What keeps you up at night? Moral distress in nurse leaders in the USA, Germany, Austria and Switzerland.

PURPOSE: Nurse leaders are challenged by ethical issues in today's complex health-care settings. The purpose of this study was to describe and analyze key elements of moral distress identified by nurse leaders from health-care systems in the USA, Germany, Austria and Switzerland. The aim was to develop an understanding of distressing ethical issues nurse leaders face in the USA and three German-speaking European countries. DESIGN/METHODOLOGY/APPROACH: This descriptive cross-sectional study surveyed a convenience sample of nurse leaders in the USA, Germany, Austria and Switzerland. The voluntary, anonymous survey also included qualitative questions and was distributed using the Qualtrics® platform. A thematic analysis of the qualitative data in each country was carried out and a comparative analysis identified similarities and differences between the groups of nurse leaders comparing the US data to that from three German-speaking European countries. FINDINGS: The survey was completed by 316 nurse leaders: Germany, Austria, and Switzerland (n = 225) and the USA (n = 91). Similar themes identified as causing all nurse leaders moral distress included a lack of individual and organizational integrity, hierarchical and interprofessional issues, lack of nursing professionalism, patient care/patient safety concerns, finances negatively impacting care and issues around social justice. Within these six themes, there were also differences between the USA and the three German-speaking European countries. ORIGINALITY/VALUE: Understanding the experiences associated with distressing ethical situations can allow nurse leaders and organizations to focus on solutions and develop resilience to reduce moral distress in the USA and three German-speaking European countries.

Community Nurses' Perspectives on Conceptual Challenges Related to the Need for Nursing Care in Germany: A Constructivist Grounded Theory Study.

In Germany, a person's need for nursing care is assessed by evaluators according to the federal legal definition of the statutory long-term care insurance (LTCI). This definition and the associated standardized assessment tool constitute the conditions for providing nursing care in a community care setting in Germany. Furthermore, the community care setting is regulated by state law and negotiations between long-term care funds and associations of providers of nursing care. During nursing care, nurses engage in a variety of interactions with people. The extent to which the legal definition of the need for nursing care leads to challenges in these interactions is unclear. To address this knowledge gap, we conducted 22 problem-centered interviews with nurses in the community and analyzed the data using the constructivist grounded theory. The results revealed that the negotiation processes are settled within professional-family relationships and vary between the constructs of closeness and distance, advocacy and submission of responsibility, and ethos and technocracy; these are the central challenges nurses encounter in this setting. We discuss the implications and questions that arise from the findings for the nursing profession regarding its own current and future role as well as the design of nursing support in the community, to nurture more advanced nurse practitioners and community health nurses.

Comparative Analysis of Advanced Practice Nursing: Contextual and Historical Influences in North American and German-Speaking European Countries.

This article compares the professionalization and educational standards of Advanced Practice Nursing in the United States, Canada, Germany, Austria, and Switzerland with specific attention to geographical, political, and professional factors - both current and historical - influencing the evolution of these nurse leaders. A review of the literature, scientific articles, governmental regulatory texts, and legislative codes from each country, was performed. Patterns related to the geographical, political and professional context of nursing in each country were identified with comparative insights on the evolution of the discipline. Advancement of the nursing discipline is apparent in each country over the last century, although at differing rates. The disparity in development and level of autonomous practice for Advanced Practice Nurses in each country can be better understood in the context of historical, geographical, political and professional development. This review of the literature was combined with a comparative analysis and offers insights to inform nurses in education, leadership, practice, and advocacy interested in advancing the professionalization of advanced practice nursing internationally.

Institutional excellence reloaded: a 17-years, two-phase in-depth study of corporate culture change in the health care sector.

PURPOSE: This ethnographic revisit of a general hospital aims to critically explore and describe the mechanisms of corporate culture change and how institutional excellence is facilitated and constrained by everyday management practices between 1996/1997 and 2014/2015. DESIGN/METHODOLOGY/APPROACH: A five-month field study of day-to-day life in the hospital's nursing division was conducted by means of an ethnographic revisit, using participant-observation, semi-structured interviews, free conversations and documentary material. FINDINGS: Using labour process analysis with ethnographic data from a general hospital, the corporate culture is represented as faceted, complex and sophisticated, lending little support to the managerial claims that if corporate objectives are realised, they are achieved through some combination of shared values, beliefs and managerial practices. The findings tend to support the critical view in labour process writing that modern managerial initiatives lead to tightened corporate control, advanced employee subjection and extensive effort intensification. The findings demonstrate the way in which the nursing employees enthusiastically embrace many aspects of the managerial message and yet, at the same time, still remain suspicious and distance themselves from it through misbehaviour and adaptation, and, in some cases, use the rhetoric against management for their own ends. PRACTICAL IMPLICATIONS: What are the implications for clinical and managerial practitioners? The recommendations are to (1) develop managerial practitioners who are capable of managing change combined with the professional autonomy of clinical practitioners, (2) take care to practise what you preach in clinical and managerial reality, as commitment, consent, compliance and difference of opinion are signs of a healthy corporate culture and (3) consider the implications between social structures and human actions with different work behaviours on different levels involved. ORIGINALITY/VALUE: This ethnographic revisit considers data from a labour process analysis of corporate culture change in a general hospital and revisits the ways in which contradictory expectations and pressures are experienced by nursing employees and management practitioners spread 17 years apart.

[Ethnography and fieldwork: the crisis of representation and beyond]. / Ethnografie und Forschen im Feld: diesseits und jenseits der Krise der Repräsentation.

Writing as a nursing researcher about the subjects that comprise the nursing profession means writing about oneself. Conducting ethnographic research on subjects within one's own professional culture and interacting with these subjects in the field poses a challenge. Ethnographic research analyses and opens out the horizon of one's own professional culture for the benefit of the potential reader. However, at the same time, the researcher's self within an ethnographic framework is called into question. In anthropology the researcher-subject relationship is deemed a special relationship, and in this article both authors reveal the precarious status of their research object. In this article an attempt is made to let the nursing subjects speak for themselves, while at the same time the authors write about their subjects' social practices an communication processes. To date there has hardly been any German research work within nursing dealing with this critical area of interest. The authors seek to provide an introduction to the constitutive parts of ethnography and the crisis of representation and beyond. In addition, they present two reflexive accounts.

Instilling and distilling a reputation for institutional excellence: a critical reflection on organising practice.

PURPOSE: This ethnographic investigation of a general hospital aims to critically analyse a much lauded corporate culture. Rather than accepting the managerial and academic claims concerning the mobilisation of corporate culture at face value, this study builds upon a labour process analysis and takes a close look at how it actually seems to work. DESIGN/METHODOLOGY/APPROACH: The paper explores and describes how executive managers seek to design and impose corporate culture change and how it affects the nursing employees of this organisation. This was achieved by means of a six month field study of day-to-day life in the hospital's nursing division. FINDINGS: The results lend little support to the official claims that, if managerial objectives are realised, they are achieved through some combination of shared values and employee participation. The evidence lends more support to the critical view in labour process writing that modern cultural strategies lead to increased corporate control, greater employee subjection and extensive effort intensification. The contradiction this brings into the working lives of the employees leads to the conclusion that the rhetoric of corporate culture change does not affect the pre-existing attitudes and value orientations of nursing employees. However, there were considerable variations in how employees received the managerial message and thus, by their degree of misbehaviour and adaptation, affected the organisation itself as well as using the cultural rhetoric against the management for their own ends. ORIGINALITY/VALUE: The paper concludes that an extended labour process analysis is necessary to challenge the way in which corporate culture change is explored and described by management academics and practitioners.

Theorising culture and culture in context: institutional excellence and control.

In this paper an attempt is made to focus on the ideological and practical implications of the new cultural forms of healthcare sector management variously described as institutional excellence, empowerment, total quality and human resource management. Thus, I look in detail at the managerial and academic claims concerning the mobilisation of corporate culture and go on to emphasise the impact which the literature of culture management has had on nursing employees and healthcare organisations. I also highlight the restrictions of the applied research approaches and argue that the managerial and poststructural literature is limited in that its conceptualisation of culture and change is incomplete. The focus switches then to a range of literature which has been used to study change with a labour process perspective and explains why an approach based upon the study of the disparity between the cultural rhetoric and the day-to-day practice, as well as how people experience and respond to that disparity, is to be preferred. Furthermore, I gain substance from a variety of viewpoints in order to discover a suitable way of putting the matter of interest into context. Drawing on the analytical framework of the sector model, which differentiates in the economy between private and state production sectors, it is possible to distinguish between the different modes of rationality governing each sector. As a basis for further contextualisation, the powerful and privileged positions of nursing as well as other healthcare professionals and the distinctive character of their employment relationships are considered. The paper concludes that an extended labour process analysis is necessary to challenge the way in which the concept of culture is applied by nursing academics and practitioners.