPSsimply fails to acknowledge the level of education oftoday’s nursing staff.

� Do not turn your back on or sit on a sterile field [NPS:Aseptic technique].

In the context of a nursing policy standard that isdirected to a Bachelor-prepared nursing audience, theseinstructions for completing basic mechanical steps in theprocess are inconsistent with evidence-based policydevelopment, and frankly, insulting to read. The negativetone of these policy texts is exaggerated by the author-itative tone adopted.

The core words, the basic imperative building blocks ofthe policy texts were both instructive and negative, such as‘‘do not’’, ‘‘should not’’, and ‘‘must not’’. The use of suchlanguage masked the need for rationale, explanation, orevidence. This idea of nurses doing as they are told (or told‘not to’) is underlined by a provision of step-by-stepinstructions in the policy texts, demonstrating the negativeand authoritarian tone collectively implied within thecontent.

Scattered throughout the policy texts were briefstatements, usually single dot-points printed in red andsometimes bolded font, with the headings ‘‘Nursing Alert’’,‘‘Safety Alert’’, ‘‘NB’’, and ‘‘Note’’. In the template, theseportions of text are referred to as ‘‘Nursing Alerts/Rationales’’. The information provided in these ‘‘NursingAlerts/Rationales’’ varied in intention and importance, andrarely provided an underlying rationale. In one particularlypuzzling example from the basic wound dressing techni-



que policy standard, the nursing alert cautions against theuse of cottonwool swabs.

Nursing Alert: Do not use cottonwool swabs. Use gauzeswabs only for the cleansing of the wound. [NPS: Basicwound dressing technique]

No further explanation or rationale is offered for thisprescriptive statement. Given the nature of wounddressing, and the inherent risks of nosocomial infection,it is unclear why it is any more worthy of highlightingwhich type of cleaning product should be used than theinfection control text surrounding it. It is only withcontextual knowledge from the workplace, gained fromdiscussions with other registered nurses, does the readerlearn that the practice of indiscriminate use of cottonswabs posed a serious risk of infection. This alert wasadded to address the misuse of cottonwool swabs but theevidence to support the instruction is not provided. Thecumulative effect of these ‘important’ alerts, without anysupportive evidence as justification, reinforces the impres-sion that policy standards are authoritative; they must befollowed.

When evidence was provided to support policydirectives, it was usually drawn from the medicalliterature, textbooks, and/or was often over 10 years old.Nursing and medical knowledge is constantly changingthrough research and developments, with new researchfindings published monthly. In order to achieve evidence-informed policy standards, standards developmentrequires a constantly evolving process. In the NursingPractice Standards, a cycle of three-yearly review wasclaimed (NPS: Policy and procedure initiation, review andratification). During this review, many of the ‘‘Review Due’’dates on individual policies were overdue by up to 3 years(e.g. 6 years since first published), raising the question ofthe currency of the evidence on which the policies werebased.

The lack of up-to-date policies informed by best,contemporary evidence combined with text written witha tone of authority runs the risk of guiding nurses intopractices that are not consistent with their education andpersonal learning as a professional from courses, journals,and conference presentations. Nurses, as a well-educatedand autonomous professional group, are challenged dailyby authoritative policy texts that are out-of-date andinconsistently supported by evidence. Further, whenpolicy text is written in ways that subordinate the nurse’sinterest in patient outcomes to organisational riskmanagement in the form of managing vicarious legaland fiscal liability, nurses become confused or begin topractice outside of the policy framework. Acting outside ofpolicy can shift the liability for risk from the organisationto the individual, with significant implications for nurses.

How the policy text was used to ‘support’ registerednurses is derived from the Code of Professional Conductpolicy, which stated the following.

� Nurses should observe the policies/standards whether ornot they approve of these policies/standards. Should asituation arise in which a staff member finds a policy/standard at conflict with his or her personal views, the

matter should be discussed with an appropriate seniorstaff member.

And, later in the same list of bullet points,

� Nurses should display professionalism in all facets oftheir work to ensure that the information/process uponwhich decisions and recommendations are based iscorrect, complete and fully documented to provide a highlevel of accountability.� Nurses are personally accountable and responsible for

the provision of safe and competent nursing care. [NPS:Code of Professional Conduct].

The assumption of nursing obedience to policy isexplicitly stated in the first bullet point. However, the laterbullet points are less clear in direction, beyond holdingnurses accountable for their decisions and actions. In thispolicy text, professional nursing work is subordinate to theorganisation’s interests. While there is a place fordiscussion of concerns about specific policies, there is noacknowledgement of contemporary nursing educationthat prepares nurses to critically ‘analyse’ the relevanceof policy to each unique care situation. The Code ofProfessional Conduct policy text indicates that policy maycontradict the nurses’ knowledge and skill in deliveringsafe care, but does not visibly support nurses to use theirknowledge and skills. This contradiction is one thatconfuses nurses in general, but newly qualified nurses inparticular.

5. Discussion

This study examined how nursing policy may describe,enable and limit nursing practice, and found that therepresentation of nursing in policy texts has not changed inthe last decade. The ‘docile nurse’ (Cheek and Gibson,1996) continues to be promoted. This study has found thatpolicy documents describe nursing work as ‘doing’ and‘assisting’, and highlight the traditionally subservient roleof the nurse to the doctor and the organisation.

Policy documents may enable nursing work throughthe offering of regular and consistent pathways to meetcommon situations and patient needs. Familiarity withpolicy and procedures may support the development ofsafe routines by which nurses can conduct their workquickly and efficiently. This enabling role of the policies issupported by the work of McCloskey and Bulechek (1994)who found that policy documents offer explicit descrip-tions of practice, and nurses use this to develop nursingknowledge.

However, the policy documents examined in this studywere limiting in that they did not offer scope for how anurse could work if a situation was outside the parametersof the policy. The observation that nurses are not beingsupported by their own policies is demonstrated in otherstudies, where patients’ needs (as assessed by the nurse)are contrary to procedural policy for the delivery of care(Larsen, 2005; Boogaerts et al., 2008). The policy docu-ments were thus limited in supporting nurse autonomyand professional accountability for patient care. Elsewhere,



policy has been found to control and limit nursing practice(Horsfall and Cleary, 2000), particularly when structuredas strict algorithms (Larsen, 2005). When written as stepsor rules policy has a ritualising effect on nursing work(Cheek and Gibson, 1997). The last decade of health reformthrough increased corporatisation and rationalism maynot be improving safety and efficiency as expected. Rather,nurses, the largest group of health professionals, may berepeatedly working outside of policy due to the limitationsand restrictions of the policy documents.

As with other studies, policies were found to assume a‘novice’ audience (Horsfall and Cleary, 2000), have alimited evidence base (Thomas et al., 1999; Noak et al.,2002), situate nursing in a subservient position to doctorsand the organisation which limited professional autonomy(Horsfall and Cleary, 2000), provide specific ‘how to’knowledge for busy nurses (McCloskey and Bulechek,1994), and codify nursing as ‘doing’ rather than ‘thinking’(Cheek and Gibson, 1996; Boogaerts et al., 2008; Larsen,2005). This study did not find any evidence to support theuse of policy to dispute medical dominance (Manias andStreet, 2000). This research therefore offers additionalweight to previous findings that policy documents, in theircurrent form, have questionable use in guiding nursingpractice (Noak et al., 2002), and are an inadequaterepresentation of nursing knowledge (Horsfall and Cleary,2000).

The NPS that were reviewed in this study situatednurses in a subservient position to medical doctors and theorganisation. The language of these policies was infusedwith words that implied reprimand and reinforced theimportance of organisational interests over nursingjudgement. This discourse, grounded in vicarious legaland fiscal liability, situates nurses as obedient, whichcreates a theoretical contradiction to the discourse ofautonomy produced by the regulatory and professionalnursing bodies. Instead of the well established ‘theory–practice gap’, the discourse of nursing procedural policyproduces a theory–practice contradiction for nurses. Theprofessional discourse produced by regulatory and nursingorganisations expect nurses to exercise autonomousprofessional judgement but as employees, nurses areexpected to conform or submit uncritically to externallyestablished procedures. This tension is played out insituated practices everyday, with conforming behaviourreinforced by clinical nurse leaders.

6. Future implications

When nursing procedural policy is written in ways thatexpect uncritical subservience, nurses’ clinical judgementis rendered invisible. When nurses practise in ways thatare different to the procedural policy, they risk reprimandfrom the organisation or medical colleagues. Whilst it isaccepted that policy has an important place in thegovernance of autonomous clinical practice, particularlywith the large numbers of nurses employed in healthservices, the terminology and structure of nursingprocedures can be rewritten to be more consistent withthe professional discourse of autonomy in clinical judge-ment. Specific suggestions include:

� Clearly establish the context for which the proceduralpolicy was developed, e.g. service-wide, hospital-only,unit-only;� Provide an explanation of rationale for the procedural

policy in terms of managing legal, fiscal or clinical risk;� Replace such terms as ‘must’, ‘should’, and ‘will’ with less

restricted terms such as ‘may’, ‘could’, and ‘might;� Add terms such as ‘at the nurse’s discretion’ and

‘dependent on the nurse’s assessment’;� Supply evidence and rationales which have informed the

policy; and� Consider the development of procedural policies to guide

the practice of all professionals such as doctors,physiotherapists, pharmacists and dieticians by identi-fying the audience for each policy.

Individuals and groups who are charged with writingpolicy should be provided with education on the theore-tical balance between managing organisational riskthrough generalised procedural policy and supportingclinical judgement of autonomous professionals in con-text-specific situations.

Policy development, including procedural policy,requires further research and development to inform thepractice of policy writers. Specifically, the ways thatlanguage and structure work to manage the practice ofautonomous professionals needs to be attended in policydesign. The role of procedural policy to manage the risksinherent in health service delivery is not questioned in thispaper. However, the discourse of current procedural policydoes not explicitly value the clinical judgement ofautonomous professionals, creating a theory–practicecontradiction for nurses. The implication for nurses whopractice outside of policy, based on clinical judgement, isthe risk of reprimand or disciplinary action for practising inways that are consistent with professional and regulatoryexpectations. This contradiction presents a professional,regulatory and organisational challenge that requiresfurther discussion and debate.

7. Limitations

The existing literature on this topic has focused onindividual policies or specific types of policies, whereasthis study examined a range of nursing procedural policieswithin one organisation. There is relatively little knowl-edge of the extent of variation in policy language, contentand format between different organisations in Australia orglobally. Findings from this study should not be general-ised to describe the various functions of nursing policy inother organisations. However this analysis does provideinsights into policy design that may be useful for nurseswho are responsible for managing the work of othernurses.

8. Conclusion

This study aimed to explore how the nurse was situatedin procedural policy and how these representations ofnurses define, limit and enable nursing practice. Inreviewing the nursing practice standards of one tertiary



health institution in one Australian jurisdiction, theauthors conclude that within the discourse of hospitalpolicy nurses are situated as subservient to medicaldoctors and to the organisation. This discourse is differentto that of the nursing profession, where nurses areautonomous, critical thinking practitioners. The experi-ence of the newly qualified nurse, described in theintroduction, demonstrates that these two discourses havethe potential to clash. The clash of discourses in everydaypractice can be confusing for nurses and may contribute tovoluntary separations.

Acknowledgements

The authors acknowledge the financial assistance of TheUniversity of Canberra Research Grants Scheme (EarlyCareer Researcher), and The Canberra Hospital VacationScholarship Program. The authors also acknowledge theproject instigation and initial encouragement by GlennGardner, critical input by Brendan Bail, and the contribu-tion of the Research Centre for Nursing and MidwiferyPractice at The Canberra Hospital and University ofCanberra.

Conflicts of interest: No conflicts of interest to declare.

Funding: The authors acknowledge the financial assistance of

The University of Canberra Research Grants Scheme (Early

Career Researcher), and The Canberra Hospital Vacation

Scholarship Program.

Ethical approval: There was no requirement for ethical clear-

ance for this study.

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Writing ourselves into a web of obedience: a nursing policy analysis

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