The positioning of nurses in health care in Vietnam: Interactions, organisations and space
Hong Thuy Phuong Huynh RN, BScN, MAddNP, MAppScN
Submitted in fulfillment of the requirement of the degree of Doctor of Philosophy
School of Nursing, Faculty of Health Queensland University of Technology
2020
SUPERVISORY TEAM
Associate Professor Carol Windsor Director of Post Graduate Research Faculty of Health School of Nursing Queensland University of Technology Victoria Park Road Kelvin Grove, 4059
Associate Professor Karen Theobald Director of Academic Programs Postgraduate Study Area Coordinator Health Professional Education Faculty of Health School of Nursing Queensland University of Technology Victoria Park Road Kelvin Grove, 4059
THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE i
KEYWORDS Nursing practice
Social positioning
Negotiation
Patient assessment
Pragmatism
Symbolic Interactionism
Social Processes
Social context
Space
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ABSTRACT
The complexities of nursing practice are often obscured in the endeavour to construct a generic definition of nursing. The process of the construction of nursing practice and associated contextual factors, however, ensure considerable variation in nursing work within and across nations. Nursing practice is better understood as constructed by nurses as social actors who perform roles that are negotiated and mediated in context.
The purpose of this research was to explore the nursing practices of Vietnamese Registered Nurses (RNs) in a clinical environment to gain insight into both the construction of nursing practice within that context and the broader implications for nursing in Vietnam.
The research was grounded in the broad pragmatist tradition. The methods were informed by the works of Charmaz (2014). The purposeful sample constituted 29 RNs who worked across eight departments of a major hospital in Vietnam. Periods of observations and individual semi- structured interviews were the methods of data generation. Data analysis involved a systematic abstraction of theoretical concepts.
Three key concepts, developed in the analytical process, reflected both agency and structure as important dimensions of nursing practice in Vietnam. Nurses as social actors were constantly engaged in a process of negotiation and renegotiation to sustain some sense of shared order in their practice. Yet, the shared order of practice was disrupted as medical doctors, family members and the managerial hierarchy posed varying demands as they moved in and out of the space of nurses. The concept of space was thus significant in depicting where and when nurses could practice autonomously. A broader structural interpretation of the space, both material and symbolic, in which the nurse participants worked, was framed within the historical, economic and political contexts of nursing work in Vietnam.
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Table of Contents
SUPERVISORY TEAM ...... I
KEYWORDS ...... II
ABSTRACT ...... III
LIST OF FIGURES ...... VIII
LIST OF TABLES ...... IX
LIST OF ABBREVIATIONS ...... X
STATEMENT OF ORIGINAL AUTHORSHIP ...... XIV
ACKNOWLEDGEMENTS ...... XV
CHAPTER 1 INTRODUCTION ...... 1
1.1 Background ...... 1
1.2 The Vietnamese context ...... 3 1.2.1 The reform in the Vietnamese Higher Education and Healthcare System ...... 4 1.2.2 The Vietnamese healthcare context after reform ...... 7 1.2.3 The current Vietnamese healthcare context ...... 8
1.3 Nursing in Vietnam ...... 11
1.4 The research problem: A systematic process of reflexivity ...... 17
1.5 Research purpose and aims...... 19
1.6 Roles of the researcher ...... 19
1.7 Definition of terms ...... 21
1.8 Overview of the thesis ...... 22
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CHAPTER 2 LITERATURE REVIEW ...... 24
2.1 Introduction ...... 24
2.2 Nursing decision making around patient assessment ...... 24 2.2.1 Patient assessment ...... 24 2.2.2 Patient assessment in nursing practice ...... 25 2.2.3 Limitations ...... 26 2.2.4 Issues around nursing patient assessment ...... 28
2.3 Summary ...... 32
CHAPTER 3 THEORETICAL TOOLS ...... 33
3.1 Introduction ...... 33
3.2 The genesis of symbolic interactionism ...... 34
3.3 Pragmatism and the early symbolic interactionism ...... 36
3.4 Core concepts ...... 38 3.4.1 Human actions as social performances ...... 38 3.4.2 Human actions and structure ...... 48
3.5 Summary ...... 55
CHAPTER 4 METHODS...... 56
4.1 Introduction ...... 56
4.2 Research methods ...... 56 4.2.1 Research setting ...... 56 4.2.2 Sampling strategy...... 57 4.2.3 Data generation process ...... 61 4.2.4 Initial coding ...... 71 4.2.5 Theoretical analysis ...... 72 4.2.6 Strategies of ensuring quality of qualitative research ...... 79 4.2.7 Ethical considerations ...... 84
4.3 Summary ...... 85
CHAPTER 5 INTERNALISING NURSING PRACTICE ...... 87
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5.1 Introduction ...... 87
5.2 The process of negotiation and mediation ...... 88 5.2.1 Understanding nursing practice in the world of others ...... 88 5.2.2 Mediating nursing practice ...... 93 5.2.3 Intuition and nursing practice ...... 99
5.3 Summary ...... 101
CHAPTER 6 INSTITUTIONALISING NURSING PRACTICE ...... 103
6.1 Introduction ...... 103
6.2 Nursing practice - the negotiated order ...... 104 6.2.1 Interactions and negotiations ...... 105 6.2.2 Professional boundaries – the permeable product of negotiation ...... 108 6.2.3 Negotiations at the structural level ...... 113
6.3 Summary ...... 124
CHAPTER 7 SOCIAL SPACE OF NURSING PRACTICE ...... 125
7.1 Introduction ...... 125
7.2 Nursing practice and the social space ...... 125 7.2.1 Social space of nursing practice ...... 127 7.2.2 Symbolic power, social space and nursing ...... 135
7.3 Summary ...... 139
CHAPTER 8 DISCUSSIONS AND CONCLUSIONS ...... 140
8.1 Introduction ...... 140
8.2 Key research findings ...... 140
8.3 The social positioning of nurses - the paradoxes ...... 144 8.3.1 The positioning of nurses in the political context of conflicting interests ...... 145 8.3.2 The positioning of nurses in the historical and cultural context of Vietnam ...... 149
8.4 Methodological considerations ...... 151
8.5 Conclusion ...... 152
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REFERENCES ...... 154
APPENDICES ...... 180
Appendix A Hospital Classifications (Vietnamese) ...... 180
Appendix B Nursing Competency Standards (Vietnamese) ...... 213
Appendix C Synthesised documents ...... 230
Appendix D The ethics approval of the University of Medicine and Pharmacy ...... 234
Appendix E Information sheet ...... 237
Appendix F The Research Poster ...... 242
Appendix G Bachelor of Science Nurse Curricula ...... 243
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List of figures Figure 1-1 The structure of health care system in Vietnam. Adapted from “A Health Financing Review of Vietnam with a Focus on Social Health Insurance”, by Tran Van Tien et al., 2011, WHO, p.4...... 10 Figure 1-2 The administrative structure of health care in Vietnam. Adapted from “A Health Financing Review of Vietnam with a Focus on Social Health Insurance”, by Tran Van Tien et al., 2011, WHO, p.5...... 11 Figure 4-1 Data generation process ...... 72 Figure 4-2 The theoretical lens ...... 79
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List of Tables Table 1.1 Healthcare professionals in Vietnam (MOH, 2014) ...... 12 Table 1.2 Simulated pay table for employees in government institutions in Vietnam pre October 2015 (2004) ...... 14 Table 1.3 Simulated pay for employees in government institutions in Vietnam post October 2015 (2018) ...... 16 Table 4.1 The process of purposeful sampling for participant approach and recruitment ...... 59 Table 4.2 Participant demographic data ...... 60 Table 4.3 Observation recording template ...... 63 Table 4.4 Categories of selected documents ...... 68 Table 4.5 Process of field notes taken ...... 70 Table 4.6 Theoretical analysis ...... 74 Table 4.7 Levels of interpretation. Adapted from “Reflexive Methodology: new vistas for qualitative research”, by M. Alvesson and K. Skoldberg, 2009, London: SAGE, p.274 ...... 82 Table 4.8 The memo-writing process ...... 83
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List of abbreviations ABBREVIATION DEFINITION
Introduction
CHS Commune Health Station
DHC District Health Centers
EWS Early Warning Scores
HMU Hanoi Medical University
ITPA Interactive Tailored Patient Assessment
MOE Ministry of Education
MOH Ministry of Health
PHB Provincial Health Bureaus
RN Registered Nurse
RRS Rapid Response System
SI Symbolic interactionism
UMP University of Medicine and Pharmacy – Ho Chi Minh City
US United States
VNA Vietnam Nurse Association
WHO World Health Organisation
Literature review
ANA American Nurses Association
ACSQH Australian Commission on Safety and Quality in Healthcare
EWS Early Warning Scores
ICU Intensive Care Unit
JSAPNC Jefferson Scale of Attitudes toward Physician-Nurse Collaboration
MET Medical Emergency Team
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MP Medical Practitioner
MOH Ministry of Health
MSU Medical-Surgical Unit
NCEPOD National Confidential Enquiry into Patient Outcome and Death
NHS National Health Service
NP Nurse Practitioner
NSQHS National Safety and Quality Health Service
RN Registered Nurse
RRS Rapid Response System
UK United Kingdom
VNA Vietnam Nurse Association
Theoretical tools
MOH Ministry of Health
MOHA Ministry of Home Affairs
RN Registered Nurse
SI Symbolic interactionism
VNA Vietnam Nurse Association
Method
BSN Bachelor of Science Nurse
HCMC Ho Chi Minh City
MD Medical doctor
MOH Ministry of Health
MOHA Ministry of Home Affairs
REIS Research Ethics Integrity and Safety
RN Registered Nurse
QUT Queensland University of Technology
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SI Symbolic Interactionism
UMP University of Medicine and Pharmacy – Ho Chi Minh City
VNA Vietnam Nurse Association
Internalising nursing practice
MOH Ministry of Health
RN Registered Nurse VNA Vietnam Nurse Association
WHO World Health Organisation
Institutionalising nursing practice
AP Atlantic Philanthropy
HPET Health Professionals Education and Trainings
MOET Ministry of Education and Training
MOH Ministry of Health
UMP University of Medicine and Pharmacy – Ho Chi Minh City
VNA Vietnam Nurse Association
VNCS Vietnamese Nursing Competency Standards
Social space of nursing practice
MOH Ministry of Health VNA Vietnam Nurse Association
Discussion and Conclusion
ADB Asian Development Bank
ANEP Advanced Nursing Education Program
AP Atlantic Philanthropy
ASEAN Association of Southeast Asian Nations
CTU Can Tho University
HMU Ha Noi Medical University
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HPET Health Professionals Education and Training
MOET Ministry of Education and Training
MOH Ministry of Health
MRANS Mutual Recognition Arrangement on Nursing Services
NDU Nam Dinh University
PNTU Pham Ngoc Thach University
RN Registered Nurse
SESDP Socio-Economic Strategic Development Plan
SI Symbolic Interactionism
UHC Universal health coverage
UMP University of Medicine and Pharmacy Ho Chi Minh City
UNESCO United Nations Education, Scientific and Cultural Organisation
VHE Vietnamese Higher Education
VHS Vietnamese Health System
VNA Vietnam Nurse Association
VNCS Vietnamese Nursing Competency Standards
WHO World Health Organisation
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STATEMENT OF ORIGINAL AUTHORSHIP
The work contained in this thesis has not been previously submitted to meet the requirements for an award at this or any other higher education institution. To the best of my knowledge and belief, the thesis contains no materials previously published or written by another person except where due reference is made
QUT Verified Signature
Signature
Date: 23/03/2020
THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE
xiv ACKNOWLEDGEMENTS I wish to acknowledge and thank the study participants for the voluntary participation they provided that I was able to achieve valuable information.
I wish to express my very great appreciation and heartiest gratitude to my respected Assoc. Prof. Carol Windsor for her mentoring support and supervision which provided inspiration for me in research.
I also wish to thank Assoc. Prof. Karen Theobald for her sincere supervision and support during my research journey.
I would particularly like to thank the Cho Ray Hospital, the Queensland University of Technology, and the University of Medicine of Pharmacy HoChiMinh City for their support in making the research possible.
My special thanks are extended to the Australian Government, and staff of the Australia Award Scholarship for giving me financial support to study in Australia.
Advice given by my friends and colleagues has been a great help for me in conducting the research.
Finally, I wish to thank my loving and supportive husband, Ngoc Toan, and my wonderful 4-year daughter, Mai Thi, and my family members for being by me without conditions throughout this beautiful journey.
Everytime I look at you, I know that I am a lucky person
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Chapter 1 Introduction
1.1 Background The work of nurses in health care workforces worldwide is considered critical in ensuring health security and in improving the quality of health services (WHO, 2019). Technological, demographic, medical and scientific developments within the healthcare industry have also underpinned an increasing demand for advanced nursing practice roles to meet the changing health needs of populations (Bryant-Lukosius et al., 2016). Indeed, there is a growing body of evidence on the effectiveness of advanced nursing practice in enhancing health service outcomes in terms of improved mortality and morbidity and reduction of healthcare utilisation and costs (Bryant-Lukosius et al., 2016; Donald et al., 2015). As part of this movement, there have been ongoing changes in nursing education to address the preparation of nurses for emergent practice roles.
The initial impetus for this research was an observed apparent disconnect between nursing education and the practice of clinical nursing in Vietnam and particularly in the area of patient assessment by nurses. While nurses have always engaged in forms of patient assessment this practice has been more overtly associated with the role of the medical profession (Marsden, Dolan & Holt, 2003). More recently, however, there has been a growing theoretical interest in patient assessment as a fundamental feature of nursing practice (Cooper et al., 2010; Kyriacos, Jelsma & Jordan, 2011). Patient assessment is considered an integral phase of nursing care that enables nurses to recognise early abnormal changes in the health status of patients and thus ensure that effective interventions are implemented (Fennessey & Wittmann-Price, 2011; Javis, 2015; Taylor, Lillis, LeMone & Lynn, 2011). It is assumed that because nurses have the most continuous direct contact with patients, the performance of timely and appropriate patient assessment by nurses is more likely to contribute to patient safety (Fennessey & Wittmann-Price, 2011; Fero et al., 2010). In terms of enhancing the capabilities of the nurse, relevant knowledge and skills in physical assessment of patients and health history assessment is routinely included in most nursing programs including the bachelor of nursing in Vietnam.
An early review of literature in the area found that questions had arisen in relation to the range of patient assessment skills which nurses apply in clinical areas. For example, Giddens
CHAPTER 1 1 (2007) conducted a cross-sectional survey to investigate physical assessment techniques performed by registered nurses (RNs) in the United States. The study found that only a small set of skills were performed in nursing clinical practice even though nursing programs broadly address patient assessment. Subsequent work by Giddens and Eddy (2009) similarly concluded that nurses used a limited set of assessment skills. These findings were confirmed by the research of Anderson, Nix, Norman and McPike (2014) and Birks, James, Chung, Cant and Davis (2013) also found that nurses self- reported the regular application of only 30 percent of taught patient assessment techniques in their clinical practice. Research in non-western countries such as Iran have similarly concluded that nurses perform a lower than desired level of patient assessment skills (Adib-Hajbaghery & Safa, 2013). In response to the above, a body of evidence has appeared around factors that might explain why nurses are constrained in the conduct of patient assessment. The evidence suggests that a diverse range of barriers impact patient assessment from the more abstract such as professional boundaries (Birks et al., 2013; Douglas et al., 2014; Edmunds, Ward & Barnes, 2010; Osborne et al., 2015), interprofessional relationships (Geogiou, Papathanassoglou & Pavlakis, 2017; Gotlib- Conn, Kenaszchuk, Dainty, Zwarenstein & Reeves, 2014; Schadewaldt, McInnes, Hiller & Gardner, 2013) and nurse autonomy (McGibbon, Peter & Gallop, 2010; Papathanassoglou et al., 2012), to the concrete factors of lack of time, frequent interruptions to practice and over reliance on technology (Birks et al., 2013; Douglas et al., 2014). The evidence reviewed was developed to address decision-making processes around patient assessment and made clear that the issue was complex because the influencing factors were interactive and interrelated (Birks et al., 2013; Douglas et al., 2014; Gidden & Eddy, 2009; McElhinney, 2010; Osborne et al., 2015). There were, moreover, structural factors that shaped nursing practice and not least the influence of the contexts within which nursing practice occurs (Johansen & O’Brien, 2016). Yet, there is limited evidence on the significance of context in relation to nursing activities around patient assessment (Johansen & O’Brien, 2016). Further to the above and for the purpose of improving early detection of deteriorating patients a variety of solutions have been instituted internationally including the Rapid Response System (RRS), the Early Warning Scores (EWS), and the Interactive Tailored Patient Assessment (ITPA) tool. Nonetheless, research findings on the effectiveness of these interventions is equivocal (Dawson, King & Grantham, 2013; Ludikhuize, Smorenburg, Rooij & Jonge, 2012; McDonnell et al., 2012; Odell, 2015; Pimentel, Clifton, Clifton, Watkinson & Tarassenko, 2013).
CHAPTER 1 2 There has been no published research, in the Vietnamese context, on patient assessment by nurses. The lack of research evidence, specific to patient assessment in nursing practice in Vietnam, posed numerous questions early on in this research journey. Ultimately, however, the concept of patient assessment and perceptions of this practice, as articulated by registered nurses in Vietnam, became a lens through which the broader contextual processes that informed and shaped nursing work in this setting were explored. In other words, the research moved beyond why and how registered nurses in Vietnam undertake patient assessment to examine, from intersubjective and structural perspectives, the construction of nursing work and the positioning of nurses within the health care system in Vietnam. There is no published research that addresses nursing work in Vietnam from both interpretive and critical perspectives. Any consideration of contextual factors related to the work and practice of nurses in Vietnam has been largely confined to government policies. Most significantly, the Vietnamese Ministry of Health (MOH) sought to identify barriers that affect the quality of healthcare services and particularly medical and nursing practice. A prevailing issue has been the perceived burden on hospital healthcare outcomes, both financial and in terms of quality outcomes, as a result of high levels of unmet demand for health services and healthcare workforce shortages (Decision No 92/QD-TTg, 09 January, 2013). As a result, a series of national action plans for the period 2013-2020 were designed to ensure quality improvement of health care services (Decision No774/QD-BYT, 11 March, 2013). Yet, while the broader economic and political Vietnamese context is considered important in the national action plans the process of translation of these issues into policies around nursing care is absent.
1.1. The Vietnamese context Vietnam is well-known as having a rich history of political economic development and one that is generally divided into two periods: 1) pre 1975 the fight for independence; and 2) post 1975 the development of a capitalist economic system (Steinfeld, & Thai, 2013, p.1). The struggle for independence covered the eras of the 1000-years under Chinese colonial rule, 100- years under French colonial rule and the 20-years of civil war with the intervention of the United States (US). The legacies of these periods included the strong influence of the Confucius social system from China, the entrenched divisions between the North and the South and over 30 years of poverty in Vietnam (Steinfeld, & Thai, 2013).
CHAPTER 1 3 In 1976, Vietnam attained complete independence with the unification of the Republic of South Vietnam and the Northern Democratic Republic of Vietnam to form the Socialist Republic of Vietnam. From 1976 to the mid 1980s, Vietnam had a closed economy heavily dependent on agriculture. In the early 1980s, the economy was seriously undermined by recession and in 1986, the Vietnamese Communist Party officially endorsed the Doi Moi (Renovation) which marked an era of development of free-market economic policies or indeed a shift from centrally planned socialism to the development of a market based socialist economy (Vuong, 2018). The shift in policy orientation reflected a more global trend regardless of the system of government. Thus, the period of Doi Moi economic reform was the antecedent for socioeconomic change in Vietnam which saw calls for reforms in all areas including higher education and healthcare services. A series of reforms in the health and education sectors were introduced from 1986 onwards. The second period is recognised as a time of reformation where Vietnam opened itself to the world.
1.2.1 The reform in the Vietnamese Higher Education and Healthcare System Decentralisation and socialisation have been the interrelated key strategic objectives of reform in both the Vietnamese Higher Education (VHE) and Healthcare System (VHS) (London, 2011; Nguyen, 2018; Rahmes, 2013; Tran & Marginson, 2018). The definition of the concept of decentralisation is generally shared worldwide and refers to the transfer of governance authority to lower organisational levels to enhance sub-national government autonomy in fiscal, administrative and political matters (Nguyen, 2017; Tran, 2014).
The latter concept of “socialisation” is commonly used by the Communist Party of Vietnam in public government statements and through both formal and informal media channels in discussing strategic reforms in education and health care (Nguyen, 2018). The use of the term “socialisation” has given rise to debates on what this term means. Some argue that socialisation is the equivalent of privatisation within the socialist system (Le, 2014). The rather nuanced Vietnamese government view is that socialisation is not privatisation but simply enhances the involvement of the private sector (Nguyen, 2018). Regardless of definition, socialisation in Vietnam took the form of an open-door policy whereby the private sector, or non-government bodies in the Vietnamese context, could contribute to higher education and health care. The
CHAPTER 1 4 concept of socialisation rather than privatisation is used in the discussion below to be consistent with the language of Vietnamese government policies.
From the mid 1980s, reform of higher education in Vietnam has been a priority viewed as integral to national economic reform and the integration of Vietnam into the international economy (London, 2011; Tran & Marginson, 2018). A strategic objective within the reform plan was a shift from administrative centralisation to decentralisation. From 1996, the administration of Vietnamese education, that previously reflected centralised governance in the form of historical French colonisation and subsequent socialist management, shifted towards decentralisation alongside changes in government structures (London, 2011; Tran, 2014). In 2005, higher education reform was repeatedly targeted in strategic policies starting with a policy framework to guide the comprehensive implementation of higher education reform (The Resolution 14/2005/NQ-CP, 2 November, 2005). The decentralisation policies of the Vietnamese government sought to increase the autonomy of education institutions, particularly universities, in relation to all aspects of education. As the Resolution 14/2005/NQ-CP statement of the Vietnamese Higher Education Reform Agenda (HERA, 2005, p.7), translated into English by Tran (2014, p.75), reads;
“…switch public tertiary education institutions to operate under an autonomous mechanism whereby they shall have the full legal person status and the right to decide on, and bear responsibility for training, research, organisation, personnel and finance”…
“…concentrate the state management on the formulation and direction of implementation of the development strategy; direction of operation of the tertiary education quality control and inspection systems;…”
In 2012, the government approved the Law on Higher Education (No 08/2012/QH13, 18 June, 2012) followed by strategies for socio-economic and education development wherein decentralisation of governance and management was reaffirmed. This decree contributed to the expansion of the education system as seen through the number of new universities, colleges, and schools and lecturers, teachers and students (Tran, 2014). National Education Strategic Plan, 2009 – 2020, was then developed based on the Resolution numbered 06/NQ-CP, 07 March, 2012 and the Decision numbered 1666/QD-BGDDT, 04 May, 2012 to proceed;
CHAPTER 1 5 “… a comprehensive innovation of the Vietnamese Education which focused on modernisation, socialisation, democratisation and internationalisation….”
Yet, the Law on Higher Education (No 08/2012/QH13, 18 June, 2012) and the National Education Strategic Plan continued to support the central role of the Ministry of Education and Training (MOET) in controlling the education system (London, 2011; Tran, 2014). Thus, the management of universities in Vietnam remained the responsibility of the ministry and the MOET continued to control important educational activities within universities and particularly public universities (Dao, 2015; Tran, 2014). In addition to line-ministry management, the education system was controlled by each university’s Party Committee which divides Vietnamese higher education into two authority systems: 1) the academic administrative system and 2) the Party system. The Party system is obviously the leading force to ensure educational institutions adhere to socialist principles (The Law on Higher Education No 08/2012/QH13). This meant that higher education existed under multiple layers of management rather than being decentralised. The HERA (2005), however, provided unclear guidance that subsequently caused difficulties for universities in implementing change. In 2018, the revised Law of Higher Education (No 34/2018/QH18, 19 November, 2018) was declared which affirmed and provided clear guidance for the process of implementation of decentralisation. Universities were empowered to made decisions on: 1) Academic training; 2) Organisation and human management; and 3) Management of finance and property. Hence, the Law officially affirmed the comprehensive decentralisation of Vietnamese higher education.
Decentralisation was also undertaken in the Vietnamese health care system with a focus on financial autonomy in public hospitals. The decentralisation process in health care commenced in 1993 after the institution of Resolution No 04-NQ/HNTW, 14 January, 1993. The Resolution stated that both the government and society had responsibility for the development of and quality improvement in the Vietnamese healthcare services and thus, every person and institution was encouraged to engage. The Resolution, in particular, targeted the attraction of financial investment from private health sectors. The Resolution also emphasised the importance of increasing the financial autonomy of Vietnamese public hospitals through a combination of investment from the government, private health sectors and health insurance. Yet, the government retained authority in decision making overall activities including finances.
CHAPTER 1 6 Similarly to the education sector, the process of decentralisation in healthcare created uncertainty because of a lack of clarity from the government and the MOH. In 2017, the Vietnamese government underscored the importance of decentralisation in health care within Resolution No 20-NQ/TW, 25 October, 2017 which posed this as a strategic national objective. The national action plan also recognised the significance of human resources and the competence of the health workforce. The Administration of Science Technology and Training (ASTT) collaboration with the Department of Personnel and Organisation were required to develop and provide new standards for the health care workforce to meet the demands of the labour market.
Socialisation encouraged the involvement of the private sector in the reforms of VHE and VHS (Nguyen, 2018). As such, private hospitals and universities were now to share responsibility with the public sector (Hoang, 2018; Le, 2014). The private sector could also extend its involvement in public institutions such as in partial privatisation of public universities (Hoang, 2018) or the role of private companies in providing supportive services including medical equipment and materials (Nguyen, 2018). The combination of decentralisation and socialisation encouraged the increasing fiscal autonomy of public institutions of both the VHE and VHS.
1.2.2 The Vietnamese healthcare context after reform There is limited information on pre 1945 health care services in Vietnam. What is recorded is the influence of Chinese medicine on Vietnamese traditional medicine (Government Portal, 2019). The domination of China over thousands of years has continued to influence the health care model in modern Vietnam whereby family members have assumed an important role in health care delivery. After 1945, the government attempted to develop and enhance a health care structure that could be accessed by all Vietnamese with a focus on primary health care and the provision of free medications and services. This meant that healthcare was community-based which helped to reduce the burden of a shortage of healthcare workers. Thus, health care evolved as a combination of modern medicine and traditional practices. The development of a unified healthcare system in Vietnam was interrupted by the 1954 Geneva Accord partitioning of the country in two, supposedly temporarily, with a promise of democratic elections in 1956 to
CHAPTER 1 7 reunite the country. However, the country remained divided until 1976 and the end of the Vietnam War. From 1975 to 1986, the healthcare system faced serious problems related to funding for salaries, poor maintenance of medical equipment and facilities, and unequal distribution of medical services (Witter, 1996). The poor were more likely to access community health care centers in rural areas while those with more economic resources used hospitals in urban areas. The majority of highly qualified medical staff worked in hospitals, classified at the tertiary level, and so there existed a quality-related gap between primary care and hospitals. As a result, there were increasing questions raised around the effectiveness of national primary care programs and the different levels of qualifications across the healthcare workforce (Witter, 1996). These issues contributed to a relatively weak primary healthcare system compared to the tertiary hospitals of the modern-day health-care system in Vietnam.
Following the economic reforms commenced in 1986, three phases of healthcare reform in Vietnam were introduced: 1) reduction of subsidies in public healthcare institutions; 2) expansion of health insurance to increase health service accessibility; and as noted above, 3) decentralisation of the healthcare system (Ramesh, 2013). For example, the infant mortality rate decreased from 45 per 1,000 live births in 1989 to 24 per 1,000 in 2007 (Ramesh, 2013). The effects of the reform to reduce government subsidies for the healthcare system were, however, considered disappointing. Between 1998 and 2008 a higher proportion of GDP was spent on healthcare (Ramesh, 2013). A number of issues, moreover, manifested in relation to changes in the healthcare system through the period of the institution of reform (Witter, 1996). First, accessibility to healthcare services was dependent on income which reinforced inequalities between the rich and the poor. Second, the public health sector had a weakened leading role in the healthcare system. These two were the outstanding issues identified in the Vietnamese health context.
1.2.3 The current Vietnamese healthcare context Over 30 years following major economic reform, Vietnam is currently considered a middle-income country (Worldometers, 2015). In 2015, the Vietnamese population was approximately 94 million people and ranked the 14th nation by population worldwide. The high population density, 279 people per square kilometer, has caused and will continue to cause, CHAPTER 1 8 challenges for the Vietnamese health care system in addressing health problems related to the environment, food safety and communicable and non-communicable diseases (NCDs) (Worldometers, 2015). Vietnamese health care also continues to carry the legacy of a low quality community health service and poor accessibility while emergent issues such as population aging, climate change, urbanisation, industrialisation and globalisation pose new challenges (JAHR, 2015). In an attempt to strengthen the health care system to address contemporary issues, the MOH, in 2011, instituted the first five-year health sector plan (JAHR, 2011) focused on the ‘protection, care and promotion of the people’s health’.
In terms of structure, Vietnamese healthcare is hierarchically organised at three levels: 1) the tertiary level which is the responsibility of the MOH; 2) the provincial level which consists of 63 Provincial Health Bureaus (PHB); and 3) the primary level (basic health network) which covers district health centers (DHC), commune health stations and village health workers (Figure 1.1 & 1.2). The MOH is the overarching authority that formulates and executes health policies and also consults with the Ministry of Education (MOE) to formulate education programs in the field of medicine (Tien, Phuong, Mathauer & Phuong, 2011). Also organised hierarchically are Vietnamese general hospitals which are categorised at five levels (from highest to lowest) based on the National Standards for Hospital Classification (Appendix A). These levels are Special- Grade; Grade-1; Grade-2; Grade-3, and Grade-4. Special-Grade hospitals care for the most complex of patients. Grade-1 through Grade-4 hospitals care for patients on a diminishing trajectory of complexity, with the Grade-4 hospitals providing only the most basic of care. The Special-Grade hospitals are managed by the MOH while other hospitals graded 1-3 are overseen by the PHB. Grade-4 hospitals come under the management of DHC (Circular numbered 23/2005/TT-BYT, 23 August, 2005). The following figures depict the structure of healthcare in Vietnam.
CHAPTER 1 9
Figure 1-1 The structure of health care system in Vietnam. Adapted from “A Health Financing Review of Vietnam with a Focus on Social Health Insurance”, by Tien et al., (2011, p.4)
CHAPTER 1 10
Central Hospitals
Ministry of Health Research Institutes
Medical Colleges & Universities
Provincial Hospitals
Provincial Health Centres of Preventive Medicine Bureaus Medical Secondary Schools
District Health Centres District Hospitals District Health Administrations
Commune Health Village Health Stations Workers
Figure 1-2 The administrative structure of health care in Vietnam. Adapted from “A Health Financing Review of Vietnam with a Focus on Social Health Insurance”, by Tien et al., (2011, p.5).
1.3 Nursing in Vietnam As is the case elsewhere, nurses and midwives combined constitute the largest proportion of the Vietnamese healthcare workforce. According to the General Statistics Office of Vietnam (GSOV, 2019), in 2011 there were approximately 141,494 registered nurses (RNs), across all educational qualifications, and 44,104 doctors working in the health care system. The MOH planned to increase the number of healthcare staff, particularly nurses and doctors, based on
CHAPTER 1 11 labour market needs. There was an expectation that, by 2020, the number of registered nurses would have increased by almost 50 per cent and the number of doctors would double in Vietnam (Table 1.1).
Table 1.1 Healthcare professionals in Vietnam (MOH, 2015)
Professionals Number Expected Expected Number of (2011) Number (2020) RNs and Doctors per 10,000 inhabitants (2020) Registered Nurses 141,494 225,345 20
Doctors 44,104 99,351 8
Others 36,114 134,006 12 Medical technicians 24,076 89,337 8 Pharmacists 16,875 27,762 2
Vietnamese nursing is shaped by the legacy of the complex historical development of the country. Prior to 1985, nurses were largely expected to “follow orders without question” in Vietnam (Jones, O’Toole, Hoa, Chau & Muc, 2000, p.317). Nursing practice was not recognised as a profession, nor an autonomous area of practice, until officially acknowledged in 1990 through the establishment of the Vietnamese Nursing Association (VNA). Nursing was subsequently legally endorsed by the Vietnamese government in 1992 through the institution of the nursing office in the department overviewing national treatment and caring. Nursing roles, however, remained poorly defined until 1997 prior to which nursing titles differed between the North and the South as a result of the war between the two regions. Nursing education curricula also varied throughout Vietnam.
In 2012, the Education Law (numbered 08/2012/QH13), referred to above, determined the levels and programs of the national higher education, including the nursing profession. There were four levels of nursing education which included: 1) 2-year training (vocational); 2) 3-year
CHAPTER 1 12 training (college); 3) 4-year training (bachelor) and 4) Master level education. The MOET was also responsible for producing a national curricula for nursing higher education at all levels (Circular numbered 01/2012/ TT-BGDDT, 13 January, 2012). In 2015, the MOH approved a national action plan of healthcare workforce development to cover the years 2015-2020 (Decision numbered 2992/QD-BYT, 17 July, 2015) which moved to delete 2-year training qualifications in health education.
There was no legal system, however, to underpin the development of nursing as a profession with a lack of working policies, nursing regulation and competency standards. In seeking to redress the absence of any regulatory framework, Jones et al. (2000, p.318) translated the definition of nursing by VNA as;
“… a profession which is a science and art and humanistic giving of holistic care to people to prevent illness, maintain and promote health, and provide rehabilitation for individuals, families, and communities”
The VNA (1997) defined three nursing role functions: the nurse as health caregiver, health cooperator and health counsellor. Following an evaluation of nursing work, however, the VNA reported that 70% of nurses employed in hospitals performed the caregiver role only (Jones et al., 2000). In response, the organisation determined ‘empowerment’ as a key strategy to enhance and strengthen the nursing profession in Vietnam.
The empowerment of nursing appeared idealistic. Nursing in Vietnam had been undermined by: 1) a prolonged focus on first aid care due to the long history of war; 2) the overlap of physicians, assistant physicians and multiple-level nurses in nursing roles; 3) the low social status of health workers, and particularly women, who provided care; 4) the lack of nursing education; and 5) the lack of contextual understanding associated with international support (Jones et al., 2000). Nurse training traditionally focused on tasks and medical doctors and medical assistants played a significant role in overseeing all nursing activities. It is unsurprising, therefore, that an enduring view in Vietnamese society was that nurses were assistants to doctors rather than practitioners with some autonomy (Jones et al., 2000). Despite the efforts of the VNA, government policy documents from 1993 to 2007 continued to make reference to the nursing role as “medical assistant”. These documents explicitly stated that nurses were to follow the orders of doctors (MOH, 2011, 2015).
CHAPTER 1 13 Thus, the subordination of the nursing profession in Vietnam was reflected through policy where, for example, the government determined low remuneration for nurses which further undermined the development of the profession. As pointed out by the Ministry of Home Affairs (MHA), from the period 2005 to 2015, there was a lack of definition of nursing roles, their functions and education levels (MHA, 2005). As Table 1.2 below suggests, regardless of qualification, there was little difference in the wages of RNs according to qualification.
Table 1.2 Simulated payment for employees in government institutions in Vietnam pre October 2015 (2004)
Catergorisation Educationl Starting Procedure for rise of salary Minimum Minimum of Employees Level in Pay rate wage Basic pay Nursing A1 Bachelor 2.34 2.34 2.67 3.00 3.33 3.66 3.99 4.32 4.65 678,600 1,587,924 (Increase 678,600 774,300 870,000 965,700 1,061,400 1,157,100 1,252,800 1,438,500 every 3 years) B 2-year 1.86 1.86 2.06 2.26 2.46 2.66 2.86 3.06 3.26 539,400 1,003,284 training (Increase 539,400 597,400 655,400 713,400 771,400 829,400 887,400 945,400 every 2 years)
From 2007 on, greater emphasis was placed on the independence of the nursing role in health care services in Vietnam (MOH, 2011). The issue of health human resources has been a priority in the development and renovation of the Vietnamese health system. The objective of the health human resource development plan (2011 to 2020) was to improve professional quality, ethics and responsibility (JAHR, 2011). The nursing profession was directed, in the plan, to meet the standards of Asian nursing generally so that Vietnamese nurses would have the capacity to work in other Asian countries (MOH, 2012).
In 2012, the Vietnamese Nursing Competency Standards were proclaimed as the national professional framework by which graduate nurses and registered nurses employed in hospitals were to be evaluated (Decision 1352/QD-BYT, 24 April, 2012). The policy document on the nursing role in hospital care was considered significant in re-defining nursing as an independent profession that adhered to standardised criteria which reflected international nursing. Hence, nursing competency standards were recommended as the framework for nursing curriculum development. In the same year, the MOET also promulgated the circular No 57/2012/TT- BGDDT to change the national traditional education system. This change required all medical
CHAPTER 1 14 universities throughout Vietnam to reform medical training curricula (of which nursing was a part) and to change training and learning approaches (MOET, 2012; JAHR, 2016). The move motivated curriculum developers to apply the competency standards to the new national baccalaureate nursing curricula whereby nursing professional education was developed around competencies. The appearance of these two documents contributed to what was perceived as the revolution of nursing in Vietnam (MOH, 2012).
The application of competency standards in nursing curricula has been supported by various international projects around health care workforce development such as the Atlantic Philanthropy (AP) and the Health Professional Education and Training (HPET) for health system reform, a key area of the 2011-2015 five year plan (MOH, 2015). The involvement of international bodies reflected the strategic direction of VHE which recognised internationalisation as the key to the future of education (London, 2011; Nguyen & Tran, 2017; Tran & Marginson, 2014). The policy of internationalisation encouraged greater involvement of international organisations which, in turn, had a significant influence on the policy making of the VHE (Tran et al., 2014; Nguyen & Tran, 2017; Tran & Marginson, 2018). Nursing education followed the direction of the Vietnamese higher education reform and was also influenced by the underlying ideologies of foreign institutions that became embedded in education policies. Notably, there was inconsistency between developments in nursing education and nursing clinical practice. The competency standards were confined to education and were absent in policies that defined nursing roles and functions in clinical work.
In the second five year health sector plan, published in 2016, the MOH stated that medical education in Vietnam, which as noted, was inclusive of nursing, would consist of two training systems: 1) a research-based system managed by the MOE; and 2) a medical practice-based system managed by the MOH (JAHR, 2016). The existence of two training systems, under the governance of two separate ministries, was likely to cause conflict that could constrain the development of the nursing role. Competencies, as noted above, while underpinning nursing education had no role in clinical practice. Furthermore, in 2015, the MOH and the MOHA produced a Joint Circular (26/2015/TTLT-BYT-BNV, 07 October, 2015) on a code of conduct for Vietnamese RNs which marginalised the competency standards in defining nursing practice. Indeed the Joint Circular outlined a list of tasks that supposedly defined the work of nurses.
CHAPTER 1 15 Vietnam uses the Minimum Wage System for as a measure of wages and particularly for people who work in government organisations. The concept of “Minimum Wage” first appeared in March 1947 where it was defined as “the amount determined by the government for the non- professional worker who lives alone to cover their daily cost of living in a given area”. This amount has risen from 220 VND/month in 1947 to 1.300.000 VND/month in 2017 (Decree numbered 27/2016/QH14 dated 11 November 2016) based on consideration of economic and social change in Vietnam. Another important concept in determing wages in the salary coefficient which indicates the differences in salary levels across positions and job levels based on worker qualifications. As such, in nursing t there were different salary levels based on educational qualifications.
The revised definitions of nursing work in the above document provided the basis by which payments for nurses were now determined (Table 1.3). Nursing here was portrayed as a profession and one that worked in collaboration with medicine. Nonetheless, nursing wages have remained relatively low
Table 1.3 Simulated pay for employees in government institutions in Vietnam post October 2015 (2018)
Level Educational Starting Procedure for rise of salary Minimum Minimum of RN Level in Pay rate wage Basic pay Nursing Level Master 4.40 4.40 4.74 5.08 5.42 5.76 6.10 6.44 6.78 6,116,000 26,910,400 II (Increase 6,116,000 6,588,600 7,061,200 7,533,800 8,006,400 8,479,000 8,951,600 9,424,200 every 3 years) Level Bachelor 2.34 2.34 2.67 3.00 3.33 3.66 3.99 4.32 4.65 3,252,600 7,611,084 III (Increase 3,252,600 3,711,300 4,170,000 4,628,700 5,087,40 5,546,100 6,004,800 6,463,500 every 3 0 years) Level 2-year 1.86 1.86 2.06 2.26 2.46 2.66 2.86 3.06 3.26 2,585,400 4,808,844 III training (Increase 2,585,400 2,863,400 3,141,400 3,419,400 3,697,40 3,975,400 4,253,400 4,809,400 every 2 0 years)
More broadly, Vietnamese society was significantly influenced by the patriarchal culture of the period of Confucianism, which positioned women as subservient to men in all aspects of life (Lam & Laura, 2017) and has continued to shape the lives of women 2,000 years later and across South East Asia. Subordination of women contributed to the consolidation of the low status of nursing which was predominantly female. Indeed, nursing work was popularly defined as female work which meant, in Vietnam, nurses held positions of little influence in the
CHAPTER 1 16 healthcare context (Hagell, 1989; McDowell, 2015). As such, nursing practice was ruled by medicine and nurses were seen as “medical assistants” rather than collaborative professionals.
1.4 The research problem: A systematic process of reflexivity As argued earlier, patient assessment is a pivotal nursing role in clinical practice and is integral to nursing education curricula worldwide (Birks et al., 2013; Douglas et al., 2014; Giddens & Eddy, 2009; McElhinney, 2010; Osborne et al., 2015). In following the global trend, patient assessment was now also considered critical to Vietnamese nursing education. In Vietnam, the knowledge and skill acquisition in relation to patient assessment was covered in Fundamentals of Nursing subjects in undergraduate nursing programs across Vietnam. This area of nursing practice was allocated approximately 20 hours in curricula. A holistic patient assessment, including history taking and physical assessment (examination) (head-to-toe), was covered in the subject content. Students were required to pass the subject as a mandatory pre- requisite to clinical placement. Moreover, providing accurate patient assessment information appeared as the 9th standard in nursing competencies of the VNA (Appendix B).
Given the strong evidence that suggests a disconnect between teaching and clinical practice, where nurses perform approximately one third of taught patient assessment skills in their clinical settings (Adib-Hajbaghery & Safa, 2013; Giddens, 2007; Giddens & Eddy, 2009), it was thought that similar issues would exist in Vietnamese nursing practice. As such, the initial focus of this research was decision-making processes around patient assessment. What became apparent early on in the research, however, was the assumption that key nursing concepts and research undertaken in Western countries were unequivocally applicable to a country such as Vietnam was misguided. As has been argued, organisational factors were and are contextual and significantly influence nursing performance (Estabrook et al., 2015; Kringos et al., 2015; Lau et al., 2016; May, Johnson & Finch, 2016). These arguments gave force to the view that nurses in this research were social actors within a complex Vietnamese healthcare context.
Thus, the research manifested as an evolving and systematic process of reflection whereby research evidence and the ideological views of the researcher combined to identify issues related to nursing in the Vietnamese healthcare context. The views of the researcher were the product of work experiences in the two quite different contexts of hospital and university. The context of nursing practice made obvious the differences between what nurses learn and what nurses do.
CHAPTER 1 17 This related to a wide range of nursing skills which gave focus to the problem of the translation of nursing education into clinical practice.
An assumption that RNs passively respond to external factors, such as workload management, the stand out issue of the Vietnamese healthcare system (Decision 92/QD-TTg, 09 January, 2013), gives support to a focus on professional competence and education as an explanation for the limited skills that nurses apply in patient care. As such, it was initially presumed that factors at this level were key to the construction of nursing performance. Yet, in taking the Alvesson and Kärreman (2011) conceptualisation of research as mystery, the imperative was to move beyond “a narrow way of seeing that determines the results a priori” (p.67). Clinical nursing practice could not be simply interpreted as the passive construction of RN work in response to immediate factors such as workloads. Rather, what was required were some preliminary interpretations that did not embrace the obvious but allowed for the unexpected or largely invisible to be explored and theorised. This process required additional theoretical resources.
The perception of how nurses made decisions in relation to patient assessment also progressively changed through the process of reviewing literature which shifted the research lens from a focus on nursing practice to incorporate a much broader realm of influences that shaped practice. It appeared that the Vietnamese government was concerned about the healthcare workforce workloads, healthcare quality assurance, improvement of primary healthcare, financial independence of public health sectors and healthcare resource development (the Resolution numbered 20-NQ/TW, 25 October, 2017). There was, however, no focus in policies on Vietnamese nursing practice and within the broader political, economic and social context of Vietnam. What emerged from a review of policies was a contradiction between the statements of the MOH and MOET on what was actually happening in nursing. The absence of research to explain the contradiction and other issues then became the starting point of this research. This shift in focus manifested as a realisation that the research was not about identification of discrete factors that impact upon nursing work but rather about generating broader sociological insight into the micro and macro issues that underpinned nursing practice. As such, the research shifted quite rapidly to an exploration of the positioning of nursing at the micro and macro levels of the Vietnamese health care system. Importantly, the practice of patient assessment was not put aside but became the lens through which clinical nursing in Vietnam was broadly explored. The initial
CHAPTER 1 18 observation of the disjuncture between university nursing education and clinical nursing also remained a critical factor. But this disconnect was not to be explained as an issue of professional boundaries or interprofessional communication. The distinctive historical, political and economic context of Vietnam and its positioning internationally pointed to complexities that could not be researched drawing purely on Western assumptions.
1.5 Research purpose and aims The purpose of this research was to explore the decision making of clinical registered nurses as the lens through which to interpret the construction of nursing practice. The research aims were to:
• elicit and analyse the perceptions of RNs in Vietnam on the clinical practice of assessment of patients;
• explore the ways in which RNs in clinical practice in Vietnam negotiated and therefore constructed nursing practice;
• gain insight into the positioning of nursing practice within the micro and macro contexts of Vietnam;
• develop a contextual understanding of relationship between nursing education and nursing practice in Vietnam;
• draw some analytical conclusions about the implications of the above for the future of nursing in Vietnam
1.6 Roles of the researcher I assumed two different but related roles, as nursing lecturer and registered nurse (RN), throughout the conduct of this research. In reflecting Breen (2007), the choice of research topic was influenced by my experiences of working in both nursing education and clinical practice. As a nursing lecturer, I had long considered what presented as a gap between the education and practice of implementing patient assessment in nursing in Vietnam. Teaching experience helped me to confirm the content of patient assessment that nursing students were supposedly required
CHAPTER 1 19 to perform in clinical practice to achieve the competencies to qualify them to work following graduation. The differing requirements expected of nursing students in the university and what RNs would routinely practice in the clinical setting raised questions about how and why nurses make their decisions in clinical practices. Yet and as asserted earlier, it soon became obvious that inquiry at the level of nurse decision-making was far too limited to produce insight into the complexities of nursing work in Vietnam.
As an RN I approached the research with some pre-existing assumptions. Working as a RN in the Vietnamese context meant that I was aware of some views and practices that may significantly impact practice such as interactions between nurses and other healthcare professionals and the effect of the structural context. In light of the above, an area of symbolic interactionism, was applied as a theoretical lens that allowed for a focus on human action as a social performance within the context of clinical nursing. The researcher also, drew on the constructivist methods of Charmaz for data generation (2014) which acknowledges the co- construction of research data by both researcher and participants. This meant that the researcher brought her knowledge and perspectives to the co-construction of data.
One advantage of my position in the research context was that the content of interviews and observations was informed by insider knowledge. Being an insider also helped minimise differences between me and participants because I had an understanding of the context and was able to interact with participants in such contexts (Bonner & Tolhurst, 2002). From here, it was inevitable that I would bring my social and professional knowledge to the interpretation of data. An obvious and potential disadvantage was that analytical conclusions would be drawn too soon. To minimise this risk, I continuously reviewed interview and observation processes and data content during data generation to ensure that analysis was not limited to manifest issues and concepts.
As a lecturer, I recognised that knowledge produced from nursing education was not readily transferrable to nursing practice. The question was raised about the extent to which curricula content and design contributed to a gap between education and practice. This suspicion was strengthened by comments from RNs with whom I had contact during the data generation process. Other participant comments referred to policies that defined the nursing role and function. Such comments prompted an analytical review of documents related to Vietnamese nursing. CHAPTER 1 20 Thus, I drew on my knowledge as both RN and lecturer to explain the processes by which nurses came to practice in particular ways. In assuming a reflexive stance there was a constant move back and forth between the two lenses as essential to an exploration of contradictions or differences. For example, in taking a lecturer position, I focused on the lack of application of assessment skills and thus competencies in nursing practice. As a RN, I was very aware of the constraints on nurses which limited their role to perform effective patient assessment. As a researcher, I had to adopt a reflexive stance and interrogate research processes and data from different positions by asking different questions and considering different answers. As Laine (2000, p.212) argues, it is important to grasp the stories behind stories and thus to generate enriched data for more comprehensive insights.
In enagaging the above process, I moved back and forth between insider and outsider roles throughout the research process which was essential to reduce self-imposed distortions. In the words of Rose (1985, p.77); “There is no neutrality. There is only greater or less awareness of one’s bias”. The change in lens reminded me to be aware of the knowledge, background and perspectives brought to the research which could be easily ignored when engagement in the research setting was long lasting. Maintaining a balance between insider and outsider roles was difficult and required a discipline on my part.
1.7 Definition of terms Social performance: The term social performance is used as a theoretical concept to reflect the processes by which nurses undertake nursing work. In the thesis, this concept is theorised from a pragmatist and symbolic interactionist stance to explore and position the nurse participants as active players in the research situation. Thus, nursing work is understood as a social process by which nurses interpret the meaning of care in relation to patients, physicians, other nurses, family members and even themselves. Nurses take into account surrounding social interactions in forming their social actions.
Registered nurse: In Vietnam, a prolonged period of war contributed to a unique nursing structure which consisted of multiple levels of nursing education. Pre 2012, graduate nurses at all levels were defined as Registered Nurses which meant that nurses with 2, 3, and 4 years of training and postgraduate education were referred to as RNs following graduation. There were
CHAPTER 1 21 insignificant differences between 2-year trained nurses and 4-year trained nurses since all were titled RNs. The MOH then distributed a Circular (14/2011/TT-BYT) which required graduate nurses to have a license to work in clinical healthcare settings. In order to qualify for a license, graduate nurses needed to have provided direct care for patients under the supervision of a RN for at least 9 months. The definition of the Vietnamese RN was, therefore, re-defined as licensed nurses. The 2-year trained nurses were also removed from the definition of an RN.
1.8 Overview of the thesis The thesis is structured around eight chapters and various appendices. The first chapter provided background information on the Vietnamese political, education and health contexts and described a hierarchical health care system and a relatively new nursing profession. Some initial information was provided regarding patient assessment in nursing practice and how this practice came to be the lens through which the research explored the construction of nursing in Vietnam. As such, patient assessment by nurses was the starting point rather than the end point of the research.
In light of the above, the review of literature is organised around two chapters: 1) Chapter Two addresses issues around patient assessment as one manifestation of nursing practice; and 2) Chapter Eight provides broader insight into nursing practice in the Vietnamese health care context. As such Chapter Two reflects the early development of the research with a focus on issues addressed in the body of published evidence such as professional boundaries, the hierarchical nurse-physician relationship and nursing autonomy.
The origins of symbolic interactionism (SI) is the initial focus of Chapter Three which argues and justifies the theoretical framework of the research. The chapter moves on to address further theoretical concepts applied in the analysis including Goffman’s work on presentation of self and performance, Strauss’s negotiated order and Harvey’s theoretical consideration of the concept of space.
Chapter Four presents and justifies the methods applied in the research. The chapter firstly argues how the theoretical perspective and the methods of Charmaz (2014) were integrated and incorporated in data generation and analysis. The chapter moves on to the research sampling strategies and participant recruitment. The generation of data from interviews, observations and CHAPTER 1 22 documents is comprehensively explained as is the process of data analysis. The chapter then explores strategies used to ensure the quality of the research and finally, consideration is given to ethical issues as relevant to the research.
The conceptualisation of internalising is explored in Chapter Five. The chapter focuses on the process of internalisation whereby nurses absorbed social norms and transferred such norms into a taken for granted nursing practice.
Chapter Six turns to the processes of negotiation by which the social norms of nursing practice were given standing as the accepted daily routine of nursing practice. Negotiations related to the construction of institutions such as clinical units and the hospitals and hence the salient structural attributes of these institutions were significant in shaping nursing practice.
Chapter Seven explores the concept of space and argues the significance of spatial dimensions in the social process of constructing nursing practice. The chapter recognises the contribution of space whereby the ways in which nurses negotiated nursing practice was dependent on the material and symbolic location of nurses in the research context. The construction of nursing practice formed and was formed by a process of creating new spatial forms.
The final chapter situates the research findings in terms of a number of paradoxes which characterised the research context. These paradoxes appeared at all levels of the organisation including policy making, the historically constructed norms of nursing practice and around gender constructs. There were the conflicting interests of the MOH and the MOE in instituting the reform processes of the Vietnamese health care and higher education sectors. The disparate interests were reflected in policy making that resulted in a disjuncture between nursing education and nursing clinical practice. The chapter also recognises the significant influence of diverse ideologies in defining the norms of nursing practice. Finally, the construct of gender is considered as symbolic of the devaluation of nursing in Vietnam.
CHAPTER 1 23 Chapter 2 Literature review
2.1 Introduction
This chapter provides a critical appraisal of literature related to patient assessment in nursing practice. The chapter content reflects the starting point of an exploration of published literature that informed this research. At the outset the chapter discusses a range of definitions of patient assessment which are used interchangeably throughout previous research. A brief description of patient assessment in the Vietnamese nursing bachelor program is also provided. The chapter then identifies current research worldwide around the importance of patient assessment and the role of nurses in making decisions around this practice. In so doing, a synthesis of published evidence presents prevailing views on how the decision making of nurses is shaped. Finally, some limitations of nursing patient assessment research are addressed.
2.2 Nursing decision making around patient assessment
2.2.1 Patient assessment
A review of literature concluded that patient assessment is considered a fundamental nursing competency which enables the generation of timely and accurate background information to support the provision of care for a patient (Fennessey & Wittmann-Price, 2011). Various terms have been used to refer to patient assessment in this area of research such as health assessment, nursing assessment, focused assessment, physical examination and head-to- toe assessment. While a lack of agreement on a definitive term suggests some confusion there is a shared view on the two attributes of patient assessment; competency and decision making.
Nursing competency around patient assessment has historically been referred to in relation to sets of skills. For example, Reese, Swanson and Cunning (1979) reported on the patient assessment skills of psychomotor, perceptual and cognitive function. Psychomotor skills were inspection, palpation, percussion and auscultation. In terms of cognitive skills, the authors argued that nurses are required to analyse results from psychomotor and perceptual assessment to reveal any abnormal symptoms. These three domains of skills were to be performed simultaneously and continuously until no more abnormal signs or symptoms are identified. CHAPTER 3 24
The second attribute of patient assessment, decision making, was argued to be the result of the integration of knowledge and skills (Fennessey & Wittmann-Price, 2011). It has been proposed that patient assessment decision making consists of seven stages including identification of a problem, planning, considering multiple perspectives, information gathering, judgment, action and reaction. Patient assessment decision making was also described as uncertain due to the complexity and changeability in health care area (Hunink & Weinstein, 2014). Thus, the patient assessment decision making process is perceived as a changeable and continuous process during which multiple actions occur. It is hard to negate that physical assessment is significant in nursing practice. The following section provides support to this argument.
2.2.2 Patient assessment in nursing practice It has been argued that patient safety depends on patient assessment by nurses (Kyriacos et al., 2011; Liaw, Scherpbier, Klainin‐Yobas & Rethans, 2011). Fero et al. (2010) also highlighted the need for adequate and effective patient assessment by nurses to accurately respond to patient deterioration because nurses have the most direct contact with patients. Additionally, Liaw et al. (2011) confirmed the significance of the role of nurses in preventing patient adverse events through effective patient assessment. Zambas (2010) similarly argued that a key role of patient assessment is to detect and respond to changes in patient health status so that deterioration of a person is identified and appropriate interventions actioned.
Evidence has demonstrated an association between preventable deaths and delay in detecting patient deterioration (Hogan et al., 2012). Hogan et al. (2012) conducted a retrospective case record review to identify problems in care which contributed to preventable deaths. The research reviewed approximately 1000 medical documents on the death of patients that occurred in 2009, in 10 hospitals across England. The authors concluded that of preventable deaths, 29.7% were related to a diagnosis process including patient assessment. Delay in diagnosis or failure to detect abnormal changes in patients’ conditions thus contributed to patient deaths. In addition, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD, 2005, 2012) found that patients’ physiological abnormalities can remain undetected for up to 24 hours and hence there is delayed intervention. NCEPOD (2005, 2012) found an
CHAPTER 3 25 association between the delay in detection of the deteriorating patient and the number of patients experiencing adverse events. This evidence raises questions about the patient assessment capability of health care professionals including Registered Nurses (RNs).
In Australia, the Australian Commission on Safety and Quality in Healthcare (ACSQH, 2010) has identified the importance of recognising and responding to patient deterioration through patient assessment. From 2007 to 2011, the ACSQH made various attempts to improve the quality of assessment. The National Safety and Quality Health Service (NSQHS) Standards, which were developed by the ACSQH, pose the standard of patient assessment as a prerequisite of clinical deterioration detection in acute health care (NSHQS, 2012). In a similar vein, the MOH in Vietnam promulgated the Vietnamese Nurse Competency Standards developed by the Vietnam Nurses Association in which the 9th standard also focuses on the nursing competency of assessment of patients (MOH, 2012). These reports highlight the value attributed internationally to patient assessment. The issue of ensuring quality and improving healthcare professionals’ capacity to assess patients is also emphasised. Despite the importance of patient assessment in nursing practice, the existing body of research in this area points to a number of limitations in practice as discussed below.
2.2.3 Limitations
It is generally acknowledged that patient assessment is more commonly conceived of as a process of assessing and recording vital signs and other parameters rather than one that involves decision-making and action (Fennessey & Wittmann-Price, 2011). Osborne et al. (2015) conducted a cross-sectional survey at a tertiary referral teaching hospital in Queensland, Australia, to determine which core skills of patient assessment nurses used to assess hospitalised patients. Findings from a survey of 434 RNs and midwives concluded that nurses used a small set of assessment skills in clinical settings focused on vital signs. The most often used patient assessment skills were temperature, blood pressure, respirations and oxygen saturation. Edmunds, Ward and Barnes (2010) had earlier conducted longitudinal qualitative descriptive research to explore advanced patient assessment skills used by cardiac nurses. Of 14 cardiac nurses approached, seven were interviewed and their practices observed. The nurses were also asked to self-report their activities over 10 working days. It was found that the use of patient
CHAPTER 3 26 assessment skills by the nurses was limited to some physiological systems, namely cardiology and respiratory systems. Nurses were, therefore, more likely to follow a pre-determined list of tasks in undertaking patient assessment while an active role in decision making appears to have been ignored.
Existing research does not address the ways in which nurses come to make decisions on patient assessment in particular contexts. A review of 16 articles by Massey, Aitken and Chaboyer (2010) supports this argument in finding a lack of evidence to explain nurses’ reluctance and delay in assessing a patient. The current review suggests a need to explore reasons why RNs, in particular, delay patient assessment. In addition, the question around the role of patient assessment in activating nurses’ responses to patient deterioration is raised by Mackintosh, Rainey and Sandall (2012, p.269). A comparative case study of the use of rapid response systems in two UK hospitals revealed a lack of data to explain nurses’ decision-making process in responding to deteriorating patients. Similarly, Osborne et al. (2015) reported a lack of nursing action or intervention when patients were trending to deterioration.
There is limited qualitative research that seeks to explain the process of nurse decision making around patient assessment. Chua, Mackey, Ng and Liaw (2013) applied a critical incident technique to explore the experience of enrolled nurses (ENs) in recognising and responding to deteriorating patients in general wards. The research context was Singapore where, the authors argued, ENs were participating in less bedside nursing care. The ENs appeared to engage in pattern recognition or, in other words, recognition of salient features of deterioration based on what had been observed previously. This meant that patient assessment was invariably incomplete. The authors concluded that to assess patients, nurses needed to report their observations such as changes in a patient’s condition and vital signs. As such the research focused on what RNs did, and should do, in practice and not on the why and how of their practice. These findings are consistent with a further qualitative research study that focuses on nurses’ perceptions of accessing a Medical Emergency Team (MET) (Massey, Chaboyer & Aitken, 2014). Nurses in this research indicated that changes to vital signs prompted extended patient assessment and activation of a MET. The review suggests that there is still a lack of attention on how nurses formulate decisions around patient assessment.
CHAPTER 3 27
2.2.4 Issues around nursing patient assessment
2.2.4.1 Professional boundaries Evidence indicates that occupational, professional and hierarchical boundaries, in both nursing and medicine, partly shape decision-making around interventions including nursing care and medical treatment (Mackintosh, Rainey & Sandall, 2012). Findings of an instrument development study by Douglas et al. (2014, p.691) confirm this statement and suggest that professional boundaries “largely shape” nurses’ perceptions of their patient assessment role. Patient assessment, particularly physical examination, may not be seen as part of the nursing role or nurses may perceive that they are not required to conduct a comprehensive assessment. Osborne et al. (2015) found similarly, through a survey of 434 RNs and midwives, that nurses may be seen to overstep professional boundaries in undertaking physical examination. Yet, it is also argued that the responsibility for patient assessment should be shared among medical doctors, nurses and other healthcare professionals (Fennessey & Wittmann-Price, 2011). Nonetheless, there is a perceived need to justify each professional role in patient assessment (Birks et al., 2013; Edmunds et al., 2010). Birks et al. (2013) surveyed 1220 RNs to examine the relevance of physical skills used by RNs in patient assessment. From there, the blurring of roles between RNs and doctors was suggested as a barrier to the conduct by nurses of patient assessment. Edmunds et al. (2010) reported diverse views regarding role boundaries among professionals. Some participants asserted the existence of a clear boundary around the nurse’s role in patient assessment while others noted that role boundaries were blurred. Douglas et al., (2014) argued that the lack of clarity for nurses around patient assessment means that nurses have to negotiate with doctors and this may give rise to tensions around professional boundaries. For example, patient assessment may depend upon how and to what extent a nurse is able to negotiate decision-making with doctors.
It is argued that the hierarchical nurse-doctor relationship contributes to tension around professional boundaries. The electronic Delphi research of McElhinney (2010), conducted in Scotland with 21 nurse practitioners, indicated that medical doctors were not accepting of a nursing role in patient assessment. In this research, 81% of participants reported that doctors hindered the capacity of nurse practitioners to undertake physical examinations. It was concluded that the dominance and power of doctors impacted on the nursing scope of practice. Edmunds et al. (2010) confirmed this finding in their longitudinal qualitative descriptive CHAPTER 3 28 research, noted above, which also explored factors associated with the use of patient assessment skills in cardiac nursing practice. The research involved 11 cardiac nurse practitioners in South Wales and found that “permission from medical colleagues” was needed before nurses could perform patient assessment (Edmunds et al., 2010). This finding reflects a hierarchical interprofessional relationship, and particularly the nurse-doctor relationship, which may impact patient assessment of nurses. Given the evidence above, hierarchical nurse-doctor relationships could be considered as a significant factor in explaining nurses’ decision making around patient assessment.
2.2.4.2 Nurse-doctor collaboration Following on from the above, issues related to nurse-doctor relationships have been researched over a long period of time and within varying contexts. The existence of a body of contemporary research in this area suggests that the interrelationships, or collaboration, between nurses and doctors continues to be a significant factor in shaping professional roles. An integrative review of 27 studies, both quantitative and qualitative, regarding views and experiences of nurse practitioners and medical doctors reported collegial collaboration (Schadewaldt et al., 2013). However, this review argued that there were various differences between nurse practitioners and doctors in perceptions of collaboration. Nurse practitioners defined collaboration as having discussions with doctors about caring for patients and frequently perceived that hierarchy was a factor in collaborating with physicians. By contrast, doctors viewed collegial collaboration with NPs as constituting seeking advice. These differing perceptions pointed to an ongoing unequal power relationship between the two key healthcare professional groups in patient care (Schadewaldt et al., 2013). A cross-sectional survey from Japan which investigated 248 physicians also found compatible findings with participants agreeing that their relationships with nurses were hierarchical (Onishi, Komi & Kanda, 2013). In this research, the Jefferson Scale of Attitudes toward Physician-Nurse Collaboration (JSAPNC) was undertaken to examine physician attitudes toward their collaboration with nurses. Low scores of the JSAPNC were reported which suggested the existence of a clear understanding of hierarchy rather than collaboration between nurses and doctors. The research also found an association between the attitudes of doctors and practice. Doctors were less likely to use information provided by nurses and nurses more likely to use information from doctors. CHAPTER 3 29
The existence of hierarchies in healthcare environments is a shared phenomenon across nations. The hierarachical structure of health care systems has also been a focus in the eclectic literature on nursing autonomy and professionalisation. A descriptive correlational study was conducted to survey 163 RNs in five Intensive Care Unit (ICUs) of four public hospitals in Cyprus about their autonomy in collaborating with doctors (Geogiou et al., 2015). Nurses were found to have a moderate level of autonomy when working with doctors and the level of autonomy of nurses was associated with acuity of patients. Nurses reported less autonomy when caring for patients with more acute conditions. The complexity of decision-making in high acuity situations was used to explain this association (Geogiou et al., 2015). In addition, the doctor’s role was also found to dominate the nursing role (Gotlib-Conn et al., 2014). Gotlib et al. (2014) undertook mixed method research using survey and ethnographic methods to examine how nurses and Medical Doctors (MDs) rated one another in their working collaboration. Findings from the study supported existing evidence that nurse-doctor collaboration is generally unequal. It was found that doctors perceived that they held greater authority than nurses in the clinical workplace. A descriptive survey by Johnson and Kring (2012), which recruited 170 nurses in Medical-Surgical Units (MSUs) and ICUs, also found that nurses continued to assume a handmaiden role in collaborating with doctors. In the similar vein, Churchman and Doherty (2010, p.46) used in-depth interviews with a purposive sample of 12 nurses who worked in an National Health Service (NHS) acute hospital in England to explore points of view in challenging doctors in clinical practice The findings concluded that the handmaiden role is still evident in nursing. Moreover, the hierarchical nurse-doctor relationship was described as teacher-pupil where doctors tended to issue orders, instruction and advice rather than engage in discussion with nurses (Churchman & Doherty, 2010). In the study noted above on nurse practitioners and doctors it was also determined that doctors were likely to view nurse practitioners as their assistants to be supervised in patient care (Schadewaldt et al., 2013).
2.2.4.3 Nurses’ autonomy in decision making The dominance of the medical profession in nurse-doctor relationships is assumed to detract from nurses making autonomous decisions. In a study employing qualitative methods, Robert, Tilley, & Petersen (2014) reported on the appearance of a hierarchical norm between nurses and doctors in preventing nurses from seeking assistance to assess patients. A sample of 27 nurses and 30 physicians at the Children’s Hospital of Philadelphia were involved into open-
CHAPTER 3 30 ended semi-structured interviews. The authors pointed to nurses’ perceptions of a hierarchy as a key barrier in asking for help. Through a systematic review of 14 studies, Odell, Victor and Oliver (2009) added that tensions existed in professional hierarchies which caused difficulties for nurses when they require support. Traynor, Boland and Buus (2010) conducted a focus group study of nurses in the United Kingdom (UK) to examine nursing professional through explaining how nurses account for their decision-making processes in clinical practice. The authors argued that teamwork and hierarchical issues undermined the autonomy of nurses in decision-making. As a result, nurses were unlikely to independently make decisions when they perceived dominance from other professionals. Thus, nurses’ autonomy in formulating decisions is assumed to be limited within the context of hierarchical interprofessional relationships
As noted above, the nurse-doctor relationship is perceived a key contributer to the lack of autonomy of nurses in decision-making. Karanikola et al. (2011) conducted a cross-sectional survey to investigate the association between moral distress and nurse autonomy and MacGibbon et al. (2010) explored the factors that influenced nurses’ moral distress. Both articles argued that the issue of power inequality must be considered in explaining nurse-doctor collaboration. Where a hierarchy exists around nursing work, it is suggested that the level of nurse autonomy reduces as decisions fall under the control of other professionals with greater power (Traynor et al., 2010).
The above is confirmed by the work of Papathanassoglou et al. (2012) who surveyed 255 intensive care nurse delegates at a European critical care conference on levels of autonomy and perceived nurse-doctor collaboration. The survey found moderate practice autonomy scores and also an association between lower levels of autonomy and lower perceived nurse-doctor collaboration. Bertolini et al. (2010) also noted, in a study of 3,793 ICU patients for whom a decision of treatment limitation had been made, that nurses participated with doctors in 25 percent of decision making on limiting treatment. This result suggests some collaboration in complex cases but given the intensive care of patients by ICU nurses this level of participation by nurses in decision-making is surprising. What is not known, and could not be known from a survey, is what nurse decision-making looks like in different contexts. This is confirmed by Vaismoradi, Salsali, Esmaeilpour and Cheraghi (2011), who explored independence in decision making in medical and surgical wards. The nurse-doctor hierarchical relationship raises the issue of dependence where MDs give permission for nurses to undertake activities such as patient
CHAPTER 3 31 assessment. From these findings, nurses are predicted to have limited freedom and participation in undertaking patient assessment, especially given the hierarchical healthcare context in which they work. Further exploration of nurse autonomy in decision-making may more comprehensively explain the process of nurse decision-making around patient assessment.
2.3 Summary The above literature review provides a general overview of research around patient assessment in nursing practice. Various studies have been undertaken that examine aspects of patient assessment, from describing nursing procedures to implementing new systems to enhance nursing practice. The body of work provides evidence that patient assessment in nursing practice appears as largely a process of taking and monitoring vital signs. Thus in considering possible constraints to decision-making around patient assessment the review turned to a number of identified barriers including professional boundaries, hierarchical interprofessional relationships, and the existence of communication problems between health care professionals.
As noted in the previous chapter, this research, while maintaining a focus on patient assessment during data generation evolved to incorporate contextual complexities. Rather than focus on a range of factors that constrained nursing practice in Vietnam, early analysis brought attention to the ways in which nurses actively negotiated practice and later on, how this manifested differently within different spatial contexts. Those nurses were social actors whose interactions with other health professionals, with patients and their families and within socially constructed spaces highlighted the ways in practices and actions were both reproduced and disrupted. The nurse participants were also the product of historical, social and political trajectories. The concepts of negotiation and space required a much broader review of literature and theory in order to test out emergent analytical ideas and thus inform the analytical chapters. The following chapter engages with and justifies the theoretical frame as the proposed lens for this research.
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Chapter 3 Theoretical Tools
3.1 Introduction Human actions and surrounding processes raise questions which can be explained from disparate fields of knowledge. From the standpoint of the psychological and sociological sciences, human action is described as the product of various factors and their interactions (Meltzer et al., 1975; Reynolds & Herman-Kinney, 2003). Psychologists consider stimuli, attitudes, conscious or unconscious motives, psychological inputs, perception, cognition and personal characteristics as factors that form human action. For sociologists, other factors, including social position, status demands, social roles, culture, norms, values, social pressure and group affiliation, are given prominence (Blumer, 1969). Thus, a range of theories have evolved that depict associations among identified factors as impacting or creating human action.
It has also been argued, however, that in seeking to explain human action, individuals are likely to be ignored as active objects in creating actions through interactions in their social worlds (Blumer, 1969; Reynolds & Herman-Kinney, 2003). Symbolic interactionism (SI) evolved as a very broadly conceived theoretical approach interested in the role of interactive social processes in the formation of people’s actions. The purpose of this chapter is to explore key concepts drawn from the pragmatist and symbolic interactionist traditions that underpin the current research. In so doing, it is noted that the contributions to these traditions varied, and have continued to vary, to the extent that any attempt to define pragmatism or symbolic interactionism is an uncertain undertaking. Nonetheless, the chapter firstly engages with the genesis, antecedents and formulations of SI to provide a general background for the subsequent exploration of key concepts. The chapter then moves on to discuss two core concepts related to this research; social performance and society. The chapter also explores the influence of complex social relationships on the human action forming process. Justification for the application of key concepts in this research is integrated throughout this chapter.
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3.2 The genesis of symbolic interactionism It is generally acknowledged that SI is a product of 20th century democratic American society (Meltzer et al., 1975; Reynolds , 2003). Indeed, the works of a number of sociologists in the US significantly influenced the evolution of the principle premises of SI. Charles Horton Cooley, William Isaac Thomas and George Herbert Mead are confirmed as the most prominent contributors to this area (Reynolds & Herman-Kinney, 2003). Of these three early representatives of SI, Mead is renowned as the founder because of the l influence his work has had on other interactionists and sociologists (Plummer, 1996, 225). Mead’s work on mind, self and society was largely communicated through lectures which formed the basis of subsequent publications. The conceptualisation of these concepts provided the foundation for SI as articulated by Blumer. Blumer (1969) then set down three premises which became the essence of SI (Meltzer et al., 1975; Reynolds, 2003).
Mead’s work on SI was influenced by four precursors that included evolutionism, Scottish moralism, German idealism and pragmatism (Reynolds, 2003). From evolutionism, Mead adapted Darwin’s interpretation of social life as the process of interaction between social and natural environments. From there, action was considered a product of the interaction between an organism and surrounding environment. In terms of Scottish moralism, the economist Adam Smith’s concept of sympathy indirectly impacted Mead’s work through Cooley’s concept of “sympathetic imagination”. Based on this concept, it was argued that humans take the roles of others to explain people’s actions.
Mead also argued that the conversation of “gesture” and “the use of significant symbols” were central to social interaction (Blumer, 1969, p.8). The concept of “gesture” was originally described by Wilhelm Wundt who identified with the German idealists. The greatest influences on the work of Mead, however, came from the pragmatists Charles S. Peirce, William James and John Dewey (Reynolds, 2003). The formation of actions based on the given meaning reflects Peirce’s criterion of truth which was not an individual matter but an agreed upon position by the collective (Reynolds, 2003). In other words, an object’s meaning lies only in the behaviour directed towards that object. Where Pierce was interested in the practical consequences of an object or activity for a collective for James the truth was whatever met the needs of the individual. People make sense of and construct meaning in their social worlds by which they
CHAPTER 3 34 develop “plans of action”. Indeed, a key tenet of SI is that human beings actively construct plans of actions based on their sense of their social environments (James, 1890). Hence, James’ concept of “plans of action” and Dewey’s extension of this concept in the context of human association, further shaped the image of the human as an active actor in Mead’s analysis of the human action process. From here it was understood that humans have the ability to note and to interpret the meanings of things and then act towards such identified meanings to form human actions.
Blumer subsequently theorised and modified Mead’s work on mind, self and society to form a “cohesive theory” (Carter & Fuller, 2015). SI evolved into a theoretical approach that enabled researchers to address the ways in which actors see and interpret surrounding objects and people (Blumer, 1969). The other purpose of SI was to explore the process of translating interpretations into actions (Blumer, 1969). Blumer adapted the two concepts which originated in Mead’s work on the theorisation of self and of lines of actions, ‘I” and ‘Me’, to explain an actor’s self- indication (Blumer, 1986, p.70-77). In Mead’s conceptualisation, the ‘I’ is addressed as the way one sees oneself while the ‘Me’ is the way one thinks others see one. Blumer further described the concept of self-indication as a process of approaching, analysing and giving meaning to an object and then forming particular actions based on the object’s meaning (Blumer, 1969). The three premises articulated by Blumer (1969) are as follows:
First, human beings act toward things on the basis of the meanings that the things have for them. Secondly, these meanings are the product of social interaction in human society. Thirdly, these meanings are modified and handled through an interpretive process that is used by each individual in dealing with the things he encounters (p.2).
Blumer’s work thus assumes interdependent relationships between individuals and society as society is built up by individuals while individuals are members of society (Blumer, 1969). This assumption defines human beings as active organisms with selves that direct their actions in an interactive way with others.
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3.3 Pragmatism and the early symbolic interactionism
Pragmatism is far from a coherent or unified body of knowledge as evident in the varying ideas of James, Pierce and Dewey. It is not surprising, therefore, that the work of Mead and Blumer also diverged on key ideas even though Blumer’s self-elected task was to record the key tenets of Mead’s work.
Pierce’s focus on the collective deemed him a realist and James was considered a nominalist because truth for him was that which was true for the individual. Blumer followed the Dewey- James tradition in constructing the sociology of SI as both theory and method (Lewis, 1976). The function of SI in exploring interactions between individuals and society is derived from the work of James who had earlier addressed the interactive nature of individual and group relationships. Dewey also sought to explain human action through the interpretation by individuals of the social and physical environment (Lewis, 1976). The SI assumption that human beings self- indicate their actions based on interpretations of the meanings of objects is clearly derived from James’ work (Lewis, 1976). James provided an analysis of perception to demonstrate the productive process of human thought based on the three concepts of “habit”, “instinct” and “social-self” which subsequently became most relevant to the interactionist explanation of human social actions (Meltzer et al., 1975). Thus, James’s conceptualisation of the social self and human beings as active and creative “provided the basis for an image of humans that was congruent with the developing interactionist perspective” (Meltzer et al., 1975, p.8). James (1890, p.190) defined the social self as follows:
Properly speaking, a man (sic) has as many social selves as there are individuals who recognize him and carry an image of him in their mind. To wound any one of these images of his is to wound him. But as the individuals who carry the images fall naturally into classes, we may practically say that he has as many different social selves as there are distinct groups of persons about whose opinion he cares. He generally shows a different side of himself to each of these different groups.
People are assumed to have different selves as the result of different interactions with others where the subjective assessment of those others differs between individuals. Each person has
CHAPTER 3 36 various selves which are then selected to be expressed appropriately in reality. This argument reflects SI’s definition of an individual’s interpretation of the meanings of objects to themselves which is expressed through Blumer’s statement that; “One has to get inside of the defining process of the actor in order to understand his (sic) action” (Blumer, 1969, p.19).
The pragmatism of John Dewey, in posing the concepts of thought, mind and society, reflected James’s works. Dewey, however, moved on from James to demonstrate the relationship between thought, mind and society (Reynolds, 2003). Dewey used the concept of habit to describe the relationship between individuals and social groups (Dewey, 1922, p.42). Habit was not repetitive but, rather, people’s habits were shaped by interactions with others (Dewey, 1922). This view challenged James’ use of habit to define a reflex path of concatenated discharges in nervous system of human being (James, 1890).
In terms of the concept of “mind”, Dewey referred to the interaction between human mind and the environment to explain the relationship between individuals and their social environment. For Dewey, the human mind is developed through a communication process within which language is the key element (Dewey, 1922). Dewey’s work on the human mind and social environment was proposed as an attempt to combine the individual and social elements in explaining human actions (Meltzer et al., 1975). There is a reflexive image of this combination in the SI three premises outlined above. Dewey’s work, therefore, set down the philosophical basis for SI.
SI is more of “an extension of the James-Dewey pragmatism” than the Peirce-Mead social realism where the former perceives individuals as autonomous social actors (Lewis, 1976, p.348). Indeed, it is not surprising that SI was influenced by ethos of individualism which was and is dominant in American society. While Blumer (1969, p.61) addressed Mead’s focus on the role of social organisations in the formation of self to explain the nature of human society (Lewis, 1976), his work is criticised because it poses (but does not explain) the dual existence of individualism and social realism in SI (Azarian, 2016; Lewis, 1976; McPhail & Rexroat, 1979). Based on the work of Joas (1997) and Stryker (1980), Powell (2013, p.21) pointed out that Blumer’s subjectivist emphasis reinforced “the dichotomy between subject and object in social thought”. Yet as Powell (2013) argues, Irving Goffman’s work modified Blumer’s stance in focusing on the connections between everyday interaction and society. The implications of the
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“social-self” of Mead, the “everyday self of life” and the nature of SI, as discussed below, brings some clarification to this criticism.
3.4 Core concepts Two concepts relevant to this research and drawn from SI are social performance and society. These two concepts represent different integrative levels of action forming mechanisms. The concepts provide the basis for explaining the complex social processes that constitute nursing actions around clinical decision making and practice. Thus, nurse clinical decision making is reviewed and analysed in terms of the individual perspective of the nurse and social interactive influences. The relevance and contribution of these extracted concepts to the present research are explored in the following discussion.
3.4.1 Human actions as social performances SI describes human beings as acting organisms which differs from previous dominant schools of thought in the social and psychological sciences that situated humans as responsive organisms. Human action had been explained as the response of one person or human reaction to factors at a non-symbolic level (Mead, 1934). The three premises of SI, however, provide a theoretical explanation of the nature of society, social interaction, acting organism, object meaning and human action. SI sees human action from a distinctive perspective as a product of social processes where social interaction is taken into account in the form of action. In SI, social interaction assumes two forms: 1) interaction between people which is normally seen in other theories, and 2) self-interaction which focuses on the interaction between people and themselves.
3.4.1.1 Social interactions In SI, human beings indicate and interpret the meaning of objects in order to determine responses. This understanding is derived from Mead’s work on the “social-self” concept which addresses people’s ability to indicate the meaning of objects through self-interacting with themselves (Blumer, 1969). Mead’s work on a “social-self” drew directly on the ‘the looking- glass self’ concept of Cooley (Reynolds & Herman-Kinney, 2003).
Cooley is known for the concepts of ‘the looking-glass self’ and ‘primary group’. Along with the concept of ‘human nature’, these ideas set in place the background of Cooley’s work in
CHAPTER 3 38 conceptualising the relationship between individuals and society (Meltzer et al., 1975). Cooley argued that individuals begin their interactions with society through what he called the primary group. The interpretation of society by the group results from the interpretations of individual group members. Hence, the primary group fundamentally forms an individual’s social nature (Cooley, 1909). The link between the concepts of ‘human nature’ and ‘the primary group’ is evident in Cooley’s discussion of the third level of human nature as social rather than natural. Thus, human nature develops within the primary group.
Cooley’s third concept, the ‘looking-glass self’, links all three concepts to explain the influence of individuals and society on human actions. Based on this concept, people imagine their appearance to others. In contemporaneous time, people also imagine the judgements of others of their appearance. It is assumed that nurses produce various appearances regarding patient assessment which can be presented to other health professionals and patients before they form their actions. Nurses, at the same time, also consider the possible judgments of others including patients towards these available presented appearances. Perceived judgement will inform the choices of nurses on how to present the self.
According to Mead (1934, p.149), “the activities of play and the game”, besides the conversation of gesture, is one issue contributing to the genesis of the self in which people have to take another’s roles to form their actions. Mead, however, goes beyond Cooley by expanding the concept of “the looking-glass self” where Mead addressed the role of social interaction in which the “self” arises (Epstein, 1973). People generalise attitudes from all others who are involved in a social group through the process of taking others’ attitudes toward themselves and toward each other to fully develop a self (Mead, 1934). This process has two phases which in Mead’s (1934) words mean that;
At the first of these stages, the individual’s self is constituted simply by an organization of the particular attitudes of other individuals toward himself and toward one another in the specific social acts in which he participates with them. But at the second phase in the dull development of the individual’s self that self is constituted not only by an organization of these particular individual attitudes, but also by an organization of the social attitudes of the generalized other or the social group as a whole to which he (sic) belongs (p.158)
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The common attitudes of a group contribute to creating the “organized self” of all in that group (Mead, 1934, p.158). Mead, therefore, considers the self to arise and to be continuously developed in relation to others’ selves within a social group. The process of development of self, therefore, reflects social interactions within a group (Mead, 1934). In terms of full expression of the self, Mead (1934) referred to the “I” and the “Me” as the two essential aspects defined as follows;
The “I” is the response of the organism to the attitudes of the others, the “me” is the organized set of attitudes of others which one himself (sic) assumes. The attitudes of the others constitute the organized “me”, and then one reacts toward that as an “I” (p.175)
Mead explained that people respond to the attitudes of a community in reference to one’s own experiences through the “I”. The “Me” then helps people take the shared attitudes of the community from which people make responses which are considered as the “I”. When applied to this research, the decision making of nurses is considered a social action and the groups of patients for whom nurses care constitute the community. Thus the “I” of nurses refers to what nurses do in relation to patient care as shaped by both patient responses and the experiences of nurses. The interactions between patients and nurses then mean that nurses use the “Me” to access new shared understandings from patients. The cycle of “I” and the “Me” continues when nurses then respond to those newly identified understandings. As such, nurses’ decision making can be described as a circular process of taking the views of patients and responding to such views. This explanation can be applied in other contexts such as interactions between nurses and physicians.
Self-consciousness is then achieved based on the ability of people to take and organise others’ attitudes towards a community (1934). Mead (1934) used self-consciousness to describe a social process as 1) where people form social actions under other’s influences; 2) where people take others’ attitudes regarding social actions toward themselves; and 3) where people react towards such responses from others. From there, the existence of social interactions in the process of forming social actions is addressed.
Blumer also addressed social interaction in Mead’s definition of the “self” but refers to the use of the concept of “joint action”. According to Blumer, individuals who belong to a social
CHAPTER 3 40 group construct actions that align with other’s actions in that group. In other words, within the process of constructing actions, people have to interpret other’s actions and use such interpretation to guide their actions. Ultimately, the actions of individuals who are in the same group are aligned together (Blumer, 1969). This dynamic reflects the process of constructing actions which derives from Mead’s discussion of social interaction where people construct their actions under their consideration of other’s acts. Human actions are, therefore, seen as social actions (Blumer, 1969). It is here that SI differs from other social theories that explain human actions simply as products of various factors as appears in much of the research on nurse patient assessment and other nursing care. Thus, SI assumes interdependent relationships between individuals and society as society is built up by individuals while members of society (Blumer, 1969). This assumption defines human beings with selves who direct their actions in an interactive way with others.
The above principle points to the importance of explaining nurses’ actions in decision- making around patient care as they align with interactions with stakeholders such as physicians, nursing colleagues, other healthcare professionals, patients and relatives and the organisation. Decision-making may depend upon the expression of attitudes of others in response to nurses’ actions. It may be, for example, that if a doctor negatively responds to a decision made by a nurse this may covertly cause nurses to constrain their actions. From here, nurses may perform only those aspects of patient assessment that are approved of or may withdraw totally from undertaking this area of practice. A further example focuses on patient responses to care performed by nurses. Since patients are direct objects of nursing actions, their responses are assumed to significantly impact on nurses’ decision making. Nurses may avoid some aspects of patient care where patients respond with doubt or questions. The above examples support the importance of the alignment of actions in nurse decision making processes. Hence, an exploration of responsive actions from all stakeholders was an important component of this research.
3.4.1.2 The meanings of objects Self-interaction describes the process of indicating the meaning of objects for people. Meanings are produced through a series of activities, from noting an object, self-communicating, identifying meaning, selecting meaning and using indicated meaning to form actions. The concept of meaning is extracted from Mead’s work on the “mind”. Mind is considered a process CHAPTER 3 41 whereby a parallel exists between the neurological and psychological in the human central nervous system that helps individuals indicate meanings of objects to others and to themselves (Mead, 1934). In other words, individuals identify meanings of objects and select responses. Mead’s work on the mind originated from Wundt’s interpretation of “gesture” which was used to explain the process of forming a social act through the work of the central nervous system and individual’s own experiences. “Gesture” was originally identified as the stimulus for the response of other forms in the very early stage of social acts. “Gesture” then becomes a significant symbol for communication of certain meanings to other individuals. In this sense, gesture is used to elicit a response. The fundamentals of communication, gesture being one such fundamental, provide similar interpretations for both individuals who produce an understanding and for those who respond through adjustment to identified meaning. In the words of Mead (1934);
… every gesture comes within a given social group or community to stand for a particular act or response, namely, the act or response which it calls forth explicitly in the individual to whom it is addressed, and implicitly in the individual who makes it,; and this particular act or response for which it stands is its meaning as a significant symbol (p.47)… …if this gesture calls out a like gesture in the other individual and calls out a similar idea, then it becomes a significant gesture (p.48).
Thus, the basis of meaning came to reflect three issues: 1) gesture; 2) adjustive response; and 3) resultant social act. A gesture from an individual may initiate a resultant social act that shapes an adjustive response from another. Meaning indicates to both others and the individual at the same time. Furthermore, while individuals define meanings as they appear from the perspectives of others, they also interpret meanings themselves. In capturing the above points and again from Mead (1934);
Meaning is that which can be indicated to others while it is by the same process indicated to the indicating individual. In so far as the individual indicates it to himself (sic) in the role of the other, he (sic) is occupying his(sic) perspective, and as he (sic) is indicating it to the other from his (sic) perspective… (p.89)
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The above is a complex process of recognising and indicating meanings which is called “recognition” rather than a simple process of receiving images, analysing information and responding. There is, moreover, a selection of the most optimal response in each situation as the result of the reflective intelligence of human individuals. Humans have the capacity to analyse situations and to initiate beginning responses. The responding process continues with an adjustment phase to communicated meanings. This means that humans can re-organise a set of existing responses and then select another one which may be more appropriate to a new situation. This reflective intelligence and resultant selectivity of responses differentiates humans from other organisms. The argument as put by Mead (1934) is that;
Where we have to determine what will be the order of a set of responses, we are putting them together in a certain fashion, and we can do this because we can indicate the order of the stimuli which are going to act upon us. This is what is involved in the human intelligence as distinguished from the intelligence type of the lower forms (p.96).
The selection of a response by a nurse when assessing a patient is used as an example to explicate this argument. The meanings of patient assessment are projected to patients, physicians, other medical staff and nurses themselves. Nurses organise and adjust these received meanings to determine an appropriate response. The adjustment happens when nurses consider the adaptation of each response to the situation. Finally, the most appropriate response is decided upon. Where a nurse determines the need for a more comprehensive assessment the nurse also recognises that the patient will need to agree. A further necessary element is that doctors support the nurse to undertake this role. Given these conditions, all identified meanings of patient assessment are positive. On the contrary, if nurses realise the need for a full patient assessment but perceive a negative patient response the nurse will then have to decide how to act in response to the patient. The nurse-performed assessment may be further constrained in the absence of the support of the doctor. The point to be noted here is that a decision by a nurse in patient care is a process of selecting actions rather a single response to patient or physician reactions.
Based on Mead’s work, the second premise of SI (Blumer, 1969), focusing on the origin of the meaning of things, defines meaning as a social process and a social product. Based on this premise, SI helps to explain the formation of human action in a distinct and unique way whereby
CHAPTER 3 43 interaction between people towards things creates the meanings of such things. In other words, the activities which are produced through interaction between people toward a thing are expected to form meanings of that object. As Blumer (1969) argued;
The meaning of a thing for a person grows out of the ways in which other persons act toward the person with regard to the thing. Their actions operate to define the thing for the person. Thus, symbolic interactionism sees meanings as social products, as creations that are formed in and through the defining activities of people as they interact. This point of view gives symbolic interactionism a very distinctive position... (p.4)
This explanation differs from two dominant traditions which also focus on the source of meaning. One view is that meaning is considered a natural part of an object while the other suggests that human perceptions toward things are the origins of meanings (Blumer, 1969, p.4). From there, meaning may be identified merely through observation of the object or through the analysis of human sensations toward that object. The third premise of SI provides the tool with which to explain this process. This premise refers to the ways in which meanings are central to the process of interpretation where meanings are self-indicated and handled (Blumer, 1969). People firstly self-indicate the meanings of things followed by an interpretation of these meanings as perceived. These interpreted meanings are then selected and adjusted to fit the surrounding context. This means that people analyse situations whereby the meanings of things are identified and particular meanings are then selected to guide actions. This premise makes SI becomes more distinctive in explaining human action forming process.
3.4.1.3 Social performances We see from the above that while Blumer drew on the interactionist conceptualisation of self from Mead’s work, he is criticised for separating the subject and object in explaining the social action forming process (McPhail & Rexthroat, 1979; Powell, 2013). Blumer’s work focuses on individual experiences and interpretations which are situated in social contexts to explain human actions (McPhail & Rexthroat, 1979). In other words, Blumer argued that we can understand social organisations through the study of the interpretative processes of individuals
CHAPTER 3 44 who are members of those organisations (Lewis, 1976). To overcome this limitation, the current research drew on Goffman’s work (1959) on “the presentation of self in everyday life”.
The value of Goffman’s work is in providing a pathway to explain human action from both individual and social perspectives. While Goffman is not considered a symbolic interactionist, his work closely relates to SI as reflected in the shared concepts of symbol, meaning and identity (Carter &Fuller, 2016). Goffman (1959) points to the concept of “presentation” to account for the impact of a situation to explain human action. In other words, people define a situation and set up standards of judgement which are then used to evaluate their performances within that situation. Actions are thus purposefully selected to create one’s self- presentation and are adjusted in light of the surrounding social environment. The dramaturgical approach in Goffman’s representative work eas, therefore, adopted to explain the actions of actors in this research as social performances.
Goffman (1959) explains that individuals always express themselves in communication with others while the others, in turn, are assumed to be impressed in some way. Furthermore, in order to communicate, individuals perform a series of activities, both intentionally and unconsciously. Individuals seek to control their expressions to others in such a way that defines the situation in which performances are presented. Goffman (1959, p.26) defines “performance” as;
… all the activity of a given participant on a given occasion which serves to influence in any way any of the other participants.
Goffman (1959, p.26) argues that the major concern of his work is “the participant’s dramaturgical problems of presenting the activity before others” rather than the content or the role of this activity. An individual performs based on an identified benefit to the audience. A reality is produced which may differ from that which is real. For example, a nurse might undertake what she purports is a physical examination for an admitted patient and yet engages only in the taking of vital signs.
Throughout the performing process, individuals may either be “sincere”, where they are convinced by the reality of the performance, or “cynical” where they have no belief in the produced reality (Goffman, 1959, p.28). Individuals are likely to move back and forth between
CHAPTER 3 45 sincerity and cynicism during a performing process which contains phases of conduction and presentation until they reach the point of achieving self-belief.
This backward and forward movement between disbelief and belief may be seen in newly graduated nurses. The autonomy and cooperation of the nursing role is a reality produced during study at university, even though students engage in clinical practice in hospitals. That nursing students, as registered nurses, will have the skills and knowledge to perform autonomously is strongly communicated to students. Following graduation, nurses are confronted with a different and limited nursing role. The cycle moves then to a disbelief phase where nurses become cynical about what they are really able to perform in clinical patient care. The disbelief-to-belief phase commences when nurses adapt to the situation. Nurses come to accept a nursing role that may be narrowed. This new produced reality is sustained until something disrupts that reality and prompts nurses to re-assess. In relation to the research focus, nursing students are taught holistic assessment skills and how to use patient assessment appropriately and effectively through simulation in universities and clinical practice in hospitals. Nurse-led patient assessment, however, is limited by factors such as social prejudice, workplace policy, the domination of doctors and the attitudes of patients. The result is the appearance of another reality of patient assessment which differs from that taught.
The performance of an individual, whether sincere or cynical, has a number of dimensions which contribute to the “front”, defined as “the expressive equipment of a standard kind intentionally or unwittingly employed by the individual during his performance” (Goffman, 1959, p.32). The two important dimensions of the “front” are the setting and the personal front. The setting contains background items such as furniture, decoration or physical layout that provide the scenery and stage props for individuals to present their performances. The personal front, on the other hand, is what is constitutive of the individual such as gender or age. It may be assumed that a social front is established based on tasks which are taken on by individuals. Goffman (1959), however, rejects this assumption about the selective characteristic of social front. He suggests that there is likely to be an established front for individuals to choose rather than a new front. This means that individuals usually find that there are particular fronts for every task and they are required to select a front for their performance. A difficulty is in deciding an appropriate front particularly where the choice is limited. The decision-making is thus seen
CHAPTER 3 46 as a working frame where established options present for nurses to follow. For example, patient care may be defined simply as taking vital signs. Taking vital signs, therefore, becomes an established front that nurses present whenever patient assessment is required.
There is a further issue which may impact the performance of individuals that Goffman refers to as dramatic realisation. Here individuals dramatise their activities to convey the desired expression to others (Goffman, 1959). In the case of nursing care for a patient with pain, for example, nurses dramatise their practice in taking vital signs, collecting patient health-related information and undertaking pain assessment. Based on this dramatisation, patients understand that they are being closely monitored and that the nurses are competent and have the authority to make decisions on patient care. The status of the nursing role may be increased from the patient’s view. A difficulty, however, occurs when activities are invisible and require individuals to work much harder for the desired expression. Here individuals face “the dilemma of expression versus action” as they may produce effective activities to complete tasks but fail to enact well received performances (Goffman, 1959, p.43). This difficulty manifests in the Vietnamese nursing care context where nurses are considered socially inferior by patients and families. The domination of physicians also contributes to the invisibility of nursing activities since physicians indirectly or directly limit the nursing role. Nurses and physicians may invite different reactions from patients where similar assessments are undertaken. For example, patients expect and respect physicians’ questions about their pain while they may ignore the same questions from nurses. The imperative for nurses then is to employ strategies to transform activities, both visible and invisible, in their performance.
Goffman was interested in the notion that expression is idealised in multiple different ways rather than in a one-way process in which an individual’s performance is socialised to present the “common official values of the society in which it occurs” and therefore ensures that the performance fits that society (Goffman, 1959, p.45). There are ideal social standards whereby performances take place to convey an impression. This means that individuals need to conceal actions which are inconsistent with those standards. In terms of concealment, individuals tend to correct mistakes or errors before a performance (Goffman, 1959). This helps to explain the complexity of human performances in a real social context because of the requirement to adapt to social standards.
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Based on the above argument, social standards are assumed to play a very important role along with professional standards in influencing nurses’ making decision. In Vietnam, the professional standards for nursing are based on working policies from Ministry of Health (MOH), Ministry of Home Affairs (MOHA) and Vietnamese Nurse Association (VNA) which concretely define nursing tasks. Social standards, however, are rarely considered in either Vietnamese nursing education or clinical practice since limited evidence exists around this issue. These standards become more abstract and changeable in the Vietnamese context due to the nature of “common official values of the society”. The use of Goffman’s work on social standards suggests a new perspective to explain the performance of nurses in this research.
3.4.2 Human actions and structure
3.4.2.1 The concept of “Society” and Symbolic Interactionism Society is the third key concept of SI that Mead addresses to explain human actions. Individuals are expected to self-indicate others’ reactive actions and then process attitudes on the basis of identified indications. Human actions are formed and selected to performed based on such attitudes. Mead (1934, p.244) wrote that the human being has an intellgence that is;
…not based on physiological differentiation, nor based upon herd instinct, but upon the development through the social process which enables him to carry out his part in the social reaction by indicating to himself the different possible reactions, analyzing them, and recombining them. It is that sort of an individual which makes human society possible.
Mead (1934) also points to the concept of “cooperative activities” which differentiate the social organisation of humans from other species such as insects. “Taking the role of the other” enables humans to construct actions cooperatively with others within a social organisation. This is also the premise for humans to control social actions (Mead, 1934). Thus, role-taking and cooperative actions are constructed through a social process where the attitudes of all involved in the social group are adjusted. The resultant generalised social attitude helps individuals to engage in shared responses in situations. Mead’s explanation of a process that begins with self-indication of the attitudes of others and results in the appearance of social institutions leads to the assumption that the individual self is fully developed only when there are organised social
CHAPTER 3 48 attitudes and activities. Mead (1934) was concerned with how we make our world in arguing that human society;
… does not merely stamp the pattern of its organized social behavior upon any one of its individual members, so that this pattern becomes likewise the pattern of the individual self; it also, at the same time, gives him a mind, as the means or ability of consciously conversing with himself in terms of the social attitudes which constitute the structure of his self and which embody the pattern of human society’s organized behavior as reflected in that structure. And his mind enables him in turn to stamp the pattern of his further developing self (further developing through his mental activity) upon the structure or organization of human society, and thus in a degree to reconstruct and modify in terms of his self the general pattern of social or group behavior in terms of which his self was originally constituted (p.263).
Based on the above, Mead developed the term “organized social attitudes” to refer to shared attitudes of a social group which is the core principle of the “I”. Individual response, as the adjustment of the self, as previously noted, is related to the “Me” which addresses a fusion of the “I” and the “Me”, the two issues of the “Self”, in human social actions. The interrelationship of human society and actions then becomes one of the “root images” of SI (Blumer, 1969, p.6).
There has been further debate around Mead’s work on the “Self” and that SI was informed primarily by Mead’s pragmatism with a focus on self-consciousness in forming human actions. This focus ignores the fact that society is changeable and is likely to create a variety of situations which construct actions in different ways (Stryker, 2008). It appeared that both Mead and Blumer have less interest in the analysis of social change and social structure (Meltzer et al., 1975). Nonetheless, as a result of this debate, there emerged the view that SI should be conceptualised more broadly to engage with structural and constructionist dimensions rather than be confined to individual self-indication (Snow, 2001; Stryker, 2008). Mead (1934) argued that the “Self” is developed by society and contributes to the construction of social actions whereas Blumer situated the “Self” in individual interpretations. Indeed, Mead’s philosophical view of society was more than the conception of the autonomous individual reflected in Blumer’s work (Lewis, 1976). The adaptation of Mead’s work in the current research addresses the limitations
CHAPTER 3 49 of SI. The application of dramaturgical thinking reflects a modification whereby the concept of society in SI can be broadened and thus become more sociological (Kuhn, 1964). The use of Goffman’s work as it informs the theoretical framework of this research allowed for more focus on structure in explaining nursing actions around patient care.
3.4.2.2. Human actions and socio-spatial organisation Criticism around the capacity of traditional SI to deal with conflict (Fine & Fine, 1984; Huber, 1973) raised questions about how nurses managed conflict as part of daily nursing practice. The work of Goffman (1959) suggests that nurses perform in response to the expressions of others as a way to avoid or solve conflict. Yet, the nurses in this research appeared more actively engaged with others which, as Strauss (1963) pointed out, involved processes of negotiation rather than simply responses to others. Thus, the negotiation processes that underpinned the practices of nurses were further explored from the perspective of human action as negotiated order (Strauss, 1959). As Maines and Charleton (1985, p.272) wrote;
“… one of the principal ways that things get accomplished in organizations is through people negotiating with one another, and it takes the theoretical position that both individual action and organizational constraints can be comprehended by understanding the nature and contexts of those negotiations.”
Strauss and colleagues explained that the concept of “negotiated order” emerged from their research at two mental hospitals which depicted the flexibility of divisions of labour in those hospitals (Strauss, 1959). Participant observation revealed differences among staff regarding their self-interpretations of the workings of the hospitals. The result was conflict in terms of both professional and locational differences. Strauss, Schatzman, Bucher, Erlich & Sabshin (1964) recognised that rules of action were not set or stable but constantly renegotiated.
Negotiation is constructed rather than occurs by chance and thus involves active performances in the construction of negotiation (Strauss, 1978, pp.107-122). The products of negotiation, as human actions, also undergo ongoing revision and change. In other words, negotiation is a process of social interactions constructed and re-constructed continuously. Fine and Fine (1984) argued that the “negotiated order” metaphor sensitises researchers to look at
CHAPTER 3 50 human actions as social products which are inevitably and continuously changed based on social interactions embedded within a particular structural organisation. This means that actors communicate with others to determine how they will perform and then make adjustments to a situation which contribute rule changes within an organisation.
Both Goffman (1959) and Strauss (1959) acknowledged the contribution of social norms which, in this case, were shared between nurses within a context of legal standards such as laws, rules and policies that sought to define the nursing profession. As Strauss (1978, p.5-6) wrote;
The negotiated order of any given day could be conceived of as the sum total of the organization’s rules and policies, along with whatever agreements, understandings, pacts, contracts, and other working arrangements currently obtained.
Interprofessional interactions were also central to the work of Strauss and reflected SI and Goffman’s work on performance. Yet, the concept of a negotiated order gave more emphasis to the active engagement of nurses in their professional and social worlds.
Corbin and Strauss (1993), in focusing on the importance of negotiations in constructing social contexts, was subsequently criticised for ignoring the concept of power. Farberman (1975) and Denzin (1992) sought to address this issue in explicating the relationship between power and social organisation in the construction of human actions. Stryker (1987b, 2008) proposed a modified SI, termed Structural Symbolic Interactionism (SSI), which conceptualised social structure at two levels. The first was large-scale structures that included class, age, gender and ethnicity and the second was referred to as the intermediate structure of neighbourhoods, schools and associational memberships (Stryker, 1987b, 2008). In a similar vein to Stryker, Hall (2003) suggested a conceptualisation of inequality, institutional analysis, collective action across space and time, and the making of history and the importance of temporality. Inequality, from Hall’s view, comprises the three categories of race, gender and class which are interrelated in the social process of human actions. Institutional analysis looks at human actions within the broader social context. Space is the further concept associated with the structure of human collective actions where individuals form their actions and respond to others’ actions in differing ways within different special or temporal contexts (Hall, 2003). These concepts were considered as
CHAPTER 3 51 analytical tools through a forward-backward process between theoretical ideas and data generation in this research.
Among these concepts space, which is integral to hierarchy, division of labor and organisational power, assumed importance in the research due to the impact of these issues on the nature of social interactions whereby social actions were embedded and/or constrained (Sjoberg, Gill & Tan, 2003).These issues were comprehensively analysed both individually and as they interrelated to explain the processes underpinning social actions within the research organisation. This focus allowed for an exploration of the context wherein human actions in relation to nursing work both constructed and were constructed by hierarchy, division of labor and organisational power. Thus, the work of Henri Lefebvre (1991, [1947]) and David Harvey (1973) was brought to the analysis to explain how nursing practice was constructed within space and contributed to shape a particular spatial form.
Lefebvre’s early work, Critique of Everyday Life” (1991, [1947]), is an approach to action that focuses on how meanings attributed to, rather than knowledge of, everyday life transforms actions. The author then engaged in a long process of working on the concept of space as fundamental to understanding capitalism. Throughout this work, Lefebvre (1991, [1947]) dialectically depicts space as both a product of, and a determinant of social interactive actions. This means that everyday practices were examined within a space in relation to the spatial form in which the practices were performed. In other words, human action both shapes and is shaped by spatial forms within which the action is socially constructed. Where Lefebvre (1991, p. 101) depicts the construction of a city as the “production and reproduction of human beings by human beings rather than the production of objects” was applicable to approaching nursing as a social product which is produced and reproduced within the social context of interactions and relationships. Thus, this approach facilitated an examination of nursing practice within specific spatial forms of social interactions.
The dialectic approach applied to space examines what the world is as an ontology whereby, as epistemology, constitutes the methods or theory of knowledge that one uses to organise the world (Zieleniec, 2007). Lefebvre’s dialectics of space address the importance of social interactions embedded in space within which human actions are produced. Zieleniec (2007) argues that Lefebvre (1991) focuses on the interplay of social interactions, human actions
CHAPTER 3 52 and how movements of these mobile elements produce space. In the research, the concept of space allowed for an exploration of how social relationships both reflected and were constituative of the political organisation of nursing practice. Thus, the concept of socio-spatial form was used to dialectically explain the production and reproduction of nursing practice and space.
In addition to the dialetic approach to the production of space, Lefebvre (1991) raises the central role of space in social and historical processes where there are conflicts and tensions around the meanings and values of social actions. As Lefebvre states;
…What we are concerned with, then, is the long history of space, even though space is neither a ‘subject’ nor an ‘object’ but rather a social reality – that is to say a set of relations and forms. This history is to be distinguished from an inventory of things in space … as also from ideas and discourses about space (Lefebvre, 1991, p.116)
…In space, what came earlier continues to underpin what follows. The preconditions of social space have their own particular way of enduring and remaining actual within that space… (Lefebvre, 1991, p.228)
This raises an awareness of the meanings and values of routine nursing practice and the importance of exploring surrounding conflicts and tensions which were socially and historically constructed.
Harvey’s work on space (1973), like that of Lefebvre (1947, 1991), builds a theory of knowledge to depict the production of space and yet places greater emphasis on the political and economic interests of particular spatial forms. In other words and in addition to social interactions, there are political and economic issues which constitute the production of space and thus these three elements are considered as they interrelate in examining how nursing practice was formed and performed within space. In the words of Harvey;
… It took something more to consolidate space as universal, homogenous, objective and abstract in most social practices. That ‘something’ was the buying
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and selling of space as a commodity. The effect was then to bring all space under the single measuring rod of money value (Harvey, 1985, p.13)
Harvey (1991, 1996) was interested in the accumulation and circulation of surplus value where use value and exchange value became elements in the production of space. There is potential conflict between use value and exchange value where, for example, the use value of nursing knowledge and skills is in ensuring better outcomes for patients and the exchange value is the financial worth of such skills. That there is tension between these values points to the existence of powerful interests that are maintained and organised within a space to sustain the contradiction. In other words, conflict exists between the purpose of individuals or groups as members belonging to a space and the power interests within that space. Hence, Harvey’s conceptualisation of space was brought to the research to give focus to the implications of the use and exchange values of nursing work. While Harvey writes about urbanisation and specific spatial forms, he focuses on space as an essential element of human existence which is thus relevant to all spaces as reflected in the following:
The question ‘what is space?’ is replaced by the question ‘how is it that different human practices create and make use of distinctive conceptualisations of space?’ … An understanding of urbanism and of the social process – spatial form theme requires that we understand how human activity creates the need for specific spatial concepts and how daily social practice solves with consummate ease seemingly deep philosophical mysteries concerning the nature of space and the relationships between social processes and spatial forms (Harvey, 1973, p. 14)
In the research field, there were social and geographical spaces that symbolised the cultural aspirations of Vietnamese society at that time as well as the existing social order. Furthermore, and as based on the needs for the accumulation of surplus value by hospitals and in turn the government the built environment, as the physical landscape of hospital departments, was arranged in a particular geographical form. Yet, this spatial form might act as a barrier for change or hinder further extraction of surplus value from nursing practice. The contradictions between use and exchange values manifest in struggles over inequities in divisions of labour and
CHAPTER 3 54 distribution of income which constituted inconsistencies within the spatial form of nursing practice.
Capital in general and its faction that produces the built environment seek to define the quality of life for labour in terms of the commodities which they can profitably produce in certain location. Labour, on the other hand, defines quality of life solely in use-value terms and, in the process, may appeal to some underlying and fundamental conception of what it is to be human. Production for profit and production for use are often inconsistent (Harvey, 1978, p.14)
Thus a dialectic approach (Lefebvre, 1991) underpinned the analysis of the ways in which nursing practice was moulded and performed in the political, economic and social spatial contexts (Harvey, 1978, 1985).
3.5 Summary This chapter explored and justified the theoretical tools applied in this research on the social processes that underpin the decision-making and the organisation of the work of nurses within a clinical context in Vietnam. The chapter situated SI within historical and philosophical contexts in exploring the key theoretical influences drawn from the broad pragmatic tradition. In so doing, the chapter addressed the genesis, nature and evolution of SI. Of significance has been the more recent shift in SI to extend consideration to structural influences on the actions and reactions of humans as social actors. The chapter moved from the discussion of human actions as social performance to the integration of such performance into a social structure. Data analysis was organised around the micro dimensions of the self-interpretation of nursing practice, the social interaction between nurses and other stakeholders, and nurse-perceived social standards of practice. What followed was an exploration of key concepts that facilitated a broader analysis of the macro dimensions of the research and the social relations and historical practices that were embedded in the specific spatial forms in which nurses practiced. The following chapter describes in detail and justifies the research methods that were applied to comprehensively investigate the research aims.
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Chapter 4 Methods
4.1 Introduction The previous chapter articulated a theoretical perspective that posed nursing practice as a social performance constructed through an ongoing process of negotiation where nurses both shaped and were shaped by the context of practice. A broad pragmatist lens, that included symbolic interactionism (SI), underpinned the theoretical sentitisation of key concepts as the basis for explaining nursing practice in Vietnam. The current chapter addresses the integration of the tenets of pragmatism and traditional and contemporary versions of SI as they informed the theoretical analysis strategies applied in this research. The chapter first describes the research setting for contextual clarification. A detailed explanation of the principles of sampling and data generation is then provided where the methods of interviewing, observation and documents as data are justified. What follows is an overview of the analytical process and a justification for the expansion of the research theoretical perspectives. Thus, the researcher’s journey in the process of data analysis is addressed. The chapter lastly engages with concepts around the concept of quality as it applies to the current research and in particular the notion of research reflexivity. Finally, relevant ethical issues are considered.
4.2 Research methods
4.2.1 Research setting In Vietnam, as noted in Chapter One, hospitals are organised, through a system of classification, into five levels (from highest to lowest): The five levels are the Special Level, Level-1, Level-2, Level-3, and Level-4. Ho Chi Minh City (HCMC) has one Special Level hospital, Cho Ray Hospital, and seven Level-1 general hospitals. The Ministry of Health (MOH) classified the hospitals based on the National Standards for Hospital Classification (Appendix A). Special Hospitals receive patients transferred from all general hospitals which have lower levels of resources and specialities. The main functions of the Special Level and Level-1 hospitals are to: • provide care for patients in HCMC and 37 surrounding provinces; • collaborate with the medical universities in teaching undergraduate and post- graduate medical students; and
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• support other hospitals to improve clinical practice as well as conduct scientific research. These hospitals also influence the clinical practices of other hospitals. They have responsibility for transferring high medical technologies, giving credibility to achievements in medical sciences, and supporting the implementation of research results into clinical practice at the lower level institutions. In terms of investigating comprehensively the social processes underpinning nurse practices, this research was conducted at the Special Level hospital in the South of Vietnam, Cho Ray Hospital. Cho Ray Hospital, a primary tertiary referral hospital, has a catchment population in excess of 2,544 inpatients and 3,500 outpatients per day. It provides support for 37 provinces in the South of Vietnam, including HCMC. In 2010, the MOH declared Cho Ray Hospital as the Special Level hospital in the South. One of only four Special Level hospitals in Vietnam, Cho Ray Hospital is considered a comprehensive national general hospital (MOHA, 2010). To provide high quality care for such patients, Cho Ray Hospital has 2000 beds, 4 centres and 38 clinical, 12 subclinical and 11 functional departments; with 1,349 nurses employed across these settings (Cho Ray Hospital, 2015). The research process of data generation took place in five departments of Cho Ray hospital. These five departments were Surgical Neurology, Surgical Gastrointestinal, Internal Cardiology, Internal Respiratory and Oncology. Due to the low ratio of participation in the five listed departments, the Endocrinology, the Internal Neurology and the Hematology departments were considered as alternatives to expand the sample size to enhance the quality of generated data.
4.2.2 Sampling strategy
4.2.2.1 Purposeful sampling Purposeful sampling guided initial participant recruitment in the research. The purposive sampling strategy was used to identify and select, as a targeted and efficient process, information rich cases or individuals (Patton, 2002). Based on the research aims, the researcher was interested in registered nurses (RNs) as experts in the area of investigation. Inclusion criteria were registered nurses who had bachelor education qualifications, at least three years clinical experience, and who were providing direct care to patients. Vietnam has three undergraduate nursing education programs including two-year (secondary nurse), three-year (college nurse), and four-year (BSN) programs. There is no
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National Licensing Examination for RNs (VNA, 2012). Hence, after graduating, nurses from all three programs were recruited to work in hospitals in RN roles. In other words, Vietnamese nurses were referred to as RNs regardless of length or content of education. In tems of educational content, nursing competencies were defined differently for each program and patient assessment was considered an advanced skill for bachelor nursing education. It was because patient assessment was the initial lens through which data was generated that the criteria that participant RNs have a bachelor qualification was considered appropriate. It was also assumed that a RN who had just graduated may not have the experience to inform the research topic. In view of the theoretical frame that informed the research the nurse participants were required to have experienced, over a period of time, the influences on the context of nursing practice. Nurses on probation, who worked under the supervision of other RNs for a minimum of one year, were also excluded. The nursing practice of the probationary group was limited and closely surveilled and thus conducted in a different space from RNs. Furthermore, it was essential that participants were working clinically with patients. As such, administrative nurses and nurse managers were not invited to take part in the research. Similarly, RNs who worked in specialist departments such as Intensive Care, Cardiology Intensive Care, and Surgical Neurology Intensive Care were not considered potential participants. Patients who were treated in those departments were routinely monitored and supported by a range of machines and monitors which significantly informed the organisation of nursing care including the assessment of patients. As data generation was focused on nursing decision-making and actions around patient assessment it required participants who were currently responsible for direct care of patients and who had experience of patient assessment. The recruitment process in each department involved four steps. First, the researcher contacted the Deans of the eight identified departments to obtain approval to generate data. Second, the researcher collaborated with each departmental Head Nurse to organise two research information sessions on two different days to provide all nurses with an opportunity to attend. In these presentations, the researcher provided a clear explanation of the research and addressed any questions related to the study. The researcher also provided information about the interviews and observations including time, space, duration and content. The nurses were informed that anonymity would be protected in interviews and observations and that there would not be any evaluation of practice. Information flyers were then distributed to all nurses working in the five identified departments. Research posters were also placed in the eight selected departments. Nurses who agreed to participate in the research made contact with the researcher through the
CHAPTER 4 58 contact office number or email address as indicated on the flyers and posters. Finally, the researcher arranged individual meetings with potential participants to establish a schedule observation followed by an interview. It was stressed that the researcher and the research would not disrupt a participant’s work routine. Participants were asked to provide informed consent at these meetings. This process helped to minimise any perception of coercion on the part of the participants. Table 4.1 depicts the sampling process.
Table 4.1 The process of purposeful sampling for participant approach and recruitment
Steps Activities 1 Contact and agreement • Contacted Deans of the eight identified departments • Collaborated with each department’s Head Nurse 2 Meeting and approach • Organised two research information sessions • Presented, explained and answered questions around the research 3 Connection and arrangement • Contact with the researcher via an office phone number or working email by potential participants • Considered potential participants based on criteria • Arranged individual meetings with potential participants to establish plans for an observation following by an interview
4.2.2.2 Sample size At the time of data generation there were approximately 60 RNs who met the inclusion criteria from all eight identified departments, all of whom were approached to participate in the study. In total, 32 RNs fulfilled the research inclusion criteria and voluntarily participated in the research. Of these, 29 RNs agreed to be interviewed following periods of observation and three RNs agreed to be observed but did not want to participate in interviews. Table 4.2 presents participant demographic data. Sufficient rich data was generated from the sample of 29 participants and the methods of interviews and observations, in combination with document analysis, to allow for the elaboration and refinement of analytically strong research categories. The theoretical analysis methodology, moreover, contributed to broad and indepth insight into nursing practice within the research context as addressed in 4.2.4.
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Table 4.2 Participant demographic data
Department Number Gender Declined Female Male an interview Surgical Neurology 3 1 2 Surgical Gastrointestinal 7 6 1 1 Internal Cardiology 6 5 1 1 Internal Respiratory 5 3 2 Oncology 1 1 0 Endocrinology 4 4 0 Internal Neurology 4 3 1 1 Hematology 2 2 0 Total 32 25 7 3
4.2.2.3 Theoretical sampling A second sampling method, theoretical sampling (Charmaz, 2014), was applied in the development of conceptual and theoretical categories. Theoretical sampling was used as a strategy for working with data to synthesise sufficient and robust categories. As Charmaz (2014, p. 199) notes, theoretical sampling does not refer to the generation of more data until patterns appear. This meant that as the research progressed, theoretical sampling was used for the purpose of ongoing data analysis to elaborate and refine information for category synthesis. This process was one of abstracting from observational data for the purposes of identifying significant analytical concepts which were then further explored in informal and formal interviews. For example, the phrase “conflicting needs” emerged and remained with the researcher from the first observation where a patient requested some form of assessment and yet the participant RN made it clear that she did not consider the assessment necessary in that situation. This concern prompted the researcher to explore with the participant a perceived conflict between patient perceived needs and nurse perceived needs of the patient. The informal interview, however, provided only a surface view of what had been observed. This issue was then explored in-depth in ongoing formal interviews to gain more insight. Similarly, initial analysis of data generated from observing and interviewing another participant informed subsequent and ongoing data
CHAPTER 4 60 collection. The initial analysis addressed the working relationship between physicians and nurses. The participant put the view that there was a close relationship between nurses and physicians and that they could talk with ease and discuss patient care issues with each other. The researcher, however, observed that physicians were unwilling, or even refused, to engage in discussions with nurses on issues related to patients. Through the informal and formal interviews it appeared that the participant accepted the domination of physicians as the taken for granted order and what was interpreted as discussion between nurses and doctors was communication of orders to the nurse. This suggested a boundary between the two domains which was explored more in-depth in subsequent interviews and observations.
4.2.3 Data generation process Individual face to face interviews, observations and documents constituted research data. The most often used data generation method in qualitative studies is the interview (Holloway & Wheeler, 2010; Polit & Beck, 2014; Roller & Lavrakas, 2015). Lichtman (2014) states that the interview is a most powerful method while Savin-Baden and Major (2013) position the interview as the central method of data generation in qualitative studies. In the words of Charmaz (2014, p.85), “Researchers adopt intensive interviewing precisely because it facilitates conducting an open-ended, in-depth exploration of an area in which the interviewee has substantial experience”. There are some limitations of the interview method, however, that can significantly influence data generation. The most obvious is that the individual interview is unable to explore social interactions nor social context (Holloway & Wheeler, 2010), both of which were central to this research. Moreover, the extent to which the interview content reflects reality should also be considered (Holloway & Wheeler, 2010; Savin-Baden & Major, 2013). It is the case that interview data is always the product, or construction, of a relationship between interviewer and interviewee. In the interview situation, both researcher and participant engage in processes of interpretation of the expectations of each other and of responses to each other (Holloway & Jefferson, 2000). Observations were therefore undertaken to mitigate, to some extent, the limitations of the interview and to enhance the exploration of the social setting (Holloway & Wheeler, 2010; Strauss & Corbin, 1998). In taking the point of Savin-Baden and Major (2013), observations challenged inconsistencies between what nurses said and what they actually did in clinical practice. There were some potential constraints on observation in the research which were considered. The presence of a researcher during observation might have influenced participant
CHAPTER 4 61 behaviour or the situation itself. For example, the RN participants may have changed their behaviours around patient care because of the presence of an observer. Savin-Baden and Major (2013) also point to the impact of the researcher in observational data generation where the researcher might develop favourable or unfavourable feelings towards the observed participants or settings. The researcher could, moreover, miss important data relevant to the research area. Indeed, a researcher cannot observe everything in the research setting and thus makes ongoing decisions on what to observe at any point. Such challenges were addressed through the careful conduct of observations. Strategies for ensuring quality, as outlined below, were also expected to minimise the risks around observation. Despite the advantages of observation, the combination of interviews and observations as methods was likely to produce more comprehensive data. Each participant was subject to a period of observation, informal interviews (conversations) and apart from two participants a more formal and extended interview. The observation of each participant in the respective clinical work areas was of the duration of approximately two-hours. The informal interviews (conversations) were conducted throughout the observational sessions to explore or clarify further what was being observed and recorded as field notes. The formal interview was then conducted outside working hours at a time and place negotiated between the researcher and each participant. Each formal interview was audio recorded and the duration of each was on average 60 minutes. Documents were treated as the third important data source in this research to fulfil four specific objectives. The analysis of documents firstly provided a systematic evaluation of information on the research context which was unable to be observed or fully understood through interviews. Data generated from documents also raised questions to be explored in interviews and brought attention to aspects of practice, or the organisation, that could not be observed. Information from documents was, moreover, drawn upon to verify or challenge research findings through comparisons with interview and observational data. Finally, comparing documents with documents helped to explore the development of and changes in the research situation (Holloway & Gavin, 2017).
4.2.3.1 Observations Based on a classification of observer involvement, as proposed by Gold (1958), the observer as participant was used as the second research data generation method. The researcher assumed the role of non-participant observer whereby she had minimal involvement in clinical
CHAPTER 4 62 activities (Gold, 1958; Holloway & Galvin, 2017; Savin-Baden and Major, 2013). This type of observation was selected as the researcher works in the University of Medicine and Pharmacy – Ho Chi Minh City (UMP-HCMC) and is not employed at Cho Ray hospital where data collection took place. Observations were initially conducted to obtain knowledge about the clinical practice of RNs and about the social and cultural context in which the RNs worked. Initial information informed sunsequent and more focused observations and interview questions. Observations were arranged and conducted after voluntary consent for participation was secured in writing. The researcher conducted observations in each department over 2-hour periods between 7:30am to 7:30pm for each recruited RN throughout the eight selected departments of Cho Ray hospital. The result was 58 hours of observations. The timing of observations was negotiated between the researcher and each participant to ensure that the participant was comfortable and able to work without obstruction. In Vietnamese hospitals, the number of health professionals on a dayshift is greater than those working on nightshift. The different time periods of the observations ensured an exploration of a range of potential multiple realities of nursing processes and interactions. A note taking chart, informed by the research theoretical perspective and the work of Spradley (1980), was used to record the observed dimensions of the social situations in initial general observations as demonstrated in Table 4.3 below.
Table 4.3 Observation recording template
Dimensions What to observe 1 Space • Description of the department and how it works ✓ Organisation: location of physician room, nursing room, Patient room ✓ Position among physicians, nurses and patients ✓ Arrangement: instruments, documents, working shifts, staffs, working responsibilities 2 Actor • Description of the observed participant: background, appearance, gesture, attitude 3 Activities • What was being done by the observed participant 4 Act • Single actions that people in the observed setting, including physicians, nurses and patients, carried out
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5 Event • What was happening related to the observed participant’s activities 6 Creation • The responses and responding process of the observed participant to situations • The responses and responding process of people in the setting, including physicians, nurses and patients, to the observed participant’s activities and/or responses 7 Interaction • The interaction between the observed participant and other people in the setting, including physicians, nurses and patients 8 Time • The sequences and length of the observed activities 9 Emotion • The expressed feelings of the observed participant toward the situations and other people in the setting and how he/she expressed these feelings • The expressed feelings of other people in the setting, including physicians, nurses and patients, and how they expressed these feelings 10 Object • The material objects in the settings
The observations were tested out against other data sources including intereviews, documents, literature and theory throughout the analysis process. For example, data from intereviews suggested distancing in social interactions between nurses and medical doctors which influenced nursing practice; RN9: … there is always distance between nurses and medical doctors… we (nurses) cannot treat them (medical doctors) as our nursing colleagues… I find it very hard to discuss with them like I can with my nursing colleagues… although they (medical doctors) are also my colleagues… Even if you have a very good relationship … with someone who is medical doctor, there is still some distance… not like between you and other nurses… The concept of “distance” became a key sensitising issue that informed the following observations. The theoretical perspective of “space” was adopted which suggested consideration of both the physical and social spatial forms in which nurses constructed and performed practice in interactions with medical doctors and others.
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As Holloway and Jefferson (2000) point out, there is more than one way to interpret data for meanings which encouraged a freedom to understand what was going on in nursing practice. It was recognised that there might be a “story behind the story” (De Laine, 2000, p.212) and a single dimensional approach would result in limited insight. To avoid missing important information, the following questions also informed the analysis of text from the observations. • What do I notice? • Why do I notice what I notice? • How do I interpret what I notice? • How do I know that my interpretation is legitimate? (Holloway & Jefferson, 2000). For example, the above questions helped in the exploration of social interactions underlying relationships with doctors which nurses tendentially had described as very good in interviews. What was noted from intial observations was an apparently happy working environment in which nurses and medical doctors had positive conversations. Yet, what the researcher noted in subsequent observations of physical and social distance was a professional divide. In order to interpret this divide, the theoretical concept of space was adopted (Harvey, 1973, 1996, 2006; Lefebvre, 1974, 1984). The questions were also used as a reflective strategy which required the researcher to explore multiple layers of meanings underlying what was immediately obvious.
Observations were recorded in hand-written notes based on the researcher’s memory, in brief notes made during observations and as full descriptions following observations. The researcher assumed an insider role in the early phase of approaching participants to engender greater acceptance and trust. Yet, the outsider role of a nursing lecturer was also employed to look at nursing practice from a distance and the researcher entered the setting with awareness of assumptions and ideologies of nursing practice rooted on background. The researcher moved between insider and outsider roles to gain different insights into nursing practice. An example of the outsider role reporting on observational data is as follows;
Observation 16: A patient has progressively deteriorated. Two nurses come and start emergency interventions. One nurse takes the blood pressure and vital signs. One nurse establishes the IV system and prepares essential emergency equipment (endotracheal, suction) and medications (adrenaline). A doctor comes and starts to assess the patient. He asks the nurses about the patient’s vital signs. He spends
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a short time thinking and then tells the nurses what medications to use. He stands at the bedside and looks at the nurses as they work. He continues to give more orders to the nurses…. He leaves the room and the nurses continue their work with the patient…
Intepretations from interviews suggested that the power of medical doctors to reduce the autonomy of nurses was informed by the researcher’s knowledge of being a RN. As such there was a focus in the observation sessions on the ways in which nurses reacted and responded to the appearance of a medical doctor rather than simply report what nurses did. The change in lens from outsider to insider added to the exploration of what was going on between nurses and medical doctors:
Observation 16: … when the doctor comes, the two nurses stop what they were doing, one nurse quickly summarises the patient’s health progress and vital signs. There is a short silence while the doctor assesses the patient. Nurses shift from providing interventions to preparing supportive equipments and medications. After the assessment, the doctor communicates orders and leaves the room. The two nurses return to their intervention work with the patient….
Thus, the use of the lens of the insider helped to explore the process of practice (Holloway & Wheeler, 1996). The researcher moved fluidly between the insider and outsider roles throughout observations rather than a static or formulaic position. Strategies to maintain a balance between the insider and outsider roles are addressed below in the section on reflexivity.
4.2.3.2 Interviews As noted, the researcher also conducted individual face-to-face interviews including informal and formal interviews. Informal interviews (conversations) were conducted for the purpose of clarifying actions and decisions as observed. These informal interviews took place in the clinical settings during the observation periods and where a participant was available to answer questions. The duration of each formal interview was approximately one hour. The interviews took place in enclosed spaces in the relevant departments and outside working hours to ensure convenience and privacy for participants. Each interview was broadly informed by the theoretical perspective in order to explore: 1) how nurses self-interpret the meaning of patient
CHAPTER 4 66 assessment; 2) how they describe their interactions with others in the clinical setting such as physicians and patients; and 3) how structural and social context influences their nursing practice. Hence, two questions and three dimensions drawn from SI, self-indication, interaction, and structural and social context, guided initial questions. The two initial interview questions are: • What are the patient assessment skills that you think every nurse should perform on every patient? • Can you talk about what you do with information from patient assessment? These two questions were used at the start of interviews which helped to explore how nurses defined patient assessment and applied this skill in clinical practice. The subsequent questions were posed around the three theoretically synthesised dimensions. The longer interview was semi-structured in format. This form of interview sets parameters around the research focus without limiting the flexibility of the interview. Additional questions were added as indicated by the direction of each interview (Holloway & Wheeler, 2010; Lichtman, 2014; Savin-Baden & Major, 2013). Importantly, the semi-structured interview allowed participants to point to what they thought was significant rather than being directed by what the researcher considered important. The interview content was constructed and co-constructed through an iterative process of data generation, data analysis and back to data generation. Theoretical sampling played an important role in this phase of data generation as the analysis of data generated from initial interviews contributed to ongoing interviews. The process ensured that interviews became more focused and condensed as the research progressed.
4.2.3.3 Documents A review was conducted to synthesise officially published documents related to nursing in Vietnam. The criteria for these documents were that they were official government or legal documents and had been implemented in the past, or were currently active documents, in Vietnam. The document sample expanded throughout the analysis process to capture relevant issues and perspectives on nursing education and clinical practice (Table 4.4). The number of documents increased from five to 50 during the analysis process and provided broader insight into the political, social and economic contexts within which Vietnamese nurses constructed and performed practice (Appendix C). This process reflected how concepts were sensitised throughout the theoretical analysis as discussed in the following sections
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Table 4.4 Categories of selected documents
Categories Health Education Others Resolution 1 3 1 Law 0 3 Decision 6 9 Decree 2 5 Circular 2 2 Joint Circular 1 0 Reports, Agreement, Standards 14 1 Total 26 23 1
The research treated extant documents as data to address the research purpose even though the documents were produced for quite different purposes. Data generated from documents was used to support or challenge outcomes of the analysis of observational and interview data. The researcher adopted the method of Charmaz (2014) who proposed that the examination of documents be organised around three comparative pairs: 1) form and content; 2) audience and author; and 3) production and presentation. This data generation process took into account the particular context of Vietnamese healthcare in which the documents were constructed.
4.2.3.4 Field notes The term “field notes”, or notes in the field, is commonly used in ethnographic research where the observation method is used for data generation (Walford, 2009). Definitions of field notes vary among ethnographers, from simple notes of daily writings in the field, to a wider range of note taking outside the field, for example, discussion or conversations happening outside research settings (Campbell & Lassiter, 2014). In this research, field notes were used to record data from both observations (in the field) and informal interviews (in the field/ outside the field). In addition to the observational guide above (Table 4.3), notes from observations of the research setting, structure and social context, interactions and actions were recorded as field notes as a subsidiary data resource. This resource provided information on what was happening in the clinical settings from a range of perspectives. For example, the following field note decribed the interaction between a nurse and patient family member.
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Observation:…Nurses are sitting in the staff room writing patient notes after doing the medications. One women, a wife of a patient, comes and knocks on the mirror window. A nurse stands up, comes and opens the window and asks the woman: “What do you want?”. The women answers in a very small and low voice: “I do not know what has happened with my husband. He feels unwell”. The nurse tells the women: “I will come and check”… Field note: The nurse speaks in a loud voice and the woman appears uncertain and maybe even frightened. The nurse did not seem very interested in what the women had said through the way she answered and her gestures and attitudes.
And interactions between nurses and doctors; Observation: Three nurses are working as a team at the beside of a patient who needs emergency intervention for respiratory failure. One nurse provides interventions such as oxygen therapy, suctioning, and preparation for endotracheal insertion… A second nurse sets up an IV, and prepares emergency medications such as adrenaline… The third nurse works with administrative documents. When the medical doctor comes, he inserts the endotracheal and gives orders on medications…. Field note: When there is no medical doctor, nurses work as a team to provide care . When the medical doctor comes, the nurses wait for orders before proceeding. In other words, nurses followed a routine: 1) worked as a team; 2) reported patient information to medical doctor; 3) medical doctor gives orders; and 4) nurses address given orders; and 4) nurses ask for further orders or report patient changes. Field notes, therefore, prompted ideas for clarification through further interviews and observations. The following informal interview with one observed RN focused on the above interaction: Informal interview 2: Researcher: It looked as though you changed your approach to decision making when the doctors appeared. There were periods of time, very short, where you waited for orders which were absolutely absent before.
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RN12: Oh, that’s the way it is… of course you (nurses) have to decide what to do for patients when they are in a dangerous situation, but when doctors come, it is their work… I mean they are responsible for that….
The above became important observational content and more so when added to subsequent observations of situations other than localised emergencies for deteriorating patients. Field notes were firstly written in the form of “jottings” which included key words and phases to keep track of important ideas as actions occurred and information was provided quickly (Bernard, 2018). The method also helped to reduce any confusion on the part of the researcher who was at once observing, talking and writing notes. The initial field notes ensured that the researcher recalled key words or phrases which were then written up in a more detailed format to provide a rich data source. Descriptive notes were also recorded to capture comprehensive explanations of what had happened while analytic notes were constructed to help the researcher organise initial analytical ideas and to reflect critical thinking (Table 4.5).
Table 4.5 Process of field notes taken
“Jottings” format Descriptive Format Key words/phases • No medical When there is no medical doctor, Interpersonal/interprofessional doctor nurses work as a team to provide relationships (MD) → interventions. When the medical autonomy doctor comes, the nurses wait for • MD → orders before proceeding. In other ask/ report words, nurses followed a routine: 1) → wait → automatically work in team; 2) report MD gives patient information to medical doctor; orders → 3) medical doctor gives orders; and follow 4)nurses asked for further orders or report patient changes.
Field notes were used as a subsidiary data source which was treated similarly to observations, interviews and document data. As such, data from field notes contributed to concept sensitisation throughout the theoretical analysis.
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4.2.4 Initial coding In the process of the initial phase of analysis, the researcher constructed codes from data through interaction with participants and data. Interactions with participants represented a co- construction of data. Interaction with data involved an interrogation to elicit the tacit meanings of the actions of nurses related to patient care rather than reading data at a superficial level. In this phase, codes were defined and refined whereby concepts and issues identified from initial participants were explored further with subsequent participants. The researcher remained open to possible nuances in data. The openness in the initial analysis also allowed new ideas to be considered. Thus, this first analytical phase helped to “bring the researcher into the data” to analytically explore potential gaps through comparing data with data, examining processes and exploring emergent links between such processes (Charmaz, 2014, p.121). For example, one interview excerpt was transcribed as follows;
Researcher: Can you tell me which skills you use to assess patients? RN3: First, I look at their breathing patterns, traits. For example, I look to see whether patients currently breathe through an oxygen cannula. I usually assess by
looking first. After that, I mainly take vital signs, and SpO2. But actually, based on my experience, I can determine whether patients need emergency care. For
example, before measuring SpO2, I can diagnose respiratory failure by looking at patient patterns and traits, such as posture to assist breathing…
In initial coding, data were fragmented into small pieces of information. Each sentence of the transcribed data was examined closely to define actions: RN3: I look at breathing patterns and traits.
I take vital signs, and SpO2 Based on experience, I can diagnose just by looking.
This process reduced the rude data to tacit assumptions whereby implicit actions and meanings were explicated. From here, the meanings explicated from the initially analysed data were; Researcher: Can you tell me which skills you use to assess patients? Meanings: 1) Looking and referring; and 2) Experience-based decision-making
The explicated meanings suggested that the RN was familiar with skills of patient assessment other than simply looking. These skills, however, were not applied in practice since
CHAPTER 4 71 the participant determined they were not needed. At this point, new dense concepts and more in- depth explanations were generated that provided abstract analytical concepts for further and deeper exploration.
Hence, generation involved interviews, observations and documents, and the initial coding is depicted as a cyclical process visualised as Figure 4.2. Generated data from the two methods were assimilated throughout the coding process. The integration of data generated from documents also informed the early analysis in situating the social actions of RNs within a macro level context.
Initial analysis
SEMI- INFORMAL INTERVIEWS OBSERVATIONS (CONVERSATIONS) STRUCTURED
INTERVIEWS
Initial analysis
Initial analysis
DOCUMENTS Figure 4-1 Data generation process
4.2.5 Theoretical analysis It is generally acknowledged that constructivist grounded theory methods broaden insight into explanations of social processes and that these methods philosophically converge with SI as evident in Strauss’s work which engaged with SI, agency, meanings and action (Aldiabat &
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Navenec, 2011; Bryant & Charmaz, 2007; Charmaz, 2014; Charmaz, Thornberg & Keane, 2017; Glaser, 1992). SI and constructivist grounded theory are thus considered compatible (Bryant & Charmaz, 2007; Charmaz, 2014; Corbin & Strauss, 2008). The methods in this research, based on Charmaz’s works, offer guidelines to explain, rather than describe, the studied phenomena logically, systematically and theoretically (Charmaz, 2014). The differing generations of GT have posed different approaches for data analysis. Strauss (1978) and Strauss and Corbin (1990, 1998) proposed an abductive approach which involves firstly a conceptualisation of categories from generated data followed by a deductive phase where theoretical ideas are used to test out constructed conceptions. Further data generation is then undertaken to enhance theoretical sensitivity (Bryant & Charmaz, 2007). It was argued that the abductive approach helped to construct and reconstruct new conceptual categories at any stage of data generation through an iterative backward-forward process of coding, memo writing and re checking. This approach, therefore, provided “a way of thinking about and conceptualizing data” rather than simply a method of coding data (Strauss & Corbin, 1994:275). The concept of abduction as explained here, however, assumes the testing out of hypotheses through a movement back and forward between bits of data. What is missing in this process are rigorous tools for testing out evolving analytical and theoretical ideas. The concept of reflexivity was more appropriate to the analytical process in this research where reflexivity meant “…bringing in issues of alternative paradigms, root metaphors, perspectives, vocabularies, lines of interpretation, political values and representations; rebalancing and reframing of voices in order to interrogate and vary data in a fundamental way” ( Alvesson & Sköldberg, p.313). Apart from the issue of abduction, Charmaz rightly focuses on the interactions between the researcher and the research which are to be taken into account during the research process (Charmaz, 2014). Rather than deny the influence of the researcher in data generation, the approach overtly takes into account the researcher’s perspectives, privileges, positions, interactions, and geographical locations (Charmaz, 2000, 2006, , 2007, 2008a, 2008b, 2008c, 2009, 2014; Clarke, 2005, 2006). In other words. this approach considers the researcher as an integral part of the data generation and analytical process. Importantly, this view assumes that there is no one reality and thus there can be a range of interpretations that explain the social processes which shape nursing decision-making around practice. The ideological underpinnings of how to think about interactions with data were embedded in the research analysis process. Research analysis progressed through emergent concept theorisation based on tentative ideas reflecting Blumer’s (1969) notion of “sensitizing
CHAPTER 4 73 concepts”. Such tentative ideas helped to raise questions and to think around the research focus which suggested a starting point for exploration. As Charmaz (2014, p.30-31) argues; “Sensitizing concepts” give researchers initial but tentative ideas to pursue and questions to raise about their topic …. Sensitizing concepts can provide a place to start inquiry, not to end it” Rather than a start of exploration, sensitising concepts provided reference points in the evolution of the following phases of data generation and analysis. A dialectic process of data analysis was applied where all resources, including literature, the Vietnamese context, theoretical lens, interview and observational data and documents, acted as sensitising material for concept theorisation. Hence, the researcher actively engaged with data to reach a level of abstraction and conceptualisation rather than passively read data to identify and describe themes. This active engagement was expected to achieve a theoretical sensitivity defined as the researcher’s ability to understand and extract abstract and analytical concepts (Charmaz, 2014).
Initial analysis (Charmaz, 2014) informed the early analytical process which then shifted to theoretical analysis. The theoretical analysis process included various ongoing phases of revision and the expansion of data sources based on decisions around the theorisation of concepts. Table 4.6 depicts the process in a linear sense for the purpose of providing explanatory clarity around how the theoretical analysis undertaken in the research.
Table 4.6 Theoretical analysis
Resource Descriptions of the process Order 1 Literature review • The literature review was initially conducted based on key words identified from research problem. The review provided contextual information around issues related to patient assessment of nurses in clinical practice worldwide and in Vietnam. The research question was also identified in this stage. Theoretical • Initial concepts were sensitised based on SI which construction suggested self-interpretation, interaction and social organisation as the three overarching theoretical concepts
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that guided the early data generation, coding and interpretation Initial analysis • The theoretical concepts noted above provided a broad framework for the semi-structured interviews, observations and documents. Initial analysis was undertaken with a focus on self-interpretation, interaction and social organisation. Sensitising concepts provided direction for further exploration from interviews, observations and documents. 2 Theoretical analysis • Further engagement with literature, theoretical content and context was then pursued to enable an interpretation of emergent issues that were not readily explained. This process was undertaken to inform a more in-depth analysis which expanded to a broader view of nursing practice rather than a focus on patient assessment.
4.2.5.1 The expansion of data through theoretical analysis As noted above, the theoretical analysis treated all resources as data. Within this analytical framework, all data sources were subject to interrogation in interaction and integration with each other. For example, a theoretical assumption that nursing practice shaped and was shaped by a political economic and social spatial forms prompted inquiry into the influence of policies, economic conditions and social norms on nursing. The analysis, as it progressed, also pointed to the influence of the positioning of nurses on the shaping of nursing practice. The literature review, therefore, shifted the focus from patient assessment to the social positioning of nursing in the political, economic and social context of Vietnam. Retrieval of documents also extended beyond professional concerns to the Vietnamese political, economic and social domains. In order to fully engage an expanding analysis, new theoretical tools were employed. As noted in the previous chapter, the theoretical perspective was initially developed based on the work of Mead (1934) and Blumer (1969) around SI. Through the lens of SI, the research explored the social processes that underpinned the actions of nurses in patient assessment in terms of three dimensions: 1) nurses’ self-indication of their patient assessment based on their interpretation of the basic meaning of that assessment; 2) interactions among nurses and other stakeholders as they align with others’ actions in patient assessment; and 3) the
CHAPTER 4 75 contribution of structural and social context in shaping patient assessment of nurses. Interview questions for initial interviews were formed around the three dimensions. These dimensions, moreover, required a focus on the interactions between nurses and others in the same context, and the impact of the research context on patient assessment of nurses. Finally, data generated from 50 selected documents related to the structural and social context was used to contextualise information from observations and interviews The initial coding revealed contradictions between interview, observational and document data that required revision and modification of the theoretical lens. The interviews addressed the important and essential meanings of patient assessment as interpreted by nurses. Nurses perceived patient assessment as essential practice and also that doctors were very supportive of nurse-performed patient assessment. Hence, there was readiness of nurses to perform patient assessment which was consistent with explanations from the theoretical perspective.
RN5: We (Nurses) are the staffs who have the most direct contact with patients. When patients have problems, we are the first ones to detect them and so accurate assessment is very important. It is the very first and critical step in nursing practice that every nurse should do…
…. Of course we (nurses) do patient assessment a lot…
Based on SI, RN actions were perceived as products of a complex process whereby RNs selectively responded to the meanings of a phenomenon and adjusted to the situation within which the phenomenon occurred. In other words, the interpretation of meaning was the initial step in the process of action construction. This understanding suggested that the actions of the RNs in performing patient assessment were constructed as nurses interpreted the skills as meaningful. There was also a strong likelihood that assessment would be undertaken where there were supportive interactions between nurses and others within the context.
RN5:...There are no problems with doctors when we do patient assessments. I think they support this practice because we can call them earlier… I mean at the early phase of patient deterioration….
Yet, data from both interviews and observations indicated that nurses performed patient assessment focused only on vital signs.
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RN5: I just look at patients for breathing assessment and then take vital signs….
… It is enough to identify that a patient currently has a problem and needs medical intervention….
There were, therefore, tensions between RN perceptions and observations of RN practices. The value of the two forms of data was in identifying such tensions. As Alvesson and Kärreman (2011, p.107) point out:
…observations will typically follow different logics from interviews. The former will usually mean a much lower degree of researchers directly producing results when compared to interviews where the questions asked will produce the empirical material. The observer will be mainly inactive/refrain from interventions, while the interviewer’s interventions will be framing and triggering interview responses.
In other words, interview questions framed interviewee responses. Nonetheless the contradiction itself was useful in leading to a broadening of the theoretical frame.
The most common criticism of SI is that the approach separates the individual from the social context of the construction of actions (McPhail & Rexthroat, 1979; Powell, 2013). To address this limitation the research turned to the work of Goffman (1959) to explain human action from both perspectives. The use of Goffman’s (1959) work on performance provided an additional explanatory theoretical tool which allowed for an exploration of the surrounding social environment. In other words, the use of the works of Mead and Goffman addressed human actions as social performances that suggested consideration of the social environment within which patient assessment was constructed and performed. Thus, the exploration extended to the meanings that nurses interpreted based on responses of medical doctors, colleagues, patients and families. Additionally, the selective process of responses of nurses in reacting to the identified meanings was a focus of analysis. In terms of social interaction, shared attitudes towards patient assessment were considered, followed by the ways in which nurses adjusted to responses.
In terms of the revised theoretical framework, social norms assumed importance. Nurses produced and re-produced the social norms of nursing practice within a particular context (Berger, Luckmman & Mustafa, 2011). Thus, such norms produced within the context of university education might have differed from the clinical settings.
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RN4: It (nursing practice/ patient assessment) is different from what I learned in university and from what I do here. It is not necessary to do all of what I learned. So… I think my practice is not like before (when studying).
And the following:
RN4: …I was lost… or maybe confused… when starting my job. I prepared myself that practice might be different and I needed to learn again because I saw differences when I came to clinical settings for practice during studying…. I was still shocked. It was a hard period where I had to adapt to a new environment, to familiarise myself with a “new” practice… not exactly new but… or you can understand that it was “new” for me….
Analysis highlighted an active engagement of nurses in negotiation processes with others and particularly medical doctors, in decision-making. Nurses interactively responded to shared norms as perceived by nurses, medical doctors, patients and family members. The way nurses constructed nursing work was thus not passive; there were active negotiations as evident in the following;
RN16:… I agree that we (nurses) have to follow orders from medical doctors but I do not think that we are depended on them… Yes, nurses hardly have a voice with them, but to me, I still can talk with them. I think the way you talk with them, the experiences you have, the competencies you demonstrate, the way you make decisions about interventions, the effective outcomes that your work results in … are important. Let them listen to you. You have to think, and to do before discussing with them…you may fail or be successful…but you need good preparation before trying…there will not be a second time if you do not make the first time happen…
The work of Strauss (1978) was, therefore, important in interpreting nursing practice as a negotiated order. The theoretical perspective, moreover, recognised a dialectic between negotiations and structural constraints. Hence, the approach to interpretation suggested that nursing work was negotiable within a context of structural constraints.
As the analysis unfolded salient organisational properties emerged as considerable contributors to the form of nursing work. The work of Hall (2003) suggested three domains
CHAPTER 4 78 which were adapted to examine the influences of structural context including; 1) Inequality; 2) Institutional analysis; and 3) Evolution whereby positioning, policy, power and gender emerged as sensitising concepts for the ongoing analysis s as depicted in Figure 4.5.
Nurse-interpreted meanings of objects •What are meanings of patient assessment that nurses percieved? •To nurses themselves •To physicians •To patients/ families •How do nurses respond to the identified meanings
Nurse-perceived social Nurse-perceived social standards interaction •How is the disbelief-to-belief circle •How do nurses interprete others' regarding to patient assessment attitudes toward patient performance of nurses? assessment by nurse? •What are strategies that nurses do •Other nurses to dramaticise the realisation of •Physicians patient assessment? •Patients/ families •What social standards regarding to •What is the shared attitude toward patient assessment that nurses patient assessment by nurse? perceive? •How do nurses respond to the •How do nurse respond to the shared attitudes toward patient identified social standards? assessment by nurse?
Institutional analysis Hospital organisation Policy • Health • Working: nursing role • Nursing competency standards Figure 4-2 The theoretical lens
4.2.6 Strategies of ensuring quality of qualitative research Data analysis was a process of construction and not of discovery which raises the issue of my contribution to interpretation of meaning.
Reflexivity has been variably defined as an assessment of the contribution of the researcher’s background, perspectives and interests throughout the research construction process
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(Ruby, 1980). Reflexivity also includes the concern of positionality of the researcher and thus there was an earlier discussion around the researcher’s back and forth movement between the two positions of a nursing lecturer and a RN where the researcher brought different lenses to data analysis. The differing perspectives contributed to diverse interpretations. For example, a nurse participant described patient assessment as looking and taking vital signs. As a nursing lecturer, I was initially critical and assumed that this was a result of poor nursing practice. Within the role of RN, I recognised that nurses did more than what was visibly obvious which encouraged me to broaden my insight into the ways that the nurses constructed nursing performance.
Social context is critical to the construction of meaning (Dodgson, 2019; Rae & Green, 2016). As Steedman (1991, p.54) argued;
Nothing means anything on its own. Meaning comes not from seeing or even observation alone, for there is no ‘alone’ of this sort. Neither is meaning lying around in nature waiting to be scooped up by the senses; rather it is constructed. ‘Constructed’ in this context, means produced in acts of interpretations.
Thus, meanings generated from research data were the products of a social process whereby I constructed a subject who was the construct of a social context (Alvesson & Skoldberg, 2009). I also understood that I, as a social construct, brought those influences on intepretations of meanings.
In acknowledging the above, I continuously questioned my interpretations during data generation and analysis. A further example, and although not explored in in-depth in this research, was that both male and female nurses also expressed frustration about nurse-doctor physician relationships. The following is an example of a male nurse considering this issue:
RN21: … I think I need to find another job.
Researcher: What makes you think that?
RN21: … I don’t like it (nursing)… I work to earn money but I feel I am not respected. They don’t listen to me.
Researcher: Who are they and why they don’t they listen to you?
RN21: Patients, families and especially doctors… you know why, they don’t think that what we (nurses)have to say is valuable. For example, I
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said that this patient needs this, this and the other (caring services) … and it seemed that they took no notice. But it is not that “they did not notice” but “they did not want to”… it happened many times until I came to the conclusion that I shouldn’t talk about anything anymore….
The above issue was not confined to male nurses. Nonetheless, responses from female nurses differed as the following example suggests:
RN24: …I think sometimes nurses should keep silent in front of doctors. Since we are women and nurses, it is harder to tell them (male doctors) what to do…
The above suggests the prominence of men over women whereby men have greater power to make decisions and to reject what they perceive as unacceptable inequalities. Reflection on the above example served as a deterrent from drawing too simplistic generalisations during data analysis.
Data was thus interpreted at multiple levels where one level may have contained reflections of other levels or levels may have interacted with others (Alvesson & Sköldberg, 2009). The work of Alvesson and Sköldberg (2009, p.273) (Table 4.7) was invaluable in facilitating levels of reflexivity. I moved forward and backward throughout the theoretical analysis to examine potential conflicts or tensions and to explore in- depth underlying meanings. Raw findings were critically reviewed rather than accepted as initial conclusions. I then explored a second meaning layer of findings using alternative lens. This process was ongoing and applied throughout the data analysis and led to layers of conclusions. Moreover, the strategy of questioning data meaning throughout the analysis was implemented to help the researcher produce rich information from data.
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Table 4.7 Levels of interpretation.
Aspect/Level Focus Interaction with empirical material Accounts in interview, observations of situations and other empirical materials Interpretation Underlying meanings Official interpretation Ideology, power, social reproduction Reflection on text production and language Own text, claims to authority, selectivity of use the voices represented in the text Adapted from “Reflexive Methodology: new vistas for qualitative research”, by M. Alvesson and K. Sköldberg, 2009, London: SAGE, p.274
Strategies of rigour such as member checking, peer review and triangulation, to ensure credibility and reliability (Lincoln & Guba, 1985) were not applied. Rather, the researcher focused on memo-writing through the process of reflective thinking. Memo-writing helped to explore the multiple layers of meanings, as noted above, through systematic reports which reflected the flow of thinking towards data. Writing memos was used as one tool to examine, explain and categorise data in this research. A memo-writing process was conducted throughout the research record analytical ideas and to justify shifts in explanations. The memo developed from the simple to the complex and from the general to the more focused. The generation of data through memo-writing meant an ongoing engagement in reflexivity. Since memo-writing is free-style writing, the researcher categorised memos as descriptive, stimulated and analytic memos (Charmaz, 2014). In descriptive memos, the researcher described steps of data generation in details. These memos provided a comprehensive picture of how data was generated and analysed, from approaching participants to categorising concepts. As the review and revision progressed, stimulated memos were written which contained notices and questions that required explanations. In analytic memos, the researcher integrated multiple sources of information such as literature, theoretical perspective and even existing generated data to provide answers and arguments. Table 4.8 exemplifies the process for writing memos.
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Table 4.8 The memo-writing process
Categories Contents 1 Descriptive memos (Memo 5 dated 12 October 2016): … More skills of patient assessment are taught than only looking. These skills, however, were not applied in practice since the participant interpreted that they are not required in nursing role. There were gaps between nursing education and nursing practice related to patient assessment… 2 Stimulated memos (Memo 5 dated 12 October 2016): …So what prevents nurses applying all skills of patient assessment? The data showed that most of the nurses used overwork as the reason to argue for their limited patient assessment. Yes, it was consistent with a strong body of evidence discussed around influencing factors of nursing practice. There was, therefore, no new findings. Yet, the research did not aim to explore influencing factors. The research was interested in the process of nurses decision making towards patient assessment…. 3 Descriptive memos (Memo 5 dated 12 October 2016): ...the process nurse made decision of patient assessment raised the looking approach and ignorance of other assesssing skills. Nurses argued that it was enough and hence nursing practice was very limited… 4 Stimulated memos (Memo 5 dated 12 October 2016): …it was not simply that nurses passively accepted that observation was enough for patient assessment. There were contradictory opinions which raised the importance of a comprehensive assessment. Nurses, moreover, had responses to increase assessing practices through negotiation with medical doctors. Negotiation emerged as a strategy of nurses to broaden their scope of practice. Yet, the theoretical perspective was unlikely to capture this aspect for explanation of human action. There might be a review of other theoretical perspective which examined how people negotiated to shape actions…. 3 Analytic memos (Memo 7 dated 18 October 2016): ...Human actions should be considered as negotiated orders (Strauss, 1978) and so was nursing practice…
As the theoretical analysis progressed, there were reconstructions of perceived meanings such that modifications to the theoretical analytical tools was required. The conceptual process of a negotiated order suggested by Strauss (1978) was extended so that nursing practice came to be understood as a negotiated social performance (Memo 7 dated 18 October 2016). Hence, writing memos also helped in the development of new ideas and insights from generated data.
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4.2.7 Ethical considerations The researcher completed the Research Ethics Integrity and Safety (REIS) modules before conducting the research fieldwork and hence was introduced to the ethical principles of human research (Appendix D). Ethical approval was obtained from the University of Medicine and Pharmacy (UMP) (Appendix E) and QUT (ethics number 1500001042) before all stages of the study were conducted. The processes of these institutions were strictly followed to identify all possible ethical risks in relation to participants. Ethical considerations in the research were judged to be of low risk. The four ethical principles of autonomy, nonmaleficence, beneficence and justice were ensured in this research (Holloway & Wheeler, 2010). This means that participants had the right to independently decide to participate in the study without any coercion from the researcher or relevant organisations such as the UMP or Cho Ray hospital. They confirmed the voluntary nature of participation through signed informed consent. The target population of RNs was considered to be healthy without any cognitive impairment, intellectual disability, or mental illness. Participants were, therefore, able to make decisions and to give informed consent for participating in the study independently. Since participants were observed while undertaking nursing practice involving patients, the researcher was introduced to patients and asked for their agreement before commencing observations. The principle of nonmaleficence indicates that any causation of harm was avoided in the study. Nurses who were asked to explain their practices, in some situations, felt uncomfortable or ashamed that they were perceived incompetent in patient care. These feelings might have increase where nurses were being observed. In addition, the study explored interactions between nurses and other stakeholders which may have given rise to concern when nurses discussed working relationships with other professionals. Only questions related to nursing professional roles were asked in the formal semi-structured interviews. Similarly, in relation to observation, the focus was on nursing practice. The researcher arranged a formal meeting and time for observation with each participant to avoid influencing participants’ workroutine. Participants could ask to stop interviews or observations whenever they felt uncomfortable. Free counseling was provided in cases where nurses may have experienced distress. No such occasion arose during the research. A clear and comprehensive explanation of the study purposes and benefits were provided to confirm that findings would not be used to evaluate nurses. Information recruitment flyers were delivered to all nurses working in the five identified departments. Nurses received full
CHAPTER 4 84 information on the study including data collection methodsthrough the information sheet (Appendix F) and posters (Appenidx G). Posters were also created and appeared in the eight departments to inform those who engaged in the same context as the observed participants such as physicians, nursing staff, patients and families. These preventive actions were used to fulfil the veracity (truth-telling) requirement in the principle of justice. Nurses who agreed to participate in the research contacted the researcher directly through the contact office number or email in the flyer. This helped minimise any risk of coercion of participants in the research. The active approach of nurses having to contact the researcher contributed to ensuring participants’ privacy and confidentiality as only the researcher was able to identify participants among nursing staff in the eight departments. The rule of anonymity was followed to prevent the identification of participants’ titles, names and positions. The interviews were undertaken in a private room and only the researcher and two supervisors could access the interview content. The audio records, observational note taking chart, and transcripts were coded to ensure participants’ anonymity. Collected data were stored in two forms: 1) hard copies which were kept in a locked cabinet at QUT; and 2) digital copies which were stored in a password protected portable data device and on QUT’s network drive. No participant requested withdrawal from the research. Three RNs decided to stop the interview due to timing issues which caused inconvience for schedules. In two instances RNs cried during interviews. The researcher stopped the interviews and offered referrals for psychological support and yet no intervention was ultimately required. The two RNs explained that it was emotional for them to have someone listen to how they worked hard to perform well as professional nurses. The two RNs demonstrated a committment to continue the interviews without interruption.
4.3 Summary The discussion of methods applied in the research started with an exposition of the assumptions of the theoretical analysis where data was generated through a backward-forward moving process between theoretical interpretation and data generation. The chapter turned to the research process with a description of the purposive and theoretical sampling strategies applied during recruitment and data analysis. The data generation process was clarified and a detailed explanation was undertaken of the process for the construction of data and the ways in which data were fragmented, generated and interpreted as a whole. Finally, the chapter addressed strategies for ensuring research transparency, the value of reflexivity, possible ethical issues and
CHAPTER 4 85 feasible solutions for the purpose of protecting participants’ rights. The methods chapter, therefore, provided a comprehensive description and explanation of how data was worked with theoretical tools to produce abstracted concepts which are explored in detail in the following results chapters.
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Chapter 5 Internalising nursing practice
5.1 Introduction The complexities of nursing practice are obscured in attempts to construct a generic definition of nursing. The WHO (2018), for example, defines nursing as a role that “encompasses autonomous and collaborative care of individuals”. Nursing practice, however, is better understood as constructed by nurses as social actors who perform roles that are negotiated and mediated within context. The process of the construction of nursing practice and associated contextual factors ensures considerable variation in nursing work within and across nations. The work of Berger and Luckmann (1966), Blumer (1969), Mead (1934) and Goffman (1959) converge on an understanding about the ways in which people come to act through shared meanings in their social worlds. This understanding is relevant to an exploration of how nurses, within the research context, conducted nursing practice. The participants had developed, what Berger and Luckmman (1966) refer to as, a sociology of knowledge which defined their practice as a social product and one that was internalised in particular ways.
The content of this chapter is focused on the process of the internalisation of nursing practice by the participants and how that manifested. There was a constant process of negotiation and mediation where nurses simultaneously absorbed social norms and transferred these norms into taken for granted practice. The chapter addresses two processes whereby nurses firstly worked to understand nursing practice, in the world of others, in order to identify social norms of practices. In order to understand how the prevailing group defined nursing practice, the chapter starts with an exploration of patient assessment practices. The chapter moves on to explain the particular ways in which the nurses actively negotiated these social norms to develop their own norms of practice. Explored throughout the chapter is a process of mediation whereby the nurses responded to prevailing social norms within context.
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5.2 The process of negotiation and mediation Nurse participants engaged with a limited range of patient assessment skills in contrast to expectations mandated/set out in the national standards, curricula and policies in Vietnam. According to the national nursing competency standards (VNA, 2012), patient assessment is formally defined as the cornerstone of the nursing process that underpins the autonomy of Vietnamese nursing practice. Hence, the standards assumed that nurses had considerable autonomy in decision making and thus occupied a space within which to perform patient assessment appropriate to each situation using nursing knowledge and skills. The standard expected of an RN was patient assessment that routinely would involve a recording of a patient’s health history and a comprehensive physical examination. The interpretation of patient assessment by nurse participants, however, suggested the acceptance of a routine that depended upon a very narrow range of skills.
RN2: I look at patients to identify whether they are confused or vague (consciousness evaluation). After that, I look at their breathing patterns. If they are breathless, I will take vital signs. If patients appear stable, I use their vital signs taken daily in the early morning.
Nursing practice was produced and reproduced in an ongoing dialectical process whereby nurses were inducted into the social context (Berger & Luckmman, 1966). In other words, while nurses came to the clinical context with practices that had been refined through education, acceptance into the clinical environment often involved changes to practice. In order to secure acceptance, nursing practice was formed in the shape of social norms produced within the clinical domain. These social norms were constructed through a process in which social interactions among nurses and relevant members were critical (Blumer, 1969; Mead, 1934).
5.2.1 Understanding nursing practice in the world of others It has been commonly asserted that newly graduated nurses find working in clinical settings difficult because of a disparity between what was taught in universities and what was practiced by registered nurses. There is a large and global body of literature that addresses the concept of a theory-practice gap in nursing clinical practice as observed in, for example, Australia (Missen, McKenna, Beauchamp & Larkins, 2016; Usher, Mills, West, Park & Woods, 2016), Canada (Rush, Adamack, Gordon, Janke & Ghement, 2015), and the United Kingdom
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(Monaghan, 2015). Multiple factors have been identified as contributing to a theory-practice gap including educator -related factors, student-related factors and cultural settings (Akram, Mohamad & Akram, 2018)
The perception of RN participants was strong that gaps existed between theory and practice in Vietnamese nursing practice as the following text;
RN: …No, it is not like what I learned … I don’t mean that it is different, but it is partly done, mostly in daily work. For example, you learn full patient assessment but here, you just do a little bit, not everything
Researcher: How much is “a little bit”?
RN: It is hard to tell exactly how much, you think it’s enough… then it’s enough. When I just start working, I didn’t know how much I should do. It made me confused to ask of myself “do I do enough?”
Researcher: It seems like nurses usually do less than what was taught
RN: Sure, not everything you learned is done here… I mean basic nursing work, not very specialised techniques
For example, in nursing education, the norms of patient assessment were comprehensively defined and it was assumed would be applied in practice. The prevailing view, however, was that registered nurses need only to engage in some aspects of assessment and usually the most basic of these were vital signs and breathing patterns.
RN: … I learn to do patient assessment from head to toe, and I used to think that this is what I will do for my patients after graduated during my studying. But, I
found that patient assessment was seen here as taking vital signs, SpO2, looking for breathing….
As noted previously, research in this area has commonly focused on those influencing factors that construct nursing work. Through this lens, nurses are perceived to passively respond to, rather than actively engage in, approaches to practice. A broader insight is to explore the active role of registered nurses as they shift from outsider to insider roles in the clinical settings. Rather than passively conform to the norms of nursing practice shared within the prevailing
CHAPTER 5 89 group, nurses constructed their own norms based on their understandings of how the group defined practice.
On entering the nursing workforce, newly graduated RNs were considered outsiders with different norms of nursing practice. Yet, in order to participate as a member, nurses came to know how nursing practice was defined based on the expressed meanings of other RNs, medical doctors, patients and families (Blumer, 1969; Mead, 1934). Based on the interpretations of nurses, each group expressed differing views on nursing practice but shared a perception of nursing as having a narrow scope of practice. Once the dominant social norms became subjectively meaningful, nursing practice shaped by interactions within the social context became the normalised practice of nurses. Simply put, nursing practice became what was addressed by the social group (health care setting) once nurses participated in that group (Blumer, 1969; Mead, 1934).
The norms noted above were interpreted based on what nurses perceived from the attitudes of other nurses towards nursing practice (Mead, 1934). For example, patient assessment was seen to be constructed to align with the positioning and views of medical doctors, patients and families, and nursing colleagues (Blumer, 1969; Mead, 1934). Indeed, nursing practice was seen through both individual and social perspectives (Goffman, 1959) as Goffman takes into account the impact of situation on human actions. This means that nurses defined the situation within which nursing practice was constructed for provision and then nurses made judgement of the situation to inform the practice performance. Hence, what RNs defined as patient assessment was soon perceived as normal practice for those being inducted into the social world of clinical nursing. For nurses, the act of looking at the patient (observation/inspection) as assessment reflected the expectations of doctors and the actions of other nurses. This was evident in comments from nurses who noted that they were simply responding to orders from medical doctors, to patient and family needs, and to the reactions of nursing colleagues. It was explained that doctors regularly and routinely required nurses to report changes in a patient’s health and to follow orders. This suggests that advanced nursing assessment and intervention was driven by medical doctors and was not a defining feature of an autonomous nursing role.
RN3: We have to report breathing patterns, SpO2, consciousness and vital signs as ordered by doctors. Researcher: How about other assessment information? RN3: It is not needed. It is enough. They (doctors)want only that information.
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Indeed, in this research, the social interactions of nurses, medical doctors, patients and families did bring focus to the appearance of professional boundaries of which the hierarchical nurse-physician relationship and positioning of nursing were the most obvious manifestations. These manifestations contributed to the perception of a subservient nursing role. A body of research argues that professional boundaries between nursing and medicine act as both barriers and facilitators in shaping nursing practice (Mackintosh et al., 2012; Niezen & Mathijssen, 2014). It appeared that nursing practice was more likely to be limited due to the historical appearance/relationship of the nurse-physician. This relationship has long been described as unequal with doctors dominating (Gotlib-Conn et al., 2014; Johnson and Kring, 2012; Schadewaldt et al., 2013). In the research context the position of nursing was relegated to that of a skilled assistant to doctors.
RN15: ... I don’t think that we (nurses) have autonomy to work collaboratively with doctors. In our work, doctors decide and nurses follow…
The above was reinforced, if somewhat differently, by the perceived attitudes of patients and families towards patient assessment. The internalised presumption of patients was that assessments and interventions were simple interventions. The following participant explains;
RN15: They don’t understand what you (nurses) are doing (patient assessment). They (patients and families) just want to breathe more easily, or take medications, or take anything that would make them feel better. They even complain about any nursing assessment. They don’t know that you need to assess their condition before making a decision about an intervention.
The norms of nursing practice reciprocally impacted on social views of which patients and families were representative. Patients and their families approached nurses as assistants to doctors;
RN5: They (patients) express disapproval with us (nurses) when we want to assess a patient over a period of time. They don’t understand that this (patient assessment) belongs to the nursing role. They even mumble like …what do they (nurses) do such a lot? Do they know how to do?…
Yet, nurses also perceived that their colleagues condoned the partial application of assessment skills. Participants described the reactions of other nurses as one factor that dissuaded
CHAPTER 5 91 an RN from undertaking a comprehensive patient assessment. One RN described this process as follows:
RN4: … They (nurses) felt strange when they saw me using assessment skills (percussion, auscultation, palpation). I only used the stethoscope to measure blood pressure, not for auscultation. It is because it (physical examination) is not applied broadly in nursing.
Researcher: So they told you that they felt strange when you used assessment skills?
RN4: No (they did not tell me)… but I can see it in the way they look at me. ..
The meanings constructed around nursing practice thus reflected the understanding of nurses about how the social context defined nursing practice. However, the above does not mean that nurses passively absorbed an understanding of the attitudes of others (Berger & Luckmann, 1966). The nurses were not passive participants but actively engaged in decisions around how to perform in the research situation.
RN: … I think we (nurses) are still able to do more than just looking and taking vital signs for patient assessment. It is up to individuals, you see that some nurses do patient assessment very well but some do not. We (nurses) have lots of difficulties and barriers to comprehensive practice as we studied but we can manage within our abilities. It is how you (nurses) deal with others, how you created to everything happened at that time….
This was because social norms are not static and present options and nurses made choices from those options. In other words, the nurses developed practice norms that were shaped both by the self and existing social norms in the work environment. Nursing practice is therefore understood as the product of the processes of negotiation and mediation (Strauss, 1978; Blumer, 1969; Mead, 1934).
The process of construction of nursing practice thus had two parallel dimensions: 1) negotiation with others to produce social norms around nursing practice; and 2) mediation of social norms and the context to actively self-develop norms of practice. These two processes occurred simultaneously whereby first, nurses worked to understand nursing practice in the
CHAPTER 5 92 world of others and second, through a process of negotiation the nurses self-developed their own norms of practices which then were absorbed into their taken for granted worlds.
While medical doctors were largely unsupportive of autonomous nursing practice, this also did not mean that doctors simply imposed the approach taken by nurses to patient assessment. Rather, nurses interpreted the attitudes of doctors and considered their subjective interpretations to objectively reflect how doctors defined the scope of nursing practice. These interpretations became meaningful to nurses who acted to align their nursing practice with the actions of others (Blumer, 1969; Mead, 1934).
The explanation above challenges arguments that the failure of nurses to fully and consistently engage in patient assessment is solely the product of factors external to nurses, such as the influence of doctors (Douglas et al., 2014; Edmunds et al., 2010; McElhinney, 2010; Osborne et al., 2015). By contrast, the work of Mead (1934) and Blumer (1969) centres on the contribution of social interaction in constructing actions. Blumer (1969, p.53) argued that sociologists explain behaviour in terms of structural factors, such as status and culture, and that psychologists attribute behaviour to such factors as motives and emotions which leaves social interaction treated “as merely the arena in which these kinds of determining factors work themselves out into human action”. Blumer went on to state that:
These approaches grossly ignore the fact that social interaction is a formative process in its own right – that people in interaction that people in interaction are not merely giving expression to such determining factors but are directing, checking, bending, and transforming their respective lines of action in the light of what they encounter in the actions of others (p.53).
Hence, in this research, the ways in which nurses constructed their actions in clinical practice suggested that nurses either sustained, transformed or challenged the norms of practice. This is, as Blumer (1969) put it, a process of mapping out the formation of one’s actions rather than adapting to existing organisational norms.
5.2.2 Mediating nursing practice In the above, it is argued that the construction of nursing performance was more complex than simply norm identification. There were various performance options from which nurses
CHAPTER 5 93 made selections. The chosen performance was judged to be the most appropriate at a point of time in a particular space.
RN: … it is hard for me to describe my practice of patient assessment, because… to me patient assessment is different according to lots of things that happened at that time. If you see me do a simple assessment for this patient this does not mean I do simple assessments all the time. It will be different with other patients, another situation … do not give conclusion that we (nurses) just do simple assessment… I think it is based on what you see at that time…. I mean the things happened that you see….
Nurses worked, therefore, through an ongoing process of mediating practice to engage in a performance appropriate to social norms. The concept of performance draws on Goffman (1959) who suggested that individuals will present themselves, or perform, in ways that are favourable to them. In reflecting this process, nurses interpreted the acts of others and made overt choices about how to practice in particular situations. In other words, prevailing social norms provided parameters around nursing practice within which a number of alternative performances could be constructed. A selected performance was that which was conceived to be most relevant to a situation.
The expressions of others towards nursing practice, however, were diverse and gave rise to the possibilities of alternative realities. One reality was engaging in practice to elicit the the approval of others. Returning to the example of patient assessment, at times nurses positioned nursing practice within the realm of the control of medicine where nurses appeared to relinquish autonomy. The dilemma was that patient assessment was performed to conform to an existing social order in such a way that deemed nursing skills invisible.
RN12: …They (medical doctors) don’t like it (nurses doing a comprehensive assessment)…
And;
RN15: …They (patients/families) don’t want it (a comprehensive assessment)…
And;
RN4: …They (nursing colleagues) don’t do it (a comprehensive assessment)…
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Nursing practice in this research was more than a social action based on predetermined meanings. The performance, as referred to above, incorporated three factors: 1) internalisation of social norms which reflected the social position of nursing; 2) how nursing practice was interpreted and assessed through social interaction ; and 3) legal standards with which nurses covertly and overtly interacted to conform with or to circumvent norms. This meant that there were varying performances that nurses could enact. Any one choice was the result of a judgement that a performance was the most appropriate to the situation.
RN10: … when you work differently from what they (doctors and patients) expect, you are at risk of inviting trouble. For example, if you tried to do more than doctors expect, you become responsible for what happens with the patients. If you do more than what patients or families need, sometimes you are harshly blamed because they don’t trust you. They say: “why does the doctor not come? What are you doing? You should call the doctor. My condition is worse because you did not call the doctor sooner.”
Thus, the work of Goffman (1959) explains how nurses made sense of the gap between standardised practice and the social norms of practice. As argued above, there were multiple ways to mediate nursing practice based on the idealisation of expressions of others. The research data, both interviews and observations, addressed the complexity and diversity of ways that nursing practice was mediated. In some situations, nurses ignored a whole range of patient assessment skills and in other contexts a more comprehensive assessment was performed. Yet, when experienced doctors appeared they sent a powerful message to nurses about who ultimately was responsible for assessing patients. Such performances, as Goffman (1959, p. 35) argued, tends to “exemplify the officially accredited values of a society” and thus reinforced the lack of autonomy for nurses.
RN8: It is up to the doctors. Some are easy going and allow us (nurses) to be more autonomous and these are mainly younger doctors. They respect us (nurses). But others … (shaking head, shrugging)
Hence, nursing practice was interpreted and defined variously and practiced differently based on context. Nurses, while studying, were persuaded that there was such an entity as professional nursing practice. Yet, nurses were taught in a context where practice conformed to the legal norms of the national nursing standards. For example, the norms of the education sector
CHAPTER 5 95 reinforced the perception that nurses performed an independent role in collaboration with other health care professionals. This explained the expectation of newly graduated nurses that they would practice with a high degree of autonomy. On commencing full time clinical work, the nurses had to reflect on situated social norms and re-adjust and to select an action thought to be the most appropriate at any one point. There was initial disbelief when nurses were confronted by negative feedback on their practice which they were sure conformed to education requirements.
The adjustment process was ongoing and a self-belief in a narrowed scope of practice eventuated which nurses came to accept as the legitmate routine of nursing work. The reality of everyday life, as it appears, is sustained through routine and is reaffirmed through interactions with others (Berger & Luckmann, 1989). The reframing of the performance of nurses was grounded in a new reality that would endure until this reality was disrupted and nurses could reassess. Hence, nurses engaged in a dialectic process in communicating with the self and in making choices about their practice (Goffman, 1959). Nurses well understood the disconnect between the nursing education and clinical sectors.
RN10: The reality is different… I mean what I do in reality is different from what I learned from university. When I had just graduated, I worked with a full passion and with the ideal expectation of working independently and professionally. But I realised that it (the reality) was not as I dreamed. Now, I just try to finish my work as required.
The above data excerpt reflects the works of both Mead and Blumer on the “meaning of meaning” where meaning is not given in a situation but emerges from an interpretive process whereby people indicate to themselves the significance of what lies before them and respond to those indications. This point again challenged a common assumption of previous research that the practices of nurses were very largely the product of the external world (Karanikola et al., 2011; Papathanassoglou et al., 2012). Rather, nurses appeared as social actors, if at times largely ignored, rather than organisms that passively responded (Blumer, 1969; Mead, 1934; Reynolds & Herman-Kinney, 2003).
In considering the interpretive process noted above the research explored the phenomenon of the act of looking at the patient as the dominant approach to assessment by nurses. There were various options of actions one of which was looking at patients as the equivalent of assessment.
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Hence nurses were focused on breathing and the maintenance of patient airways and any further observations were considered the responsibility of doctors. As reflected here there was a process of minimising scope of practice.
RN2: If we (nurses) can do what I tell you (assessment of consciousness, breathing patterns and vital signs), I am sure that it is enough for patients… it isn’t necessary to apply all knowledge from university to detect patient deterioration…
The prioritisation of looking at the patient reflected a disconnect between assessment practices in the clinical setting and that taught in nursing curricula and detailed in policy. Based on the national definition of roles and functions toward healthcare professionals in the Vietnamese healthcare system (MOH, 2011, 2012), patient assessment was defined as practice that allowed for the demonstration of professional competencies as follows:
Standard 1: Demonstrate appropriate and adequate understanding of the health conditions of patients, family carers and community
• Criteria 1.1 Assess the health conditions and identify health-related needs of patients, family carers and community
Standard 4: Make nursing care plans
• Criteria 4.1 Do a comprehensive and systematic patient assessment
This discrepancy has been previously and widely explored in research. For example, McElhinney (2010), Douglas et al. (2014) and Osborne et al. (2015) concluded that nurses used more assessment skills when they felt confident and perceived support from medical doctors and other staff. In assuming an interpretive view, the current research points to the ongoing interpretive processes that people engage with in the formation of actions. Nurses were actively engaged in the process of defining nursing practice on the basis of self-indication of the significance of the situations in which they worked.
From this perspective, nurses did not simply absorb the social norms that defined nursing practice. A mediating process existed in every situation where there were spaces for nurses to act in a number of ways. The social norms, at the time of this research, for example, situated the nursing role overtly as dependent and hence the result was a narrowed scope of practice. Nonetheless, the extent to which practice was constrained varied among the nurses. Some
CHAPTER 5 97 perceived it legitimate to assess patients by looking while others referred to the need for a range of assessment skills to be applied. The only shared view among the nurses was the perception that others were unsupportive of comprehensive nursing assessments.
Strauss (1963) argued that the work of Goffman explains human action as a social performance produced through a communication process. Yet, the way performance was selectively decided upon suggested a passive action where performance was formed to convey the desired expression to others (Goffman, 1959). While the taken-for granted practice of nurses had the appearance of a stable social order there were attempts by nurses to negotiate an expansion of practice to incorporate more comprehensive assessment.
Thus, nursing practice was not a stable social performance whereby negotiation contributed to the institution of the presentation. In other words, there was an interrelationship between nursing performance and social interaction processes central to which was negotiation. According to Strauss (1963) everything is negotiable. Strauss applies this argument to rules but it is equally applicable to nursing practice. In relation to rules, Strauss et al. (1964) wrote that; “Rules are not disembodied standards. Like other negotiable products, they are human arrangements.” (p.314)
Thus, in the negotiation process, nurses were actively involved in constructing practice rather than passively responding the desired expressions of others.
RN7: … you (nurses) can decide what you want to do, not them (doctors)….
…. nurses can decide the way to practice … and I do that… yes, it is hard to do what doctors don’t like or support, but it is not impossible. Everyone finds a way to get what we want. The question here is “do you want to do more advanced practice or you just want to stop here?”. Maybe I am a competitive person but… I don’t want to just do very basic nursing care.
Researcher: What do you do?
RN7: (Smiling) I don’t know how to tell you… but it is different according to the situation, doctors… sometimes you have to have a strong voice but sometimse, it is better to be soft … Anyway, in the end you get what you want, is it enough?
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Indeed, there was a negotiated interaction between nurses and others to identify the desired expression towards nursing practice from which performance was selected and presented.
RN12: I think they (medical doctors) have been listening to us (nurses). But I am not sure how much. It is up to the doctors and nurses, how nurses negotiate with them, the situation at that time, bla, bla, bla… but I recognize that we should talk together to get agreement on what nurses can or ca’t do. It’s better that doctors know what we will do and also that we can get agreement with each other.
Norms and rules of practice were not static and were constructed and re-constructed through ongoing social processes of negotiation. There was a positioning of nurses in healthcare with negotiation attempts expressed to form nursing practice and thus nurses actively contributed to the institution of their nursing performance. Nurses made their own decisions to shape the nursing performance in tacit and flexible ways as addressed more fully in the following chapter.
5.2.3 Intuition and nursing practice It is noteworthy that nurse participants, when asked about patient assessment, moved quickly to justify their practice as the product of intuition. Gut feeling, experience, discovery of similarities and differences, and sixth sense were terms/phrases used by nurses to explain how intuition was a central feature of assessment of patients. In appealing to intuition, nurses referred to a process of “feeling” that a patient might be deteriorating that would then prompt further action. Clinical sensitivity” was presented as symbolic of a nurse’s ability to accurately assess a patient through observation. Clinical sensitivity was trusted and argued to be a product of an analytical process because it was based on scientific nursing knowledge and work experience rather than simply subjective
RN22: It is because I have individual clinical sensitivity to detect patient deterioration. I do not know how to describe it but I can recognise whether patients have problems just by looking.
Researcher: Can you clarify the phrase “clinical sensitivity”?
RN22: Uhm… well… (smiling)… I do not know how to explain. It is all about my feeling or …maybe because I cared for patients with X disease for a long time. The early signs or symptoms become familiar. To me, most patients with this
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disease have similar problems. It has become routine for me to make immediate decisions on looking at patients.
The language used to describe the decision-making process above in relation to assessment reflects the value attributed to intuition in nursing practice. Intuition has long been argued to be a unique nursing skill (Benner & Tanner, 1987; Carper, 1978) that sits alongside evidence-based research as legitimate knowledge (Melin- Johansson, Palmqvist & Rönnberg, 2017; Robert, Tilley & Petersen, 2014). In nursing research, intuition is very largely based on the assumption that this approach, at times more so than empirical analysis, can lead to effective decisions (Benner & Tanner, 1987). Furthermore, it is widely accepted that intuition involves both knowing (judgement based on experience) and sensing (gut feeling) (Elbanna & Fadol, 2016). Expert nurses certainly have the ability to recognise and predict patient health-related responses in different situations and to detect similarities and dissimilarities extracted from previous situations to adapt to current situations for appropriate solutions (Benner & Tanner, 1987; Dreyfus, Dreyfus, & Athanasiou, 1986).
The concept of intuition, however, has long been controversial. Benner’s (1984) theory of novice to expert asserts that only expert nurses are capable of the ‘intutitive grasp’ which has raised the question of what an expert in nursing might be and who or what decides (Paley, 1996). A further problem and one related to the view of pattern recognition as expertise is the failure to consider that decision making is open to a range of interpretations (Julmi, 2019). Indeed, as Dane, Rockmann and Pratt (2012) point out, if intuition in decision-making is to be effective, it is dependent upon significant engagement in focused practice in the relvant area. Where this does not occur inviduals will not have the necessary expertise to intuit critical circumstances. Of importance, therefore, are the conditions of decision-making. In the research context the full scope of practice of nurses was arguably constrained by the conditions in which the nurses worked which would undermine the development of intuitive expertise in the nursing domain.
In reflecting the importance of context, participant language also highlighted the working relationship between nurses and doctors. As others have argued, the nature of this interrelationship exerts an effect on the decision making of nurses to the extent that nurses are subject to social control over their work (Mackintosh et al., 2012). Indeed, it has been suggested that nurses perceive patient assessment as a way in which social control feeds into socialisation whereby boundaries are set that discourage nurses from fully engaging their skills (Douglas et al., 2014; Osborne et al., 2015). In the Vietnamese context, nursing practice was confined to a
CHAPTER 5 100 minimum of skills and no autonomous decision-making. The situation reflected the degree of control and surveillance by doctors enabled by the historical positioning of nurses as assistants in medicine.
RN17: …We must follow orders and wait for them (doctors) for further orders. In theory, we have some autonomy to intervene before they come. In fact, they ask us to call them after we have, for example, provided oxygen and taken vital signs.
Researcher: Could you please clarify about “calling them right after providing oxygen and taking vital signs”?
RN17: I mean… they don’t care what we can do or what we have already done or what we will do … bla… bla... bla… they just want us to call them right after we have found something or thought that something was happening to patients. Well… you may do something or may not do anything for patients when the doctors come.
Researcher: So… what happens when doctors come after you have called them?
RN17: Well… they give orders and we follow those orders.
5.3 Summary The focus of this chapter was an exploration of the ways in which nurses interpret and internalise nursing practice in the clinical setting. We see from the research that meaning was emergent which meant that the nurses were always in a situation where they might respond differently and so forms of action were part of ongoing negotiation. Although the actions of nurses were structurally constrained, there was a reciprocal definition of situations whereby nurses and the social context both participated in the world of each other’s being.
The overall argument is that the nurses were active participants in making sense of nursing practice and in making choices about internalising social norms. Nurses were challenged by the tension between the regulated standards of nursing practice and clinical practices that were the reality of the work context. In internalising the social norms of the workplace nurses negotiated on the basis of the significance of indications to the self about what response was appropriate to any given situation.
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A paradox appeared where nurses and doctors proposed conflicting approaches to address patient issues and nurses engaged in processes of negotiation to mediate conflict. Yet, the dominance of medicine over nursing meant that the nature of mediation was largely influenced by social norms. Nurses accepted the following of doctors’ orders as a must-do task while also having the space to broaden the nursing role. It was observed that some space existed for nurses to work independently and to make decisions around patient care. However, observations and interviews highlighted the choices that nurses made to restrict their scope of nursing practice. These choices pointed to a need to understand the broader context in which nursing practice was constructed. The contribution of context in shaping nursing practice is explored in the following chapters.
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Chapter 6 Institutionalising nursing practice
6.1 Introduction The previous chapter argued that nurses actively negotiated the norms of practice which were internalised and became taken for granted. There were, however, broader institutional considerations whereby nurses constructed collective practices through negotiations that linked nurses, as agents, to the institution. Thus, in reflecting the work of Strauss (1978) and others (Goffman, 1972, 1983), nursing practice was perceived as the product of ongoing negotiation both at the micro level and within the broader context. This insight broadened the focus of analysis to understand the processes of negotiation underpinning the institutionalisation of nursing practice at the organisational level.
This chapter focuses on the processes of negotiation by which the social norms of nursing practice were given standing as accepted daily practice. In so doing, the chapter addresses the negotiation and structural contexts wherein nurses progressed to shape nursing practice. The discussion is premised on the interrelationship of interaction and structure and thus transcends the micro-macro distinction in exploring the processes of negotiation. These processes are depicted as a negotiated order which reflects the ways in which nurses interacted at the two levels of an organisation: 1) the level of interactions with relevant members including medical doctors, nursing colleagues, patients and families; and 2) the level of governance and relevant legislation related to nursing practice. Finally, the chapter moves on to broader insight into how salient structural properties constituted negotiations around nursing practice.
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6.2 Nursing practice - the negotiated order Nursing practice was defined earlier as a social product and social activity (Blumer, 1969; Mead, 1934 & Goffman, 1974) that is performed and reproduced within a dynamic structural context where external and internal changes are ongoing. The work of Strauss (1978) gives insight into the contribution of the institutional context to nursing practice where practice is conceived as a negotiated order. A dominant theoretical assumption within the broad tradition of symbolic interaction is that everything is indefinitely negotiable (Benson, 1977a, 1977b, 1978; Day & Day, 1977, 1978; and Dingwall & Strong, 1985). Nonetheless, such an approach cannot explain how nurses in some situations failed to negotiate their practice. Thus Strauss (1978) recognised the dialectic between structural constraints and negotiation and noted that there is always the appearance of some forms of negotiation in an organisation. Hence, the relationship between structural constraints and negotiation processes was based on the argument that;
… not everything is either equally negotiable or – at any given time or period of time - negotiable at all. One of the researcher’s main tasks, as it is that of the negotiating parties themselves, is to discover just what is negotiable at any given time (Strauss, 1978, p.252).
From the above it is understood that nursing practice in the research context was constructed based on negotiation in an attempt by nurses to make practice ever more negotiable. Since organisational structures were permeable and dynamic, negotiations also needed to be revised and renewed over time. This reflected Strauss’s point on the close connection between the structure of an organisation and the negotiated order as articulated below:
The negotiated order on any given day could be conceived of as the sum total of the organization’s rules and policies, along with whatever agreements, understandings, pacts, contracts, and other working arrangements currently obtained. These include agreements at every level of organization, of every clique and coalition, and include covert as well as overt agreements (1978: 5-6)
Nurses were also constantly involved in mediating tensions surrounding nursing practice which involved both the structural and interactive dimensions (Strauss, 1978). At the micro-level of the organisation, tensions appeared among nurses, medical doctors, patients and families around how nursing practice was to be defined and enacted. In order to resolve tensions, there were various interactive attempts to reach agreement on a shared definition of nursing practice.
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At the macro-level, conflicting interests existed in relation to what were considered the norms of nursing practice. The structural context included features of the regulatory system, specific to Vietnamese healthcare, which included formal rules, policies, circulars and competency standards. Regulation shaped the legal working framework of expectations and evaluation toward nursing practice. This meant that nurses were expected to conform to policies in negotiating nursing practice. Negotiations were thus integral to the construction of nursing practice within institutions such as departments and the hospital and salient structural attributes of these institutions were, therefore, important.
6.2.1 Interactions and negotiations As noted in the previous chapter, interactions among nurses, medical doctors, patients and families emerged as one dimension of the mediation of tensions surrounding nursing practice. Various forms of tension have existed in relationships among these groups throughout the historical development of health care. Conflicting interests underpinned tensions as nursing practice was perceived differently based on a range of factors. This point raised the question about formal rules such as the regulation of roles designed to ensure some uniformity in nursing practice. In reflecting the work of Strauss (1978) and others (Day & Day, 1977; Goffman, 1983), formal rules partially shaped nursing practice. Other factors centred on interactions and were underpinned by conflicting interests towards nursing practice.
Historically, nurses in Vietnam have been positioned in a role subservient to medical doctors, having been long referred to as medical assistants rather than nursing professionals (Jones, O’Toole, Hoa, Chau & Muc, 2000, p.317). Since 1997, however, and along with the development of and innovation in Vietnamese healthcare policy nursing has been attributed, in legislation, a professional status where nurses were positioned as partners of medicine and able to work equally and collaboratively with medical doctors. The appearance of the Vietnamese nursing competency standards and revision of the Vietnamese health care regulations around the nursing clinical role (MOH, 2012; 2015) promised a shift in nursing practice from medically overseen tasks to work grounded in a nursing scope of practice. Outside policy, however, nursing work was judged quite differently. The official image of nursing had not translated into practice and the expectation that nurses “follow orders” prevailed. Nurses assumed a subservient position in the hierarchy and a manifestation of this relationship was the perception that practice constituted a set of tasks to be undertaken to fulfil the demands or needs of medical doctors. The systemic belief that nursing existed to serve the interests of medicine permeated the healthcare
CHAPTER 6 105 context and society more generally and was an ideology internalised by nurses themselves. Tensions thus existed between the ways in which nurses were formally educated and prepared for practice and what nurses were allowed to perform in the clinical setting.
RN12: Here, medical doctors make decisions. It does not matter what we (nurses) learn, it is all about what doctors want nurses to do. They (doctors) do not see our role as autonomous, independent, collaborative. bla…bla…bla… They only care whether you (nurses) complete their orders.
A conflict of interest between nurses and doctors related to boundaries around work and this was evident in the research. It was perceived that doctors were intent on reinforcing the status of nursing as secondary to medicine in terms of control. It appeared that doctors preferred to treat nurses as information collectors and task followers. By contrast, nurses aspired to greater independence and autonomy in practice. The interests of nurses and medical doctors thus differed whereby each professional group sought to define what was appropriate in practice to align with respective interests.
RN15: We do not have independence (in working). We just depend on doctors. I don’t think we can have discussions with doctors because they don’t listen. We have to listen, not them… Ah, ma be they listen to us when they ask questions as in an interrogation. For example, why have you not done this, why have you not done that.
Researcher: But now we have the competency nursing standards which state that nurses (especially at bachelor level) are able to work independently?
RN15: Well… you worked differently from what you studied and what they (competency standards) described… Ok, in theory I can work independently … in fact, I can’t if doctors don’t allow it. You cannot tell them like… the standards say nurses can do this, or do that… bla…bla…bla. They (doctors) don’t listen. Some doctors even yell at you. We cannot win an argument with doctors.
Tensions also arose within interactions between professionals, patients and family carers. These difficulties were, however, embedded in power relations and thus nurse-patient interactions were seen to work in a non-reciprocal way. This meant that nurses used professional
CHAPTER 6 106 expertise to ensure that patients accepted interventions without question. The relationship was described as one-way in which nurses used their professional position to dominate.
Observation 9: The observed nurse comes to a patient’s room to deliver medications. One patient expressed that she felt uncomfortable when using the prescribed medications. The nurse stopped the conversation and told l the patient that she had to follow the medical prescription. The nurse said that it was order from doctor and she stopped any discussion …
The social norms of Vietnam shaped a hierarchy of interpersonal relationships among nurses, medical doctors, patients and families where medical doctors assumed most power and patients and family members generally the least. Patients and family members were expected to contact nurses about any matter in the first instance who then reported to medical doctors. Yet nurses were also expected to wait for orders from doctors before providing care to patients. Patients and family members recognised contact with nurses as an essential prerequisite to having a consultation with a medical doctor.
Researcher: Do patients and family members know that nurses have to follow orders from doctors?
RN13: Yes … of course…. How can they not know when you (nurses) listen to their requests and then tell them to wait for treatment most of the time? In some situations, some doctors even tell us in fromt of patients and families that we have to wait for and then follow orders.
Yet, this hierarchy was not static and nurse-patient interactions were more complex. Patients and families changed their behaviour with nurses when doctors appeared. At such times, nurses became largely invisible as reflected in the following excerpt:
RN3: They (patients and families) are inconsistent. They treat us (nurses) differently face to face and behind our backs. In front of us, they try to show their respect. Behind us, they criticise us badly. They use profanities when talking about us. They are kind towards us when there is no one else that they can ask for medical input.
Researcher: What do you mean “no one”?
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RN3: Ah, I mean medical doctors. When there are doctors, they just want to talk with them. They do not care about us or what we do for them. They just remember us when doctors have left.
The three groups within the research engaged various stragies to negotiate tensions around interactions. Indeed, all negotiations were part of the construction of nursing practice where social norms were produced and reproduced continuously. Understanding the products of negotiations was, therefore, essential in explaining how and why nursing practice was shaped and re-shaped.
6.2.2 Professional boundaries – the permeable product of negotiation Professional boundaries were a product of negotiations over tensions in the healthcare setting. The interactions and the interests brought to exchanges either reasserted customary practice or created change. The research analysis pointed to professional and social factors that gave rise to conflict around nursing practice where professional boundaries were the vehicle for resolution. Professional boundaries existed as a manifestation of the social context of nursing, medicine and patients. Boundaries reflected, to some extent, the legal and interpersonal limits governed by professional codes of conduct that determined appropriate norms of practice. Nonetheless, the concept of professional boundaries is complex because of the multilayers of interactions (Niezen & Mathijssen, 2014).
Historically, professional boundaries in healthcare appeared to ensure a monopoly over the interests of particular professional groups. In other words, professional boundaries were used to protect the power of one group over other groups withingiven contexts. The concept of power over nursing practice has long been discussed in nursing research (Allen & Hughes, 2017; Evetts, 2013). In the healthcare setting, there are traditional jurisdictional disputes between nursing and medicine where medical professionals have been able to sustain power over nursing (Bradbury-Jones, Sambrook & Irvine, 2008). Professional boundaries are also established between nurses and patients arguably to increase the engagement of nurses and to establish an effective therapeutic relationship with patients (Mendes, 2017; Feo, Rasmussen, Wiechula, Conroy & Kitson, 2017). Yet where nurses exert power over patients and family members as a result of professional boumdaries nurse-patient interactions may become less important (Mayor & Bietti, 2017). Hence, professional boundaries are considered “the spaces between the nurse’s
CHAPTER 6 108 power and the client’s vulnerability” (American Nurse Association, 2015). Asymmetric nurse- patient relationships were highlighted in the research context whereby nurses used professional authority to compel patients to comply with interventions. Here, role boundaries functioned to protect the authority of those in the more powerful position which suggests persistent professional boundaries.
Interactions among nurses, medical doctors, patients and family members were, however, changeable and thus boundaries were flexible rather than clearly defined. Professional boundaries were “live things” that were able to be negotiated and renegotiated (Aylott, 2011). In health care, as Niezen and Mathijssen (2014) argue, the notion of professional boundaries as shifting has affected task allocation in nursing practice. This meant, in the research situation, that the work that nurses performed in practice varied and thus there was shifting nursing practice rather than one firmly shaped by legal and standards criteria. For example, a nurse might perform a comprehensive patient assessment as the following nurse explained:
RN8: We (nurses) perform comprehensive assessment for patients focused on the major problems of patients. As you know, nurses learn head-to-toe comprehensive assessment. In this area, we assess patients based on their diseases and health problems. I mean we choose which parts of assessment are relevant to a patient’s current condition. It is specific assessment. Of course, we also consider other parts of assessment, but just generally and with less priority unless there something wrong and then we need d further assessment information
Conversely, other nurses undertook limited patient assessments which reflected a dependent practice:
RN2: I look at patients to identify whether they are confused or vague (consciousness evaluation). After that, I look at their breathing patterns. If they are breathless, I will take vital signs. If patients are stable, I will use their vital signs taken daily in the early morning.
Nurses, therefore, had spaces within which to negotiate permeable professional boundaries which enabled them to broaden, or reduce, their scope of practice in some situations. This appeared to be based on differences in how nurse-physician and nurse- patient professional boundaries were established and negotiated. Nonetheless, it appeared that collegial discussions between nurses and medical doctors were normally constrained as evident in the following:
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RN16: No, I rarely discuss patients with doctors… I mean what we should be doing for patients. We just talk generally about patients such as that patient has lots of problems or something like that.
Researcher: What are the reasons that you (nurses) do not discuss much with doctors?
RN16: We can’t develop the discussion. If they (doctors) see that you want to engage with them about patient care, they refuse to answer or just continue the conversation. Some more friendly doctors, they may talk to you more but not very much. Some doctors even tell you directly that it is not your business.
The strategy of negotiation, however, was to optimise control over the construction of nursing practice through the use of soft and flexible approaches. As reflected in the work of Kennedy et al. (2015, p.1808); “individual accountability for decision-making” was adopted where nurses were able to determine their practice.
RN 14: It depends on how much you can deal with them (doctors). You can move forward if you manage them well to make them compromise and, of course, step backward when they are unyielding
Researcher: Can you clarify about moving forward and backward
RN14: It is like … how can I say…. It looks like you push and pull with them (doctors). Based on my experience, you firstly just do something which is over and above what you usually do. If doctors accept this and allow you to do so, you maintain that practice and it becomes the taken for granted daily practice. After a period of time, you may try to add some other additional activities… and check the reactions of doctors. I move forward like that until I receive some symbolic form of rejection from doctors or when I perceive that they (doctors) are uncomfortable with my practice.
Researcher: I think it is a good strategy to gain more autonomy
RN14: Well… I think I have had some achievements but (I am) not successful every time… or … for all doctors. Sometimes, they tell me just to focus on what
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they wrote as orders in patient documents… well… there is 50-50 ratio to succeed … but at least you get a percentage win when you try, right (laughing)…
There was engagement of all, not only nurses, in negotiations to shift professional boundaries. Each of the three groups used strategies to move professional boundaries. In other words, every group sought to expand the extent of their influence over others involved in the context. For example, doctors made use of hierarchical precedents to develop caring and curing plans which directed the activities of nurses, patients and family carers. The social norms valued the dominant group over others whereby the positioning of each group was hierarchically established with patients and family members located at the bottom. Doctors used their authority to determine how others acted rather than negotiate and thus tensions in the context were often ignored.
RN13: Doctors meet patients when they do patient assessments for prescriptions. Patients have direct contact with us (nurses) most of the time. Patients hardly see doctors and they are always told to meet us (nurses) first. We assess them (patients) and collect information if necessary. Then we report to doctors. Doctors may come to meet them (patients) or just give orders to us
Researcher: Why are patients told to see nurses when they want to speak to doctors?
RN13: Doctors want patients to talk to nurses first because not all cases are considered serious enough that a doctor is needed. They (doctors) know that we (nurses) can assess patients and detect or categorise which case needs immediate intervention
Researcher: But why do nurses have to wait for orders?
RN13: Because doctors think that we can’t make decisions about appropriate interventions. They need us (nurses) to give them the information about patients but they don’t want us to do interventions autonomously without their supervision. Of course not all doctors like that. There are some doctors who allow nurses to work independently, just a very few. The majority of doctors want nurses to follow orders.
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The norms of nursing practice which defined nurses as medical assistants continued to underpin the ways in which patients and family members negotiated to get more involvement. These norms directed patients and their families to target medical doctors in the first instance. It was assumed that patients and carers would gratefully accept the healthcare services provided by medical and nursing professionals. There were, however, negotiations yielded by patients and carers to increase their role in decision making related to the received healthcare. Nurses were often ignored because medical doctors controlled patient care in clinical settings, including the ways nurses practiced.
Researcher: Do patients know that they have to meet nurses first?
RN13: At first they did not know but when they stay in hospital for a period of time, they know that.
Researcher: How do they react?
RN13: Most of them accept that they have to talk to us. But they try their best to talk to doctors. For example, if a doctor comes to patient’s room to assess a new admitted patient, other patients in the same room will ask questions of that doctor.
It also appeared that nurses actively limited interactions with patients and families. Managing a patient’s physical condition was the priority and involved the completion of tasks emotional and psychological support were minimised. Nursing practice, therefore, reflected not only how nurses negotiated with others but also how nurses responded to the interactions with others.
Observation 1: The nurse comes to the patient’s room to take vital signs. She says hello to the patient and, tells the patient what task she will carry out. She does not explain anything. The patient is silent and just an arm to measure blood pressure or temperature. She repeats her work from patient to patient until the task is finished. Then she leaves the room.
There were some attempts of nurses to change nursing practice through an expansion of the nursing scope of practice. Yet, the constraints on nurses in achieving change within their jurisdiction meant that there was little space for negotiation. As a result, current practice norms
CHAPTER 6 112 were largely reproduced and had became normalised. In understanding this phenomeon., broader insight into the key features of the structural context was needed.
6.2.3 Negotiations at the structural level Nursing practice took place within an organisation where salient organisational properties impacted on interactions. The context was dynamic because of the complex structure of professional and non-professional groups where multiple perspectives were brought to any issues or discussion. Dimensions of the organisational structure were relevant to the current research in addition to interactions. In the research context, negotiation processes around nursing practice were influenced by the structural and organisational domains of occupational dynamics, nursing policies, and the labour market. There were two ways in which structural issues were interwoven into the working arrangements of nurses. First, there was a disjuncture between nursing policies related to nursing clinical practice and those related to nursing education. Second, there was conflict between use value and exchange value in the evaluation of nursing practice. Each of these issues is addressed below.
6.2.3.1 Negotiations and conflicting interests The disjuncture between education and clinical practice was overtly evident in definitions where the nursing competency standards assumed nursing as an autonomous profession and MOH policies reinforced the control of medicine over nursing in the clinical area. The Ministry of Health (MOH) had entrenched in law a description of nursing tasks and the nursing education system addressed nursing competencies to be expected of nurses in practice. The MOH (circular 07/2011/TT-BYT, 2011) description of nursing activities was limited to a typology of tasks that the nurse was expected to complete. Nursing activities were categorised as 12 items informed by Maslow’s hierarchy of needs. Patient assessment, a responsibility considered integral to the nursing role in the bachelor of nursing curricula, was predictably, if understandably, absent (Appendix G). The 12 items represented the working principles for clinical nurses through activity listing rather than competency demonstration. For example, one item defines the maintenance of the personal hygiene of patients in terms of a list of concrete activities such as;
Item 6: Caring for personal hygiene of patients
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• Issue 6.1. Provide personal daily hygiene care including oral care, body care, support for excretion and clothing changes
The above example does not capture the skills of patient assessment and decision-making that are considered critical to nursing practice. The policy document as a whole was subsequently used to develop a further policy (26/2015/TTLT-BYT-BNV), instituted in 2015, that determined four levels of salary for nurses. A legal framework was fully established that continues to position nurses as medical assistants and nursing work as the completion of pre- defined tasks. Because these definitions of nursing are entrenched in legislation a shift in nursing practice that values nurses as independent professionals, in line with global trends, has become more difficult. The 2015 MOH determination of nursing levels, according to responsibilities for tasks, increased the disjuncture between nursing professional organisations and nursing clinical practice.
Four years earlier, the Vietnamese Nursing Competency Standards (VNCS, 2012) had been developed and published by the Vietnamese Nursing Association (VNA) and legally endorsed, in 2012, by the MOH. The VNCS (2012) was an outcome of the Atlantic Philanthropies (AP) series of three projects undertaken, from 2007 to 2016, as a partnership between an Australian university and Vietnam. The first project was an assessment of the current state of the nursing profession in Vietnam and its needs and was undertaken in 2007 over a period of 10 months. The second project was titled the Strategic Development of Nursing through Nurse Education in Vietnam and commenced in 2008 and was completed over 70 months. The focus of the final project was the Implementation of Competency-Based Nurse Education in Vietnam 2014-16 which commenced in 2013 and continued for 36 months (AP, 2016). The legal endorsement by the MOH of the VNCS in 2012 was perceived as reflecting the success of the AP projects.
The competency framework was viewed as the start of a revolution of reform in Vietnamese nursing. The VNCS (2012) conceptualises nursing practice in broader terms that define nursing as a profession and that position nursing as collaborators with doctors in the healthcare industry. The competency criteria allowed nurses the space to determine how nursing was practiced rather than reduce nursing to a set of discreet tasks. For example, the VNCS (2012) describes the competency of patient assessment in the following terms:
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Standard 1: Demonstrate appropriate and adequate understanding of the health conditions of patients, family carers and community
• Criteria 1.1 Identify the health conditions and health-related needs of patients, family carers and community • Criteria 1.2 Interpret collected information relating to the health condition of patients, family carers and community
Nursing competency to assess patients is also integrated throughout the other standards as the following demonstrates:
Standard 4: Apply the nursing process in constructing care plans for patients, family carers and community
• Criteria 4.1 Conduct a comprehensive and systematic patient assessment
And
Standard 9: Make appropriate decisions on interventions for patients who are deteriorating
• Criteria 9.1 Detectearly deterioration in patients through ongoing assessment to detect changes in health conditions
Yet, the VNCS (2012) document referred only to nursing curricula development and had received vague attention in relevant policy documents emanating from the MOH and the Ministry of Education and Training (MOET). The full integration of the VNCS (2012) was trialled to revise and to develop new nursing curriculum. This full integration would be only officially accepted when the MOET approved the new developed curriculum. This meant that the VNCS (2012) became embedded in nursing education and not in nursing clinical practice. It appeared that the MOH was not committed to the application of the VNCS (2012) in clinical practice and nursing practice continued to be directed by policies such as those discussed above.
Hospitals are interested in task completion and yearly examinations are organised to assess the knowledge and skills of nurses in the majority of hospitals in Vietnam. Every nurse working in a hospital is required to undertake an annual examination. Nurses on maternity leave, those with health issues and those with a master nursing degree are excluded from the mandatory testing. Nurses attend the first round of examination which assesses knowledge and
CHAPTER 6 115 skills and are required to pass to be acknowledged as having met the requirements of the hospital. Nurses who fail the examination are punished through a cut in remuneration as discussed below. The top 16 nurses who attain the highest scores on knowledge and skills continue on to a second round of examination which focuses on communication skills and problem solving. The examination, therefore, assesses nurses at the lowest level of the assessment pyramid where the focus on knowledge and skills.
Universities are interested in the demonstration of competencies that are embedded in nursing education. The curriculum of the University of Medicine and Pharmacy in Ho Chi Minh City (UMP) was explored to exemplify this argument. Since the UMP was a member of the Health Professionals Education and Trainings (HPET) project hosted by the MOH, this curriculum was revised and re-designed. The objectives and outcomes of the bachelor nursing curriculum were directly informed by the VNCS (2012). For example, objectives related to patient assessment appear in the subject “Fundamentals of Nursing 2” as;
MT6 Assess and evaluate the health conditions of patients appropriately and adequately (C2.1, C4.1)
This sixth objective suggested that nursing students were expected to be proficient in relation to two competencies after completion of the subject. The teaching content and teaching and learning methods and evaluation were designed to enable students to achieve this objective. Students’ competencies related to patient assessment were evaluated based on observation of their practice in simulation learning situations.
The nurses recognised the set of competency standards as a legal tool to confirm the space wherein nursing professionals could demonstrate independence and autonomy in clinical practice. The hospital defined minimum standards to which nurses should adhere.
RN9: … I know that we (nurses) have the autonomy to make decisions as the competency standards state but they are impractical. The hospital does not require us (nurses) to practice like that (demonstrate competencies). They (hospital, leaders, and managers) just need us (nurses) to finish our work (nursing tasks)… and doctors do not need either…
Clinical nursing practice was regulated, as noted, by the MOH and nursing curricula were subject to ongoing revision and development in line with international recommended standards
CHAPTER 6 116 from developed Western countries. Different norms of nursing practice existed in the two institutions as reflected in the exchange below:
RN14: I had to learn a lot in the bachelor degree but not all was applicable in practice. Studying at a bachelor level is not different from studying to be a 2-year nurse
Researcher: Can you tell me more about this?
RN14: Well, in the 2-year training course I learned nursing skills (techniques) and I apply almost all of that knowledge in my practice. When I studied for a degree, I learned more about advanced skills such as physical assessment but … to tell you the truth I use zero of those assessment skills in practice. I also learned a lot about t nursing theories, leadership and management and research…. But now I practice the same as a 2-year trained nurse
The VNCS (2012) was invisible in the implementation of policy related to nursing clinical practice. Hence, there was a perception that if nurses applied competency standards in practice they would be legally at risk. This was, in part, the justification for the adherence by nurses to minimum practice standards.
RN11: I know that my practice is lacking compared with what I have learned but … I hesitate when deciding what nursing care I provide… well, you can’t see the problem when nothing (errors) happen. But when something wrong occurs, nursing practice is always the first to be investigated to see where error lies. So if I did something outside the policy and an incident happens to a patient…. even if the error is not related to the extra nursing care, I am still blamed… So why do I have to do more for nothing?
The MOH initially recognised the VNCS (2012) as a mechanism for creating greater consistency of nursing practice across hospitals and universities and the need to shift the focus of practice from task completion to competency-based work. This was reflected in the recommendation of the MOH that the VNCS (2012) develop a new nursing educational curriculum as part of a national project from 2014 to 2020 which focused on Health Professional Education and Training for Health System. Yet the curriculum was at the trial phase and thus limited the impact of the VNCS (2012) in the clinical setting while other policies that had
CHAPTER 6 117 defined nurses as medical assistants had been officially approved. Issues around education do not exist in a vacuum. A key driver in the nursing education field in Vietnam was finance and this factor gave rise to further conflict between the MOH and MOET.
6.2.3.2 Negotiations and commodity values Nursing practice is part of the social reproduction of labour that is subject to a commodification process (Goodman, 2016). This social and economic process brought nursing work to the market to be bought and sold based on commercial interests. In reflecting the work of Harvey (2006, 2014) nursing practice, as a commodity, has a use value and an exchange value with contradictions existing between these values. As a use value, nursing practice provides patients and family carers services that meet their fundamental human needs. The use value reflects the ability of nurses to satisfy the needs of those groups. The use value of nursing work, drawing on the words of Harvey (2014, p.34), is “myriad, seemingly infinite and very often purely idiosyncratic” due to multiple and variable needs of patients and family carers. Nursing practice is also valued and traded in the health industry reflected in the exchange value of the practice. The value is the monetary expression which is described as “uniform and qualitatively identical” (Harvey, 2014, p.33). In other words, money is used to pay for the exchange value of nursing practice in the market of the health industry
In the research context, the use and exchange values of nursing practice were incompatible and gave rise to tensions. The use value of nursing practice was arguably far higher than the exchange value and nursing practice was hence appraised as having lesser value in the healthcare industry as a whole. The disparity between use value and exchange value rendered nursing practice invisible in terms of remuneration and as a result the use value of nursing practice was undermined.
RN9: There are many moments where I think about my job. It is about a balance between life and work but mostly about money. We (nurses) are so poor. Our salary is so low. We do not have extra money like doctors. They have money for small operations (these operations are done in departments not in operation room) and lots of extra sources (a sensitive topic related to ethical issues so information is not reported in detais). Our labour is so cheap. It makes me feel
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sad about my work. It makes me think a lot about where to go with this job. I had to learn a lot to become a nurse and I have to work a lot… But…(silent time)
Nursing practice is, moreover, a social product as noted previously and thus the practice has a social value which is dependent upon material recognition if that social value is to be visible. In the words of Harvey (2014):
…Value is a social relation established between the labouring activities of millions of people around the world. As a social relation, it is immaterial and invisible (like the relation between me, the writer and you, the reader of this text)…
… Being immaterial and invisible, value requires some material representation… (p.48:49)
Money is the material representation of the social value of nursing practice or the value of “how much” the practice is worth in the form of wages (Harvey, 2014). Harvey (2014) argues that there is usually a gap between the representation and the social reality that is represented. This means that money paid for the exchange value of nursing practice is assumed to reflect only some aspects of the practice. The MOH (2015) and MHA (2015) established criteria for the value of Vietnamese nursing practice which was materially represented by the salaries paid to nurses. The criteria were focused on nursing skills to evaluate nursing practice. Yet, nursing practice in clinical contexts is more than a range of discrete skills:
RN13: The payment is not worthy to our work. We do a lot which they don’t see. They only see that we have a wound for dressing but they do not see how big the wound is. It is different between a small clean wound and a big infectious wound with complications. They don’t care and they pay us for dressing one wound. They count the work of nurses as one wound dressing, doing medications twice a day… but we do more than that. Patients call, we have to come to check, even at midnight. How many times do they (patients) call us? And they don’t know.
The criteria were formulated to represent a standardised or routine set of practices. The nurses work, however, in difficult and dynamic working conditions where workloads are not reflected in salaries;
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RN9: The working environment is not standardised but they require us to follow international standards. Do international standards allow nurses to take care for more than 16 patients a shift? Where do such standards come from? Which countries use such standard? Nurses are required to standardise nursing practice but the working environment is not standard. How can we manage?
There is a significant shortage of nurses in the Vietnamese healthcare system: 83,851 nurses are needed to achieve the ratio of 20 nurses per 10000 people throughout Vietnam by 2020 (MOH, 2015). In the clinical setting, nurses take care of approximately 16-24 patients per shift in hospitals which is known to significantly influence nursing practice and patient outcomes (Joyner, Shefer & Smit, 2014). There is a concern that given the nursing staff to patient ratios priorities of care undermined nursing practice. Nurses were forced to make choices about the most essential care for with the result that much care was missed. Heavy workloads meant that nurses were unable to practice in accordance with the requirements of standards set down in policies.
RN4: We (nurses) cannot manage with 4 nurses taking care of over 100 patients on a night shift. We have to categorise patients according to some priorities. Patients in room number 4 have the most severe conditions so we pay more attention to this group. And for patients who have stable conditions, we just provide basic care such as medications twice a day, taking vital signs…
Nursing wages concealed the value of nursing practice. On this point, in a more abstract explanation, Harvey (2014) noted;
Money, we can say at the outset, is inseparable but also distinct from the social labour that constitutes value. Money hides the immateriality of social labour (value) behinds its material form. It is all too easy to mistake the representation for the reality it seeks to represent, and to the degree that the representation falsifies (as to some degree it always does) we end up believing in and acting upon something that is false. In the same way we cannot see the social labour in any commodity, so we are particularly blinded to the nature of social labour by the money that represents it. (p.49:50)
Thus the political system devalued nursing practice through the use of criteria that was inadequate in materialising the social value of nursing practice as money. Since social values are
CHAPTER 6 120 invisible, society judges nursing and nurses in terms of the wages that the profession attracts. Society therefore devalues nursing practice or, as Harvey (2014) would note, is blinded by money.
RN22: They (patients and family carers) do not respect us like before. In this period of market economy, money is everything. They use money to value a person. I perceived that they value us very poorly. Just 10 years ago, they respected us but now, they complain a lot. If anything happens, they call the hot line to complain. Is it because this is the period of technology that everything must be clear?
Researcher: Sorry, but I still cannot grasp your ideas
RN22: Uhm…for example, they call us and if they have to wait for a long time to meet us they complain. It is not wrong that they complain but what makes me feel angry is that they do not have sympathy for us that we have other things, more serious, to do before we can come to see them. They think that I paid for you and you have to do anything to meet my needs
Salary levels are also unlikely to reflect the quality of nursing practice since the increase of monies paid varied according to educational qualifications and years of working experience. This means that nurses who had completed tasks at work received similar payment as peers who demonstrated competencies in clinical practice. In other words, nurses at different educational levels were seen to provide similar quality of care but received different wages. The payment system was also based on number of working years and so higher wages were linked to length of service and not performance nor education. Competencies were not accounted for in terms of wages and there was no recognition of critical thinking and decision-making skills that result from higher education.
It appeared that nurses were positioned in precarious employment as nurses had “individualized bargaining relationships with employers, low wages and economic deprivation, limited workplace rights and social protection and were powerlessness to exercise legally granted workplace rights” (Benach et al., 2016, p.234). Nurses working within such conditions have little bargaining power over those areas of practice that cannot be readily measured (Folbre, 2017).
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RN22: Do not ask for a higher salary. We (nurses) have to accept that salary because there is nowhere to go. Can you ask for more? No. So why do we have to ask for more? Why do you keep it in your mind all the time and then become disgruntled? You can’t do anything so why not just accept it and make things easier?
Researcher: Do you think about changing jobs?
RN22: Lots of my colleagues complain about the low salary and compare the salary with other hospitals. But I think they pay you more and they require you to do more. You are paid for what you do here. So don’t compare.
The gap between the use and exchange values of nursing practice was vaster because of the gender identity of the occupation. There is well recorded and historical gender segregation in organisations where males dominate over females which causes inequality in unequal pay and rewards (Acker, 1990; 2006). Hagell (1989) argued that “male” scientific and medical work was considered of greater value than “female” behavioural care work. Care has long been defined as “feminised labour” understood as unskilled, ready and abundant in health care (Glenn, 1999). Nursing is thus perceived as “women’s work” and characterised as the soft and largely unmeasureable skill of caring, nurturing, and empathy (McDowell, 2015). Nursing is perceived as women’s work which, as Harvey (2014) noted, was considered as ‘natural’ work and thus unskilled;
There has been a long history, for example, of defining skilled labour in gender terms such that any task that women could perform – no matter how difficult or complex – was classified as unskilled simply because women could do it. Worse still, women are often allocated these tasks for so-called ‘natural’ reasons (everything from nimble fingers to a supposedly naturally submissive and patient temperament) (p.165)
Johnson (1998) suggested that caring work can be seen as a gift that employees, such as nurses in the research context, give health industry. The gift of giving to patients and family carers reflects what Gordon and Nelson (2005) argue is the virtue script of the 19th century, that continues to prevail in nursing, where nursing work is perceived as moral action with its own non-monetary rewards. This imposed upon nurses a moral constraint of responsibility and thus the unpaid work of nursing practice is seen as a natural component of the profession. Such
CHAPTER 6 122 arguments were made to avoid difficult questions related to equality of wages, rewards and motivation over the values of nursing brought to the health industry. Nursing practice was treated as a non-commodity while nurses worked in a commodity economy within which nurses were contracted to provide a measureable product.
Researcher: Do you have an answer about “what your future is with this job”
RN9: Well… uhm… it is hard to answer this question… Maybe because even I still do not know the answer. I want to provide quality care for patients. I want to finish my work well…But I feel tired. Sometimes I am angry and I want to ask why they (maybe the government) pay us (nurses) so little. I even think like…you (the government) pay me like that… OK, fine, I will just finish my work doing the minimum. Please do not report this to my boss (laughing)…I just joking, don’t worr. Well, but I think about patients and I feel sorry for them. It stops me thinking negatively at that time…. But thinking is easier than doing, right? I know that I should provide much better care (more comprehensive care) for patients but … ah (sighing) … my commitment is becoming less over time. But I am confident that I do as much as I can for patients. Again I don’t know when I will stop trying. It seems as though you will run out of stamina and you can’t continue anymore.
Hence, gender existed as a constitutive element of organisational logic that affected the process of defining and evaluating work.
RN 3: …. Eh…actually, male nurses such as us have … more voice… how can I say … like we can talk easier with patients and families.
Researcher: and doctors?
RN3: lots of time but not all…
Or
RN21: …it is not really that we are paid higher wages than female nurses, I think salaries differ based on experienced years of working… but… we can say we have more opportunities… Researcher: what do you mean about opportunity?
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RN21: … like studying high technologies as haemodyalisis… or working in a position of technician like administration of mechanical ventilators and instruments….
Wages in nursing are developed on the basis of work evaluation and inferior wages reflect the influence of, among other factors, gender. Such judgements suggest a decrease in the exchange value of nursing practice where gender enters into consideration of the value of medicine and nursing. The exchange value is determined within the context of unequal power relationships that, again, devalue nursing (Xerri, 2013). In this research the exchange value was socially constructed and reflected the interest of power elites within a hierarchical health system, the dominance of medicine over nursing, and the positioning of women in Vietnemese society.
6.3 Summary Nursing practice was explored in this chapter as a negotiated order with which nurses, as members of the organisation, must constantly engage. The chapter offers insight into changes and stability in nursing practice drawn from the ways in which negotiation processes are embedded in the clinical setting. Negotiation processes were worked through and sought to solve tensions that occurred at all levels of an organisation; the micro-level of interactions among involved social actors and the macro-level of structural context. There was engagement of all involved members in negotiations for improving one’s position in the healthcare context which contributed to shaping nursing practice. Yet minimal changes occurred in the system of healthcare in Vietnam where occupational dynamics, nursing policies and labour market as salient properties of the structural context.
It was argued that nursing practice was a product of negotiations to solve tensions that occurred in spaces that reflected the ways in which different stakeholders asserted power or were the subjects of power. The use of space as integral to the reproduction of power relations is explored in the following chapter.
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Chapter 7 Social space of nursing practice
7.1 Introduction Actions always happen within a space (Giddens,1984; Harvey, 1996) and hence nursing practice is understood as embedded in the particular spatial form of healthcare organisations. This chapter addresses space, not as an inert thing, but as a functioning practice that provides a frame of reference for understanding the construction of nursing practice. A dialectic analytical approach was applied to reveal how nursing practice was produced within the particular spatial form of the research context. The chapter also explores the significance of the spatial positioning of nurses which nurses made use of in negotiating practice. Space is thus also posed as the product of social relations and actions produced and reproduced by nurses to challenge taken- for-granted nursing practices that had become institutionalised social norms.
7.2 Nursing practice and the social space Nursing practice is a process of internalising and institutionalising the actions of nurses. A comprehensive understanding of the social processes underpinning nursing practice, in all their complexities, also includes the spatial forms within which practices take place (Harvey, 1973). There were variations in the practices of nurses in the research settings dependent upon the spaces in which nurses and other social actors were embedded. Spatial forms were both organised and manipulated in ways to generate various symbolic meanings which nurses interpreted to shape practice. In other words, spatial forms contributed to the construction of nursing practice whereby nurses actively used different spatial frames to direct practice. As Harvey (1973) wrote;
The problem of the proper conceptualization of space is resolved through human practice with respect to it. In other words, there are no philosophical answers to philosophical questions that arise over the nature of space – the answers lie in human practice. The question “what is space” is therefore replaced by the question “how is it that different human practices create and make use of distinctive conceptualizations of space? (Harvey, 1973, p.13-14)
An interface appeared between the geographical and social realms of nursing practice. On one hand, negotiation was described through the analytic of the social norms of practice or the
CHAPTER 7 125 interactions between social actors within the context. On the other hand and reflecting Harvey (1973), the significance of the spatial dimensions of negotiations over nursing practice depended upon the location of nurses within the context and hence the contribution of space.
Yet, Harvey (1973) emphasised the problem of implementing both social and spatial approaches to examine a phenomena due to the difficulty of conceptualising the interface of these two “languages”.
…These two language systems have rather different properties, and it is therefore dangerous and difficult to mix them in the individuation process…
…the process of individuation at the interface between the social and geographical imagination requires a thorough understanding of two rather different languages and an adequate methodology to govern their combination… (Harvey, 1973, p.38-40).
Harvey (1973, p.44) then argued for an approach that could accommodate both spatial forms and social processes within analysis and described the approach of working at the interface as “an iterative one in which we move from spatial form manipulation (with social process held constant) to the social process implications (with the new spatial form held constant)”. Hence, there was a focus on how nursing practice made use of space and created new spatial forms in the dialectics of social and spatial change. As Lefebvre (1991) argued:
(Social) space is not a thing among other things, nor a product among other products: rather, it subsumes things produced, and encompasses their interrelationships in their coexistence and simultaneity – their (relative) order and/or (relative) disorder” (Lefebvre, 1991, p.73)
In reflecting the work of Lefebvre (1991), three analytical approaches were adapted to investigate how spatial forms were produced: 1) a formal analytical approach which raises the significance of daily practice to produce spaces; 2) a functional analysis that brings attention to the ways in which spaces, such as the hospital and units in which nurses practice, are designed and managed to reinforce power; and 3) a structural analysis which focuses on how occupants, such as nurses, produce various forms of spaces based on lived experiences. The three approaches raise the significance of three dimensions which are interrelated in the production of social space (Taylor & Spicer, 2007). The spatial practice of nursing, the spatial planning of
CHAPTER 7 126 nursing practice and the spatial experiences of nursing practice were thus explored at the point at which “all come together into a single moment of social space” (Taylor & Spicer, 2007, p.335).
7.2.1 Social space of nursing practice The working spaces occupied by the nurses both reflected and constructed social practice. A description of a space depicts the physical arrangement of functional rooms as follows;
Observation 1: …Basically, every department has one staff work room which is located in between the two corridors of patient rooms, one staff meeting room used for hand over before the morning shift which is located outside the department, one resting room for medical doctors opposite of the staff meeting room, one resting room for nurses inside the department, one storing room for medical instruments and one room for small medical interventional techniques. In surgical departments, the right hand corridor is usually used for patients who are waiting for scheduled operations while post-operated patients are situated along the left corridor. In the medical surgical department, patients are located in rooms based on health conditions. The most severe patients are located near to the staff working room and the nursing resting room.
Nursing practice differed in each space due to the functions of those spaces. For example, the majority of documentation of patient information was undertaken in the nurse staff room and nursing practice was provided at the bedside. The nature of these spaces was determined as physical and thus such spaces appeared as “things”, or immobile containers, within which nursing practice was performed and in a neutral manner (Harvey, 1973). Yet and as has been argued, nursing practice was a social product of processes of negotiations (Strauss, 1978) and hence these spaces were beyond “things” (Harvey, 1973).
Andrew (2003) and Andrew and Shaw (2008) explored the interface between space and nursing behaviour where nurses were seen to make use of spaces in negotiation with other members. In Andrew’s work, spaces provided symbols for nurses to direct nursing practice and were also a manifestation of negotiation strategies. In Harvey’s work, a particular spatial form created within a context determines the social processes that construct human behaviour (Harvey, 1973). Of significance was that the construction of nursing practice in the research
CHAPTER 7 127 setting occurred within a relational space. Harvey (2006, p.121) describes this concept as follows;
… the view of relative space proposes that it be understood as a relationship between objects which exist only because objects exist and relate to each other. There is another sense in which space can be viewed as relative and I choose to call this relational space …
Relational space, as addressed in Bourdieu’s theory of practice, refers to the interrelations between actions and the social space in which the subjects are situated (Veenstra & Burnett, 2014). In reflecting the work of Bourdieu (1985, p.196), nursing practice was defined based on the “relative positions within that space”. The negotiation processes were assumed to be interconnected with the dispositions of nurses in that context (Bourdieu & Nice, 1977; Bourdieu, 2000). Yet again and as the point is made above, the connection of physical space with physical geography or material properties ignores the recognition of social space inhabited within it (Bourdieu, 2018). As Bourdieu (2018) wrote;
The structure of social space thus manifests itself, in the most diverse contexts, in the form of spatial oppositions, an inhabited (or appropriated) space functioning as a sort of spontaneous metaphor of social space… (Bourdieu, 2018, p.107)
A focus on space thus begins with how the physical working structure of the nurse participants was integral to the broader structuring of practice. According to Harvey (1973, 1996, 2006), this structure is seen as the constant environment within which all actions unfold. The two main physical working environments in which the majority of nursing practice took place, the staff room and patient rooms, were significant in the exploration of how nurses practiced.
There were differences in the physical structures of the staff room and the bedside areas that suggested contradictory notions of nursing practice; closed versus opened and individual versus interactional. The staff room was a closed space and positioned occupants hierarchically.
Observation 1: The staff room is divided into two small rooms, one for nurses and one for medical doctors and the rooms are separated by a partition. Nurses sit with nurses and doctors sit with doctors. Only the head nurse sits in the doctor’s room presumably to conduct leadership and management work. The staff room has closed doors with mirrors and patients and family carers stand outside if
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waiting for a nurse or doctor. Patients and family carers are allowed into the room when medical doctors want to have a discussion with them.
Hence, nurses, medical doctors and patients were each positioned in relation to this physical space and to each other. There were also well defined and detached spaces occupied by the two professional groups. For example, the partition located in the medical and nurse staff rooms created visible physical territories. Additionally, the closed doors and mirror windows separated professional staff from patients and family carers.
Observation 8: One group of medical doctors sit in the medical staff room writing patient reports, prescriptions and medical orders. Nurses sit together in their staff room writing up nursing notes. Nurses sometimes come to the medical staff room to collect completed documents to check medication and nursing orders. Each group engages in group talk (doctors talk with doctors, nurses talk with nurses). Sometimes, a doctor briefly comes to chat with nurses and then quickly moves away. When there is unclear information or orders in a document, a nurse asks (the nurse remains in the same place and talks loudly with the doctor who wrote such orders in the next room) the doctor for clarification or change…
… mostly family carers, and patients in some cases come to the staff working room for multiple requests. When patients and family carers come, they stand outside the room, in front of the windows. They knock on the mirror window. A nurse will come to open the window and ask what do they want…
The staff room was shared by nurses and medical doctors and yet the space was organised into discrete areas as though the appearance of nurses in the doctors’ area might signify an encroachment of space. Both nurses and doctors avoided going into the respective rooms of the others. Furthermore, the area allocated to patients and family members reduced the engagement of this group with health care professionals. While nursing practice was a negotiated order and nurses sought to make practice more negotiable (Strauss, 1978), the organisation of space in the research setting was resistant to change. Indeed, the spatial form supported individual rather than interactive social spaces. Any infringement of the space of doctors by nurses might then risk being attributed to an individual or individuals. Furthermore, the separation was publically visible and thus the material reality of this spatial form limited the space in which nursing practice could be negotiated.
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It is notable that the Vietnamese Nursing Association (VNA) (2012) asserts that nurses should engage with patients as the centre of care which suggests that nurses increase interactions with patients and family members for more engagement (Domain 1, Criteria 10, 11, 12, 13, 14). The VNA (2012) also notes that nurses should engage more with doctors to improve collaboration and the quality of nursing care (domain 1, criteria 15). Nonetheless, the spatial formation of the research context physically separated nurses, doctors, patients and family members and thus functioned as a barrier to greater collaboration and interaction. Patients and family carers were treated as outsiders by nurses and doctors and nurses were perceived as strangers when entering the space of doctors.
Conversation 8:
Researcher: I noted that nurses and doctors rarely have discussions about patient or routine care.
RN: We rarely discuss it. It is too busy here
Research: You could have a conversation when you sit together and write patient reports?
RN: We don’t sit together… no, not that meaning… I mean…. It is strange that nurses and doctors sit together and discuss patients. You sit there (in the doctor’s room) and they move away…. Or they sit there but don’t talk… I mean talk about patients… You can sit there and listen to them … but I don’t know what to talk about…It is strange that you sit there, listen to them and look at them… I think doctors don’t like it… I don’t like it either.
A more interactive nursing practice was observed in the open space of the bedside. The scope of nursing practice expanded in the space that nurses, medical doctors, patients and family carers shared. It appeared that here nurses were able to have discussions with medical doctors and patients that were limited in the other spatial contexts.
Observation 1: There are 10 beds in each patient room which are arranged into two face-to-face rows. One patient has one family carer staying in the room who has to stand outside when doctors and nurses come into the room. Nurses and doctors may or may not appear in patient rooms at the same time. Doctors carry patient records into the room and put them on the bedside table. Doctors stand by
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bedside and have a quick look at documents to get information of patient’s health progress. Doctors then approach patients to assess them (asking and doing physical examination). Prescription and medical orders are usually written in the staff room. There are various nursing techniques that nurses do such as medications (oral, injection, infusion etc), wound dressing, tube feeding…. Nurses, doctors and patients may have discussions while working with patients.
Thus, social space was realised in the two examples of physical spaces through a certain order of co-existence of inhabitants as agents and material properties. In the research context, the location of barriers such as partitions or closed doors and windows characterised a social space similar to class stratification. The situation of nurses, medical doctors, patients and family carers in physical spaces reflected the hierarchical positioning of these groups within the broader social space. Nurses had limited access to space understood as the realm of medical doctors and patients and family carers needed permission to enter hospital spaces outside patient rooms. The physical arrangement of space constructed order around routine work which reflected the dynamic social relationships between the groups.
Observation 1:… There are resting rooms, one for nurses and one for doctors. The resting room for doctors is located outside the department entrance. The resting room for nurses is inside the department which is next to the room numbered fourwhich is set up for the most severely ill patients. When something unexpected occurs, patients and family carers come to the staff room to call nurses. Nurses then come to a patient room to assess the patient. If the problem is not significant, such as fever, infusion obstruction…, nurses provide interventions and record in patient documents. If nurses recognise that patients are deteriorating or are severely ill. One nurse will use the phone to call doctors while the other nurses will start emergency procedures.
There is a reciprocal relationship between space and the social interactions that construct space and space, in turn, constructs social interactions (Harvey, 1990). While space is inseparable from social relations, the product is both a thing and a process of social relations and actions (Lefebvre, 1991). And daily practice imposes its “own meanings, values and understandings of space” (Zieleniec, 2008, p.21) and from that a spatial form of social space was reproduced.
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Lefebvre (1991), on the production of space, focuses on the contribution of the form and content of daily practice to produce a social space. In the words of Lefebvre (1991, p.149);
The interaction between form and content and the invariably concrete relationship between them are the object of analyses…
… In the case of spatial forms, for example, the form of curve is mediated by the curved line, and the straight form by the straight line…
Taylor and Spicer (2007) argued that space was also understood as “produced and managed in the experiences” of inhabitants and hence there were different spatial forms based on how nurses experienced and interpreted meanings of various symbolisms of the space which they inhabited. As noted, nursing practice is collectively constructed through social processes based on interpreted norms of practice shared among nurses, medical doctors, patients and family carers which became taken-for-granted daily practice. Nursing was limited in form and content as shaped by norms and power relations that produced a narrow spatial form of practice. Underpinning form and content were the interpretations of nurses which confirmed practice as dependent on, or subservient to, the medical profession. Within the spatial form, some actions were ensured, others highly desired and yet others were limited (Lefebvre, 1991).
RN19: I look at patients and identify whether a patient needs an intervention. I do some basic interventions to make sure that patients are alive. Then I call doctors for orders…
…We (nurses) have to follow orders, we rarely discuss…
And;
RN 21: Firstly, I assess patients generally by looking at breathing and consciousness….
… nurses need to call doctors and follow orders….we just chat generally, we don’t discuss professional issues….
The assessment method of looking at a patient and following orders had become the daily nursing practice which was ensured where discussion as a strategy to broaden scope of practice was limited by the spatial form of nursing practice. Yet, Lefebvre’s work on space, which is tied to everyday life, or everyday practices in the more focused topic of the research, is not simply
CHAPTER 7 132 understood as the frequency of daily practices, but of distance at the level of everyday practices (Beyes & Steyaert, 2011).
As noted previously, nurses self-interpreted the meanings of patient care to identify and justify the norms of limited practice.
RN3: We have to report breathing patterns, SpO2, consciousness and vital signs based on orders from doctors.
Researcher: How about other assessment information?
RN3: It is not needed. It is enough. They (doctors) just want that information
…
RN3: I don’t discuss patients with medical doctors
Researcher: What prevents you from having these discussions?
RN3: I have nothing to discuss.
…..
RN3: I collect vital information on patients for documenting t and then call doctors for orders …
Nurses who adhered to the contextual norms of patient care practiced within confined boundaries. This suggests that nurses reproduced a spatial form that created and maintained boundaries. Nurses also contributed to a spatial context where interactions with other health professionals were minimal.
Observation of RN3: From 8:30am to 9:00am, the nurses continued to do medications for patients at the bedsides (this work started at 7:30am) while a doctor was assessing patients. The nurse focused on finishing the work. After that, the nurse came back to write in patient documents in nurse staff room until 10:15am. There was chatter between the nurses and other colleagues but no professional discussion. Sometimes, the nurse came out of the patient room to change a fluid infusion or when patients had concerns…
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The contribution of nurses to a spatial context was more overtly demonstrated in the shift from patient-centered to doctor-centered spatial forms which revealed the movements of nurses around medical doctors whereby patients and family carers were spatially separated in daily nursing practice.
Observation 18: (The patient had respiratory failure that needed emergency interventions). Three nurses made arrangement to provide interventions for patients. They stood around the patient with instruments besides. When one medical doctor came, the three nurses step back and waited for the doctor did patient assessment. During this time (a very short time), one nurse prepared instruments, one nurses prepared emergency medications and the third one took vital signs again. The doctor asked for information about the patient (vital signs…) and gave orders. The nurses carried out the orders while the doctors observed and re-assessed the patient (In other situations, the doctor might have to do the interventions)…. The patient’s wife was asked to stand outside the room and to wait….
… After the medical doctor went away with the patient’s wife, the three nurses continued their work around the patient….
It appeared that the three nurses directed movements that brought the medical doctors to the centre of the activity rather than the patient. Patient-centered actions were then re-established once medical doctors were absent. There were, therefore, significant shifts in social interactions when medical doctors joined in the context. This interrelationship was conceived from the following conversation with the observed nurse which reinforced the point that nurses repositioned themselves physically and in their practices when in the presence of medical doctors.
Researcher: To me, it looks as though the practice of you and your colleagues changed when the doctor appeared. I mean that you were more autonomous in interventions and approached the patient more than when the doctor was there. Is it right?
RN18: Well… I can understand what you saw t… It was like…the rule… When there is a doctor, we should… usually have to… wait… although we know what to do… of course when no doctor is there we have to do first and report, patients
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cannot wait … Of course in some very acute situations we have to call and wait for doctors…. So because we have to wait we try to manage the time, we call “golden time” in emergency, by doing some preparation in relation to orders like instruments, medications… that we can do orders right at the time they are given… Because of this, you saw that we… not really but looked like we stepped back from the patient…
Nurses re-produced a spatial form to align with the appearance of a medical doctor. Changes in social interactions promoted spatial changes and hence nursing practice dialectically moved between dependent and independent status. In other words, the spatial form of nursing practice was produced and re-produced in the dialectic of social relations.
The above accords with the empirical work of scholars that highlights daily practice as one crucial mechanism for the production of social space (Beyes & Steyaert, 2011; Wapshott & Mallett, 2012; Wasserman & Frenkel, 2011; Zhang & Spicer, 2014). The work of Lefebvre (1991, 2003, 2008) asserted that everyday life is more than “a repository of larger processes” within which, as Zieleniec (2007, p.21) pointed out, everyday practices contribute and;
…impose their own meanings, values and understandings of space by the routine practices and techniques of everyday life…(and)
…Those who create and define the meanings, forms and practices in space (as well as time) can set the rules by which that space is used…
7.2.2 Symbolic power, social space and nursing Power “is at its most salient when it is embedded, embodied and thus taken as natural and inevitable” (Dale & Burrell, 2008. P.44). In the everyday practice context of nursing, space presents as normal and natural. Yet, nursing practice is constituted by spatial relationships (Ropo, Salovaara, Sauer & De Paoli, 2015). According to Foucault (1961, 1963, 1975) and Lefebvre (1974, 1992), spatial relations in human practice exist as power relations shaped within the macro-level structures of space. However and in reflecting the work of Lefebrve (1974), in this research, there was also a social space linked to power relations at the centre of the continuing processes of negotiation around nursing practice. All social actors simultaneously belonged to this social space which was constantly changing because of a need to transcend, and
CHAPTER 7 135 then retreat once more within, the conceived professional boundaries. Thus, geographical space was not simply a determinant in the formation of the social space of symbolic power but was constantly reproduced through the ways in which everyday lives were acted out within the space (Beyes and Steyaert, 2012; Wapshott and Mallett, 2012).
Symbolic power was clearly embodied within the spatial forms of nursing practice where relationships among nurses, medical doctors, patients and family carers produced a “front of objectivity” (Bourdieu & Wacquant, 1992, p.258) that obscured the ways in which rhetorical and other strategies were used to create symbolic power that legitimised a particular order. In other words, nursing practice was shaped by particular spatial forms of symbolic power which positioned all groups into hierarchical and relatively fixed social orders. Physical distances between nurses, medical doctors and patients reflected the social distances among these three groups since spatial distance was compatible with social distance (Bourdieu, 1990). Hence, the spatial forms were the materialisation of power relations. In the words of Foucault (1991, p.148);
It is spaces that provide fixed positions and permit circulation; they carve out individual segments and establish operational links; they mark places and indicate values; they guarantee the obedience of individuals, but also a better economy of time and gesture. They are mixed: real because they govern the diposition of buildings, rooms, furniture, but also ideal, because they are projected over this arrangement of characterizations, assessments, hierarchies.
The positioning of the head nurse in the same room as doctors was symbolic of a division between two groups, one obviously more powerful. There were no doctors situated in the nursing staff room which reinforced the prevailing hierarchy. There was the relationship of space that materialised as physical distance between nurses and medical doctors and secured a social order. In other words, the physically located positions of nurses constituted the social position of this group in the research context.
Observation 12: One nurse holding patient records comes into the doctor’s staff room and sits down with a group of four doctors who are writing prescriptions and medical orders. The nurse focuses on writing patient notes. Sometimes, the nurses listen to conversations among doctors and contribute one or two comments. Not long after (approximately 5 minutes) one doctor stands up and goes away. The next doctor goes away after 2-3 minutes. The third doctor stands
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up after 2-3 minutes with the final doctor following. The nurse sits alone and continues to write patient reports. After 1-2 minutes, another nurse comes and sits down ….
The social position of nurses in the Vietnamese healthcare context was, moreover, legally reinforced through government policies in relation to nursing scope of practice and regulation of incomes and expenditure. As such, the social distance between the nurses and medical doctors was also reinforced through a regulated division of labour. According to the MOH (2015) (Circular numbered 2922/QD-BYT on the healthcare workforce from 2015 to 2020), the standard doctor-patient ratio in tertiary hospitals was one doctor for every five patients to be increased, by 2020, to one doctor for every three patients. This meant that the workload of medical doctors was calculated in terms of numbers of patients.
The nurse-patient ratio was, however, not clearly defined within official government documents. The nurse-patient ratio was deduced from the nurse-doctor ratio of one doctor per two nurses. This meant that two nurses were theoretically assumed, on paper, to care for five patients. A further measurement scale was adapted for the purposes of determining the value of nursing practice based on a role definition in which professional and ethical criteria were embedded. The division of labour in nursing was calculated on an ideal number of patients in a particular context. Nonetheless, with a bed usage of over 200% in tertiary hospitals in Vietnam (MOH, 2014), nurses routinely cared for more than 10 patients per shift. The extent of workload was thus unrecognised since the value of nursing practice was based on a role definition and presumed patient load and hence the reality of nursing practice was obscured. Nurses, moreover, lacked the power to make nursing practice visible. In the words of Bourdieu (1985, p.209);
The symbolic power of agents, understood as the power to make things seen – theorein – and to make things believed, to produce and impose the legitimate or legal classification, in fact depends, as the case of the rex reminds us, on the position occupied in the space.
Power was translated into social space which “retranslates itself, in a more or less direct manner, into physical space in the form of a definite distributional arrangement of agents and properties” (Bourdieu, 2018, p.107). Power underpinned the reproduction of social relations between the three groups and was embedded in the construction of the actions of each group.
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This meant that nursing practice materialised and was revealed through the social positioning of the nursing group within the physical space.
As the data examples throughout this chapter indicate, the constraints of symbolic power shaped nursing performance and the construction of nursing practice in minimising spatial access and thus movements of nurses within the context. On the one hand, spaces were not equally accessible to nurses where some spaces, such as the medical staff room, medical treatment room and staff meeting room, were understood to be primarily the domains of doctors unless invitations to nurses were forthcoming. The spatial constraints underpinned the identity of nurses and functioned, what Sauer (2015) referred to, as a classifying device. On the other hand, there was the paradox of the spatial movements of nurses. Nurses had a broad scope of practice that required them to transeverse a range of spaces around various departments for patient transfer, sample delivery, medical instruments, administrative documents and formalities of health insurance which reflected the broad scope of practice. Yet, the movements were limited in the presence of medical doctors and hence power was communicated through the movements of nurses (Halford & Leonards, 2003).
Furthermore, medical doctors occupied a dominant position as authorised agents who had power to express viewpoints on nursing practice. Nurses, in turn, lacked the capacity to position nursing where it would be visibly recognised. The definition of nursing practice as dependent on medical practice and characterised by completion of tasks was the unquestioned state in the healthcare services and thus accepted by all inhabitants within the space. Nursing practice became the symbolic order negotiated in the hierarchical spatial form. The spatial form was constituted based on the intersection of knowledge and power which was defined by professionalised sets of rules and norms. While there were attempts by nurses to broaden the scope of nursing practice, medical doctors used their rhetorical authority to reproduce the status quo of nursing. Nurses did engage in negotiations over practice but within the spatial constraints of symbolic power. Medical professionals performed as the most dominated group used power to shape the practice of others (Jones et al., 2000). The spatial form secured hierarchical positions which constituted to the stable and robust order of relationship among related groups of inhabitants that guided actions of all members.
Space was, therefore, produced by both geographically designed structures and the daily practices of members (Lefebvre, 1991). In other words, daily practice was significant to the ongoing production of social space (Beyes & Steyaert, 2012; Taylor & Spicer, 2007; Zhang &
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Spicer, 2014). Spatial forms were produced and re-produced in dialectic with the processes of nursing practice construction through social interactions within the spaces. Hence, space was not neutral but shaped and was shaped by social processes (Lefebvre, 1974, 1992).
7.3 Summary This chapter explored the dialectic integration of space and nursing practice where space both shaped and was shaped by practice. Nurses made use of space to construct practice and in turn, nurses actively created new spatial forms of practice. There was the production of space, embodied in symbolic power, which reproduced the social position of nurses within space. Nursing practice was both social and spatial. It was, therefore, essential to investigate how nurses constructed different practice performances within distinctive spatial forms.
Understanding the role of space in nursing practice pointed to issues around the different spatial forms of nursing education and nursing practice which contributed to the disjuncture between these two domains as addressed in the following chapter. In reflecting the focus of this chapter, the final chapter turns to the broader geopolitical spaces within which the key social actors in the research were positioned. The intent is to move beyond the organisation to political and economic spatial practices at the national and international levels. This is not to suggest a hierarchy of spaces from the global economy and nation to an organisation. On the contrary, it is asserted that spaces are relational rather than hierarchical. As argued throughout this thesis, the intent was not to prioritise social or spatial products over the processes of their production. Rather, the focus was on the interrelationship of social actions and structure.
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Chapter 8 Discussions and Conclusions
8.1 Introduction This research provided insight into the social positioning of nursing and nursing practice within the Vietnamese healthcare context. Three concepts were generated and explored in the three analytical findings chapters and illustrated how nursing practice both shaped and was shaped by interactionist, structural and social spatial forms of the research context. The final chapter first provides an overview of the research. Second and in considering the social positioning of nurses and nursing, the chapter addresses paradoxes that existed in policy making, in the historical development of nursing and in the gendered nature of nursing as contributing factors to the contemporary positioning of nursing in Vietnam. The chapter concludes with final thoughts on the ways in which research findings might inform practice, education and research to the benefit of Vietnamese nursing in both current and further action plans. A reflection on strengths and limitations of the research methodological issues is also a component of this final discussion.
8.2 Key research findings Nurses play an important role in safety assurance and quality improvement for patients in health care systems worldwide (WHO, 2018). At least since 1990, the Vietnamese nursing profession has been recognised as and has developed to become a critical component of the national health care workforce (VNA, 2012). The reform of Vietnamese nursing has occurred in both the education and clinical domains and has situated nurses in new positions. In the education sector and through the MOE, revision and development of nursing curricula has been in progress focused on competency-based practice with the intent to strengthen nursing practice (MOH, 2015). The Vietnamese political system, articulated within the MOH, has also acknowledged nursing as a profession through policy changes that have re-defined nursing practice (Joint Circular No 26/2015/TTLT-BYT-BNV, 7 October, 2015). The shifts in official approaches to nursing professional development emanating from the MOH and Ministry of Education and Training (MOET) have raised expectations that Vietnamese nurses will be a part of a globalised nursing world.
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Despite such changes, what has endured is an emphasis on task completion as the role of the RN in clinical practice (MOH, 2015). This emphasis is a manifestation of a tension between nursing education informed by a competency framework and the focus of nursing clinical practice on health care tasks. Through the lens of patient assessment and perceptions of nurses towards practice, a growing body of evidence argues that the application of skills by nurses is limited (Adib-Hajbaghery & Safa, 2013; Anderson et al., 2014; Birks et al., 2013). Elsewhere it has been determined that decision-making processes around patient assessment are complex (Birks et al., 2013; Douglas et al., 2014; Gidden & Eddy, 2009; McElhinney, 2010; Osborne et al., 2015) and are constrained by contextual factors (Johansen & O’Brien, 2016). Given the nationwide introduction of competency-based education in Vietnam it was assumed that similar issues would be relevant to Vietnamese nursing practice and hence the research turned to explore broader contextual processes that shaped nursing practice in Vietnam. The research contributes to knowledge on the social positioning of nurses within Vietnam which has been the subject of very little research inquiry.
The purpose of this research was to explore the decision making of clinical registered nurses as the lens through which to interpret the construction of nursing practice in Vietnam. The research sought to develop a contextual understanding of the relationship between nursing education and nursing practice in this country. Hence, an analysis of the perceptions of 31 RNs in Vietnam of the clinical practice of patient assessment and the ways in which RNs negotiated and therefore constructed nursing practice contributed insight into the positioning of nursing practice within the micro and macro contexts of Vietnam.
The theoretical perspective was grounded in symbolic interactionism (SI) and specifically the interactionist Chicago School (Blumer, 1969; Mead, 1934). The theoretical frame was also informed by the broad pragmatist tradition including the Dramaturgical School (Goffman, 1959, 1961, 1963, 1983) and the work of Strauss (1978) on negotiated order. From this perspective, nursing practice was understood as a socially negotiated performance constructed within identifiable social processes. In other words, nurses were taken to be social actors who negotiated to actively construct and selectively perform nursing practice within a structural context. Nursing practice was, moreover, constructed and performed in the particular spatial form of the Vietnamese health care system. On the one hand nursing practice was shaped by space and on the other hand, nurses used spatial forms to construct practice. The work of Harvey
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(1973) informed an analytical approach which accommodated both spatial forms and social processes in an exploration of how nursing practice shaped and was shaped by space.
A form of initial coding (Charmaz, 2014) was applied in the early phase of making sense of data. The analytical process then turned to theoretical analysis. Blumer’s (1969) notion of “sensitizing concepts” provided a guide for the process of theorising based on tentative ideas drawn from existing and relevant knowledge which prompted more in-depth exploration of meanings/issues generated from data. Sensitising concepts, in the words of Charmaz (2015, p. 405), are invoked “as a beginning lens rather than a means of application”. There was also a dialectic process of data generation and analysis in which data resources were continuously tested out in the construction and reconstruction of conceptualised categories in the research.
The role of the researcher as an integral part of data generation was acknowledged and took into account the researcher’s perspectives, privileges, positions, interactions and geographical locations (Charmaz 2000, 2006, 2009, 2014; & Clarke, 2005, 2006). Hence, there was recognition that multiple possible realities could be produced from the research. This is so because researchers make choices about what is to be interpreted and how and so there may exist diverse interpretations of how nursing practice was constructed within the particular spatial form of Vietnamese healthcare context.
Given the hierarchical structure of health care in Vietnam, where hospitals are categorised as institutions at different levels from the specialty hospitals at the top to provincial level structures at the bottom, RNs who worked in specialty hospitals were the target research population. These hospitals provided tertiary health care services which theoretically required a high quality of nursing practice. It was generally assumed that RNs who worked in these hospitals would be advanced nurse practitioners with broad scopes of practice. Hence, RNs in Cho Ray hospital, the only specialty hospital in the South of Vietnam, were approached as potential research participants. Those recruited had bachelor nursing qualifications and at least three years of clinical experience. Data generation involved 29 individual face-to-face interviews, 58 hours of observations and 50 government and professional policy documents. Field notes were treated as a subsidiary data resource and memos were written as part of the process of reflexivity to explore multiple layers of meanings.
Three core concepts generated from the research analysis suggested the importance of the contribution of both agency and structure in explaining nursing practice. Nurses as social actors
CHAPTER 8 142 were constantly engaged in processes of negotiation and re-negotiation around the shared norms of nursing practice. The process of internalising nursing practice, as explored in Chapter 5, depicted the ways in which nurses encountered the shared norms of nursing practice, determined the significance of what was before them and developed their own norms that became taken-for- granted practice. Nurses perceived these norms based on the attitudes of others including medical doctors, nursing colleagues, patients and family members. These social norms were then given standing to shape the daily routine through the process of institutionalising nursing practice.
Chapter 6 focused on the process of institutionalising nursing practice which addressed the interrelationship of the micro and macro levels of practice. Here there were broader contextual considerations that linked nurses as agents to the instituition. Thus nursing practice was the product of negotiation processes at the micro-level and within a broader context. Nurses interacted at the two levels of an organisation to mediate tensions around the practice: 1) micro- level interactions with relevant others; and 2) the macro-level of governance and legal issues. The analysis thus shifted to address salient strutural properties such as occupational dynamics, nurse-related policies and the labour market. Of note and first, there was a disjuncture between nursing clinical practice and nursing education in relation to policies. The Vietnamese Nursing Competency Standards (VNCS) developed by VNA (2012), which recognised nursing as an autonomous profession, directed the development of nursing education (Decision No 1352/QD- BYT, 24 April, 2012). By contrast, the MOH (Circular No 07/2011/TT-BYT, 26 January, 2011) effectively and within policies represented nursing practice as a typology of tasks.
The concept of space emerged as significant to the formation of nursing practice. Importantly, nurses as social actors produced and re-produced spatial forms to challenge the taken-for-granted practices which had been internalised and had become institutionalised social norms. In other words, nursing practice shaped and was shaped by the specific spatial forms of the Vietnamese healthcare context. Chapter 7 explored this dialectical process. While nursing bodies sought to negotiate broader scopes of nursing practice such negotiations were disrupted by constraints at the micro and macro levels of the organisation. Hierarchical social interactions at the micro level and governance and legal issues at the macro level reinforced the subordination of nurses and nursing within a spatial form of symbolic power. Hence, nurses had limited space to negotiate for change. As evident in the analysis chapters, the reality of nursing in Vietnam was characterised by conflicting interests expressed at all levels of organisations. The
CHAPTER 8 143 final discussion now turns to a consideration of the social positioning of nurses within a paradoxical context influenced by policy, history and culture.
8.3 The social positioning of nurses - the paradoxes In the research context, paradoxes became increasingly important to the interpretation of social relations and social practices around nursing in Vietnam. Paradoxes occur at every level of organisations (Lewis, 2000; Lewis & Smith, 2014; Smith & Lewis, 2011) as a result of complex competing interests whether social, economic, political and/or cultural. A paradox can be defined as “contradictory yet interrelated elements – elements that seem logical in isolation but absurd and irrational when appearing simultaneously” (Lewis, 2000, p.760). Based on Ford and Backoff’s (1988) work, a paradox is described as a “thing” which is constructed by actors through the polarisation of reality whereby complicated social interrelationships are concealed. In order to identify and to represent paradoxes, an exploration of paradoxes is most powerful where strategic approaches focus oneveryday organisational life and taken-for-granted contradictions (Lewis, 2000).
There were, for example, taken-for-granted organisational tensions around the interrelationships between physician-nurse, nurse-patient and physician-patient as explored earlier. Significantly, at the macro-level, a complete disjuncture between nursing education and nursing clinical practice reflected a separation of the higher education and health care labour markets in Vietnam as a result of competing reforms in strategic policy making. Health care reform in Vietnam was focused on socioeconomic issues such as decentralisation of healthcare, the institution of universal health coverage (UHC), and legalisation of private health sectors (Ramesh, 2013; Reich et al., 2016). Internationalisation was the priority strategy for the government in higher education reform and one that shaped education in the health sciences (Tran & Marginson, 2018). The two elements of the Vietnamese government logically supported each other and yet appeared juxtaposed because of existing inconsistencies. This situation prompted further exploration of the political, cultural, economic and legal imperatives that underpinned the paradoxes evident in this research.
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8.3.1 The positioning of nurses in the political context of conflicting interests Paradoxes have been evident in policy making throughout the historic reform processes in Vietnam with socio-political changes influenced by various external dynamics, such as a long period of war that involved outsiders, and yet underpinning those reforms have been competing interests and ideologies. As has been argued, there was an obvious disjuncture between nursing education and nursing practice and largely as a result of conflicting interests in the reform processes of education and health. Reform requires resources and the origins of such resources in the two sectors differed markedly. While the Vietnamese Higher Education (VHE) sector looked to internationalisation as a strategic development to attract financial investment (Nguyen & Tran, 2018; Tran & Marginson, 2018; Tran, Ngo, Nguyen & Dang, 2017), Vietnamese health care policy focused on the fiscal autonomy of public hospitals (Nguyen, 2018; Minh Thị Hải & Löfgren, 2019). The reform paradox was thus one of the internationalisation of the VHE and the localisation of the VHS.
In Vietnam, internationalisation has been strongly promoted in the reform processes through various endeavours throughout all major universities (London, 2011; Nguyen & Tran, 2018; Tran & Marginson, 2018). This focus was the key objective of the 2001 – 2020 long-term education development plan (Decision No. 711/QD-TTg, 13 June, 2012). The National Action Plan of Education for Sustainable Development (Viet NatCom DESD, 2010) identified the key objective of higher education as the preparation of human resources for economic development, social equality and environmental protection. The VHE was noted as the key national target of development in the 2001 - 2010 and 2010 – 2020 Socio-Economic Strategic Development Plans (SESDP) for Vietnam (Decision No. 711/QD-TTg). According to the Education Development Strategic Plan (EDSP) for 2001 – 2010 (MoET, 2001, p.2), which positions education as central to the implementation of the Socio-Economic Strategic Development Plan (SESDP) for 2001 – 2010 (Decision No. 711/QD-TTg), education objectives were : 1) modernisation of education; 2) renovation of education to catch up with developed countries; 3) preparation of human resources, especially manpower; and 4) escape from outdated practices. The SEDSP for 2010 – 2020 (Decision No. 711/QD-TTg, 13 June 2012) emphasised the reform of national education whereby the expansion of internationalsisation, in terms of both outcomes and processes, was a central goal. Education policy making became focused on the creation of an education system which “adapts selectively to international experiences […] in accordance with Vietnamese conditions” (Decision No. 711/QD-TTg).
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Nursing education, as a significant component of education in the health sciences, also adopted internationalisation as reflected in various and ongoing foreign projects. Some prominent international projects in nursing education were the Nuffic Project to strengthen clinical advanced skills for Vietnamese nursing lecturers from 2006 to 2010 and the 2008 – 2016 Atlantic Philanthropy (AP) Projects 1 and 2 designed to improve nursing education and training. The World Bank imposed its influence on Vietnamese Medical Education, and particularly on nursing education, through a 2014 to 2020 national project called Health Professionals Education and Training for Health System Reforms (HPET). The participating medical universities in Vietnam included Ha Noi Medical University (HMU), University of Medicine and Pharmacy Ho Chi Minh City (UMP), Pham Ngoc Thach University (PNTU), Nam Dinh University (NDU), Hue College of Medicine and Pharmacy, Can Tho University (CTU) among others.
It is undeniable that the Vietnamese nursing profession has progressed and particularly in terms of nursing education based on external support from foreign organisations. For example, nursing lecturers have had many more opportunities to gain international qualifications through various training programs. Numbers of nursing lecturers across Vietnamese nursing schools have secured Master or Doctor of Philosophy qualifications from international universities through the Nuffic (Dutch Ministry of Home Affairs, 2007) and AP projects. Clinical teaching has also received more attention through a series of training workshops organised to improve the competency of nursing instructors and new models of clinical teaching and learning in nursing have been developed and researched. In addition to and following the trend of importing education programs, the HMU has collaborated with the California State University, Long Beach since 2009 to develop and implement the Advanced Nursing Education Program (ANEP) (decision numbered 7853/QĐ-BGDĐT).
All activities are undertaken for the purpose of providing nursing labour that meets the requirements of the market. Yet the complete disjuncture between nursing education and nursing clinical practice, as argued in this research, raises concerns about the degree of impact of education reform on the nursing profession and health care more generally.
Indeed, Tran and Marginson (2014) argue that a disconnect does exist between the policy dimensions of strategy, operation and implementation in the Vietnamese education system that allows spaces for conflict. In terms of strategy, government leaders provide support for education reform whereby discreet actions are taken in response to what are viewed as overly liberal policies. In terms of operation, a conflict of interest occurs between the authoritised role
CHAPTER 8 146 of the MOET to make and action plans based on strategic policies and certain economic interests of the ministry (Dao & Hayden, 2010). The disconnect noted above is reflected in debates around the extent of influence that policies have on reality. For example, Tran and Marginson (2014) address the common use of the phrase “lifelong learning” suggested by the United Nations Education, Scientific and Cultural Organisation (UNESCO) in national policy discourse which received complete support from the MOET and the government (Decision No 89/QD- TTg, 09 January, 2013) as evident in the “Building the Learning Society for 2012 – 2020” plan (UNESCO Institute for Lifelong Learning). This plan emphasises the improvement of lifelong learning as an important responsibility of higher education. Subsequently, the MOH announced a series of policies (circula No 22/2013/TT-BYT, 9 August, 2013) to encourage lifelong learning in health care workforces in clinical settings. Based on these policies, healthcare workers were required to participate in ongoing training in various programs such as short courses on Continual Medical Education, conferences and workshops, and to engage in research and produce publications. Lifelong learning was to be assessed based on credits exchanged from study activities and 48 credits each year was the minimum requirement. The outcomes of implementation, however, ignored for evaluation in health policies in the scope of nursing practice. Universities and hospitals continue to provide lifelong training and yet there is no evidence of requirements of training implementation in nursing clinical practice.
The engagement of foreign sectors in the system, particularly Western education, is attributed to a desire for greater internationalisation in VHE which is linked to policy and curriculum, program exchange, foreign investment and international collaboration (Tran Marginson & Nguyen, 2014; Tran & Marginson, 2018). Of significance is the dominance of the West in translation of VHE concerns into policies which promote the implementation of forms of Western education. This is reflected in the explosion of borrowed education models and imported programs and curricula from 200 universities worldwide, since 1986, by the Vietnamese government (Tran & Marginson, 2018).
Foreign institutions also influence the VHE through financial investments underpinning projects. The UNESCO, the World Bank and the Asian Development Bank (ADB) have made the most significant contributions to the internationalisation processes. UNESCO focuses on lifelong learning and quality assurance and accreditation processes that emulate international standards (UNESCO, 2011a, 2011b). The ADB is interested in secondary education, teacher training and vocational education with a focus on credit transfer (ADB, 2009). This focus
CHAPTER 8 147 originates from the increasing demands of Japan for employment of skilled workers. The World Bank has promoted privatisation which endorses the desire of the Vietnamese government to diversify funding resources for education by encouraging private sector involvement (MOET, 2001; Tran & Marginson, 2018). As such, agreements on financial investment rest on the acquiescence of the Vietnamese government to the specific interests of foreign organisations.
There was also a mix of diverse ideologies underlying the current policies of higher education in Vietnam (Tran & Marginson, 2018). Following the trend of internationalisation in the education sector nursing higher education was increasingly influenced by Western education in curricula development. In 2006, a comprehensive collaboration between Vietnam and Association of Southeast Asian Nations (ASEAN) countries marked a regional integration that allowed Vietnamese nurses to work in other ASEAN countries. The ASEAN Mutual Recognition Arrangement on Nursing Services (MRANS) was approved throughout ASEAN countries in 2006 and demanded changes to nursing higher education to better prepare the nursing workforce. Nursing educational curricula was also revised on the basis of a competency framework developed and approved in 2012 in collaboration with Queensland University of Technology, Australia through the AP project (Decision No1352/QD-BYT, 24 April, 2012; MOH, 2012). The World Bank HPET project (2015 – 2020) re-affirmed the implementation of the VNCS in the ongoing development of nursing education curricula (MOH, 2015). Health policies related to nursing clinical practice have been revised and updated since 2011 with important circulars declared in 2011 (circular 07/2011/TT-BYT, 2011) and 2015 (decision 26/2015/TTLT-BYT-BNV). The ways in which nursing was defined, however, were not subject to reform in the workplace and remained focused on the completion of discrete tasks. One explanation is the funding models of the two sectors. As noted, the Vietnamese Health System (VHS) reform processes authorised the fiscal autonomy of public hospitals that encouraged more involvement of private sectors (Ramesh, 2013; Vo & Lofgren, 2018). Thus, the focus of the VHS was on greater efficiencies through the reduction of state subsidy of health care.
Apart from constrained budgets, the influence of foreign sectors on policy making in the VHS was less significant than in the VHE. As such, international standards of nursing practice had little impact on the clinical area of healthcare services. The work of Vo and Lofgren (2018) argues that the local circumstances of the autonomisation of VHS reform meant that policies were based on the interests and preferences of the MOH and related government institutions. Hence, on the one hand, nursing clinical practice was a product of a process of localisation that
CHAPTER 8 148 underpinned the VHS reform. On the other hand, nursing education was characterised by internationalisation.
8.3.2 The positioning of nurses in the historical and cultural context of Vietnam The Vietnamese nursing profession has a history of encounters with cultural, political and social ideologies from both Western and Eastern countries including the Republic of China, France and the United States. These influences, in various ways, have defined nursing in Vietnam.
Before French colonisation in 1861, Vietnam was significantly influenced by the Republic of China in all aspects of life and notably in health. Traditional Vietnamese medicine or the folk treatment was grounded in the Chinese philosophy of Yin and Yang (Nguyen, 1985). Prior to the late 19th century the only health care workers were Vietnamese traditional medicine practitioners who were educated as apprentices from knowledge handed down through the generations. Nursing was brought from Western culture into the Vietnamese health area through the invasion of Western countries such as French and US. From 1861 to 1937, Vietnam was influenced by the colonial rule of the French who had control of the city of Saigon. During this time, medical doctors were systematically and legally organised which acknowledged the medical professional (Monnais, 2008). Yet, what was known about nursing in Vietnam was very limited. In 1901, the first nursing class for male only nurses was opened in the Cho Quan hospital in Saigon by the French to provide care for patients with mental health disorders and leprosy. A nursing code of conduct was approved by 20 December 1906 followed by the opening of the first School of Nursing in 1923. Nurses, however, were not recognised as professionals but as helpers in medicine whereby nurses had a very lowly social standing. That nurses are viewed as medical assistants continues to appear in definitions of nursing professional currently.
The period 1945 – 1954 saw the revolutionary uprising against the French colonial government which required a large health care workforce to care for the military. At this time, six-month medical courses were introduced as nurse training who, on graduation, were referred to as “medical assistants”. Following the increasing intensity of the war, the length of training was reduced to three months based on the assumption that “medical assistants” required only very basic medical knowledge.
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From 1954 to 1975, there were two training systems for nurses as a result of the separation of Vietnam during the revolutionary war against the US. In 1956, in the South of Vietnam, which was under the control of the US, a three-year training program for nurses was introduced. Due to the ongoing war and a severe lack of nurses, in 1968, a 12-month training program was also instituted. In 1970, the Nursing Association was established under the political orientation of the Republic of South Vietnam. At this time, in the North of Vietnam, nursing training was two years and six months. While the philosophical underpinnings of nursing of both training systems have been sparsely reported, nurses in the North and South were given different titles which partly reflected the ways in which nurses were perceived in the two broader social systems. In the South, nurses were referred to as “Điều Dưỡng” which means caring. In the North, nurses were recognized as “Y tá” or medical assistants.
After 1975, and the reunion of North and South Vietnam under the control of the Communist Party, the two and half years nursing program became the norm across the country. All graduate nurses were then referred to as “Y tá” meaning medical assistant. In 1985, the first bachelor of nursing program was instituted in the HMU followed, in 1986, by the UMC in 1986. In 1990, the MOH decreed that the title of e “Y tá” was to be substituted by “Điều Dưỡng” which was a symbolic shift of nursing away from medicine. In 1997, the Vietnamese Nursing Association (VNA) was established which marked the legal approval of nursing as a profession in the Vietnamese healthcare system. Nonetheless, the dominance of medical doctors endured even in nursing education where more than 80 percent of content continued to be delivered by doctors (Jones et al., 2000).
A significant contributing factor to ongoing medical dominance was the 1000 years of Chinese domination informed by Confucian and Buddhist ideologies (Doan, 2005). The philosophies of Confucianism defined the norms of everyday life of men and women and engendered gender-based differences in all aspects of human life in East Asia and particularly in China, Korea, Japan and Vietnam (Berthrong & Berthrong, 2014). The traditional beliefs of Confucianism have continued to influence Vietnamese thinking and particularly around gender issues. Women are not perceived as individuals but rather in terms of their roles within relationships. As such women are expected to unconditionally obey the father when single, the husband when married and the son when widowed (Vietnamese traditional folk). This philosophy, as translated in the health care context, ensures that medicine is perceived as male work and of greater value than nursing which is symbolic of women and hence of lesser status
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(Hagell, 1989; McDowell, 2015). While, as noted earlier, a fifth of research participants were male the very large majority of nurses in Vietnam are female and they have absorbed the Confucian-based masculine norms from family, education and society and thus contribute to the reproduction of a hierarchical structure of medicine and nursing in terms of social positioning. It is recognized that healthcare division of labour needs a proper analysis with the taking into account of gendered nature of healthcare organisations (Allen, 2017).
The historical development of Vietnamese nursing saw nurses legally and socially defined as medical assistants which entrenched the social norm of perceiving nurses as medical assistants. The culture of male chauvinism evident throughout the long historical development of the country also contributed to the devaluation of nursing which was viewed as female work. The globalisation of Vietnam since 1986 has provided various opportunities and also challenges for nursing to affirm the positioning of the profession in the healthcare systems.
8.4 Methodological considerations It is acknowledged that there are always strengths and limitations to be noted in relation to any research. As argued earlier, face-to-face interviews are limited in a number of ways one of which is that they do not readily capture the context in which interactions and performances occur (Holloway & Wheeler, 2010). Interviews are, moreover, products of co-constructions of interviewees and interviewers. Hence and in this research, both the researcher and participants were engaged in interpretive processes whereby all made choices about expectations and responses. If interviews constitute layers of interpretations by the interviewer and interviewees the expectation that a reality can be captured is problematic. Yet, these issues were pre-empted and thus other data resources, including observations, were conducted to mitigate the limitations of the interview method. The analysis of relevant documents also provided insight into the social context within which nursing practice was shaped.
The research data analysis process commenced with the initial coding method proposed by Charmaz (2014). This approach informed the early phase of data generation which soon shifted to theoretical analysis. This meant that there was no strict adherence to grounded theory methods in data analysis. However, the application of a systematic, predefined, set of techniques risked confining the analysis to the abstraction of discrete codes and categories that also obscured context (St Pierre & Jackson, 2014). Indeed, Charmaz (2015; 2017; 2018) has shifted
CHAPTER 8 151 significantly on this very issue in recent times in arguing the compatibility of theorising and applying a broader set of sensitising concepts along with her “box of tools”. In clearly indicating a changing grounded theory space, Charmaz (2012) wrote that:
Grounded theory is a method for studying processes; it is also a method in process (Charmaz. 2009). This method can be adopted by researchers who hold different theoretical perspectives, focus on various levels of analysis, pursue varied objectives, and address diverse areas – including social justice research, policy analyses, organisational studies, societial issues-and social psychology…
…I say use the strategies that work for you and your study but be aware of what you do and what you claim (pp. 2-3).
Furthermore and reflecting an ongoing debate around the problematic concept of inductive research, Charmaz (2015) wrote that:
…renewed interest in pragmatism and the symbolic interactionist underpinnings of grounded theory have sparked new discussions of the role of abduction in the method…The most helpful way to use abduction is to expand the range of theoretical possibilities and consequently confirm which hypothesis offers ther best theoretical account for the data. (p, 406).
A strength of the current research, therefore, was the move away from a research approach that imposed a frame of pre-defined techniques on data anlaysis to a more flexible analytical stance that allowed for an exploration of the complexities of the research situation not immediately obvious.
8.5 Conclusion The research journey started from an observation about a disjuncture between nursing education and practice in Vietnam and expanded to extend beyond what is widely known as a theory/practice gap to an analysis of the layers of complexities that characterised the healthcare system, the nursing profession and the positioning of nurses in that country. Of significance in this research has been a realisation of a relational space wherein registered nurses as social actors and political and economic structures have moulded nursing practice.
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It is important to recognise the impact of the Vietnamese political, social and healthcare context on nursing practice and the situation of nursing as a social product formed within specific spatial forms. Nursing practice is not adequately explained by giving primacy to internal factors such as inadequate preparation or by focusing on external factors including workloads, interprofessional tensions and budgeting. The development of nursing education without a much broader understanding of the context can only exacerbate (or condone) the disjuncture between education and practice and associated issues related to the practice environment.
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APPENDICES
Appendix A Hospital Classifications (Vietnamese)
BỘ Y TẾ ****** CỘNG HOÀ XÃ HỘI CHỦ NGHĨA VIỆT NAM Độc lập - Tự do - Hạnh phúc
Hà Nội, ngày 03 tháng 03 năm 2004 Số 03/2004/TT-BYT
THÔNG TƯ
HƯỚNG DẪN XẾP HẠNG BỆNH VIỆN
Thực hiện Nghị định số 25/CP ngày 23/5/1993 của Chính phủ quy định tạm thời chế độ tiền lương mới của công chức, viên chức hành chính, sự nghiệp và lực lượng vũ trang, Bộ Y tế đã ban hành Thông tư số13/BYT- TT ngày 27/11/1993 hướng dẫn tạm thời việc xếp hạng các đơn vị sự nghiệp y tế. Sau hơn 10 năm thực hiện, đến nay các tiêu chuẩn xếp hạng bệnh viện ban hành kèm theo Thông tư số 13/BYT- TT cần được sửa đổi cho phù hợp với tình hình thực tế.
Sau khi có sự thoả thuận của Bộ Nội vụ tại công văn số364/BNV-TCBC ngày 27/02/2003 và công văn số 2966/BNV-TCBC ngày 18/12/2003, Bộ Y tế hướng dẫn tiêu chuẩn xếp hạng bệnh viện như sau:
I. Quy định chung:
1.Tất cả các bệnh viện, Viện nghiên cứu có giường bệnh (gọi chung là bệnh viện) thuộc hệ thống y tế nhà nước đều được xem xét,xếp hạng.
2. Việc xếp hạng bệnh viện là cơ sở để:
- Hoàn chỉnh về tổ chức, nâng cao trình độ chuyên môn kỹ thuật và chất lượng phục vụ người bệnh.
APPENDICES 180
- Đầu tư phát triển bệnh viện trong từng giai đoạn thích hợp.
- Phân tuyến kỹ thuật trong điều trị.
- Xây dựng kế hoạch đào tạo, bồi dưỡng, bố trí lao động và thực hiện các chế độ chính sách đối với công chức, viên chức bệnh viện.
II. Nguyên tắc và tiêu chuẩn xếp hạng
A. Nguyên tắc xếp hạng
1. Việc xếp hạng bệnh viện được xác định trên nguyên tắc đánh giá chấm điểm theo 5 nhóm tiêu chuẩn:
- Nhóm tiêu chuẩn I: Vị trí, chức năng và nhiệm vụ.
- Nhóm tiêu chuẩn II: Quy mô và nội dung hoạt động.
- Nhóm tiêu chuẩn III: Trình độ chuyên môn kỹ thuật, cơ cấu lao động.
- Nhóm tiêu chuẩn IV: Cơ sở hạ tầng.
- Nhóm tiêu chuẩn V: Thiết bị y tế, kỹ thuật chẩn đoánvà điều trị.
2. Các bệnh viện được chia thành 3 hạng: Hạng I, Hạng IIvà Hạng III, dựa trên tổng số điểm mà bệnh viện đạt được theo các nhóm tiêu chuẩn nêu trên.
B. Tiêu chuẩn xếp hạng:
Căn cứ để xếp hạng bệnh viện dựa trên Tiêu chuẩn và Bảng điểm xếp hạng bệnh viện ban hành kèm theo Thông tư này..Đốivới Nhóm tiêu chuẩn V: Thiết bị y tế, kỹ thuật chẩn đoán và điều trị có quy định cụ thể cho Bệnh viện đa khoa (Mục 1) và một số bệnh viện chuyên khoa (Mục 2, 3, 4, 5). Các bệnh viện chuyên khoa chưa quy định riêng thì trước mắt, áp dụng theo quy định đối với Bệnh viện đa khoa.
C. Điểm số và xếp hạng
APPENDICES 181
Điểm sô và xếp hạng cụ thể như sau:
Xếp hạng
Hạng I Hạng II Hạng III
Điểm xếp hạng Từ 90 đến 100 Từ 70 đến dưới 90 Từ 40 đến dưới 70
D. Mức phụ cấp chức vụ lãnh đạo
Mức phụ cấp chức vụ của các chức danh lãnh đạo theo hạng bệnh viện như sau:
TT Chức danh lãnh đạo Hạng I Hạng II Hạng III
1 Giám đốc 0,9 0,7 0,5
2 Phó Giám đốc 0,7 0,5 0,4
3 Trưởng khoa, phòng 0,5 0,4 0,3
4 Phó trưởng khoa, phòng, y tá trưởng 0,4 0,3 0,2 khoa
III. Tổ chức thực hiện
1. Hồ sơ đề nghị xếp hạng
1.1. Công văn của bệnh viện đề nghị xếp hạng. Đối với những bệnh viện cần có sự thoả thuận trước khi xếp hạng thì phải có côngvăn đề nghị xếp hạng của cấp có thẩm quyền quyết định xếp hạng theo quy định tại điểm 2 mục III dưới đây.
1.2. Bảng phân tích, chấm điểm theo các nhóm tiêu chuẩn và các văn bản, tài liệu chứng minh số điểm đã đạt được kèm theo (lấy số liệu của 02 năm trước liền kề năm đề nghị xếp hạng và các tài liệu kế hoạch thực hiện của năm đề nghị xếp hạng).
2. Thẩm quyền quyết định công nhận xếp hạng
2.1. Các bệnh viện trực thuộc Bộ Y tế
- Bệnh viện Hạng I: Bộ Y tế quyết định công nhận xếp hạng, sau khi có ý kiến thẩm định của Bộ Nội vụ.
APPENDICES 182
- Bệnh viện Hạng II Hạng III: Bộ Y tế ra quyết định công nhận xếp hạng.
2.2. Các bệnh viện thuộc địa phương quản lý
- Bệnh viện Hạng I: Uỷ ban nhân dân tỉnh, thành phố trực thuộc Trung ương quyết định công nhận xếp hạng, sau khi có ý kiến thẩm định của Bộ Y tế và Bộ Nội vụ.
- Bệnh viện Hạng II và Hạng III: Uỷ ban nhân dân tỉnh, thành phố trực thuộc Trung ương quyết định công nhận xếp hạng.
2.3. Bệnh viện thuộc các Bộ ngành khác
- Bệnh viện Hạng I: Bộ chủ quản quyết định công nhận xếp hạng sau khi có ý kiến thẩm định của Bộ Y tế và Bộ Nội vụ.
- Bệnh viện Hạng II và Hạng III: Bộ chủ quản quyết định công nhận xếp hạng..
3. Đối với trung tâm y tế quận, huyện, thị xã, thành phố thuộc tỉnh (bệnh viện huyện): cũng được thực hiện chấm điểm theo hướng dẫn của Thông tư này, nếu đạt điểm xếp hạng bệnh viện nào thì được xếp vào bệnh viện hạng đó và các chức danh lãnh đạo khối điều trịcủa trung tâm được hưởng mức phụ cấp chức vụ theo hạng bệnh viện đượcxếp.
4. Thời gian xem xét xếp hạng lại
Sau 5 năm (đủ 60 tháng), kể từ ngày có quyết định xếp hạng, các cơ quan ra quyết định xếp hạng có trách nhiệm xem xét, xếp lại hạng của đơn vị. Hồ sơ đề nghị xếp hạng lại quy định tại điểm 1 mụcIII.
5. Hiệu lực thi hành
Thông tư này có hiệu lực thi hành sau 15 ngày, kể từ ngày đăng Công báo và thay thế những quy định về xếp hạng bệnh viện trong Thông tư số 13/BYT-TT ngày 27/11/1993 của Bộ Y tế hướng dẫn tạm thời việc xếp hạng các đơn vị sự nghiệp y tế.
APPENDICES 183
Trong quá trình thực hiện, nếu có vướng mắc đề nghị các Bộ, ngành, địa phương, các đơn vị phản ánh về Bộ Y tế (Vụ Tổ chức cán bộ) để nghiên cứu và giải quyết./.
KT. BỘ TRƯỞNG THỨ TRƯỞNG
Lê Ngọc Trọng.
Tiêu chuẩn và bảng điểm xếp hạng bệnh viện
(Ban hành kèm theo Thông tư số 03/2004/T-BYT ngày 03/03/2004)
I. Quy định chung
A. Các nhóm tiêu chuẩn: gồm 5 nhóm như sau
- Nhóm tiêu chuẩn I: Vị trí, chức năng và nhiệm vụ: 10điểm
- Nhóm tiêu chuẩn II: Quy mô và nội dung hoạt động: 20điểm
- Nhóm tiêu chuẩn III: Trình độ chuyên môn kỹ thuật, cơ cấu lao động: 35 điểm
- Nhóm tiêu chuẩn IV: Cơ sở hạ tầng: 15 điểm
- Nhóm tiêu chuẩn V: Thiết bị y tế, kỹ thuật chẩn đoán và điều trị: 20 điểm
B. Nguyên tắc tính điểm và xếp hạng bệnh viện:
1. Tính điểm: a. Cho điểm theo từng tiêu chuẩn cụ thể trong bảng điểm ban hành kèm theo Thông tư, không vận dụng điểm trung gian. b. Không được tính điểm trong trường hợp thông số chưa hoàn chỉnh.
APPENDICES 184 c. Căn cứ để tham khảo tính điểm: Các báo cáo, sốliệu lưu trữ của bệnh viện và qua kiểm tra thực tế. d. Các bệnh viện thuộc khu vực miền núi, vùng sâu, vùng xa, biên giới, hải đảo, được ưu tiên cộng thêm 02 điểm.
2. Điểm đạt và xếp hạng bệnh viện: a. Bệnh viện Hạng I: phải đạt từ 90 điểm trở lên và đảm bảo các điều kiện bắt buộc như quy định tại mục 4 phần B đối với BV Hạng I. b. Bệnh viện Hạng II: phải đạt từ 70 đến dưới 90 điểm và đảm bảo các điều kiện bắt buộc như quy định tại mục 4 Phần B đốivới BV Hạng II. c. Bệnh viện Hạng III: phải đạt từ 40 đến dưới 70 điểm và đảm bảo các điều kiện bắt buộc như quy định tại mục 4 Phần B đối với BV Hạng III.
Dưới 40 điểm: chưa được công nhận là bệnh viện.
3. Trình độ cán bộ:
Dựa theo Quyết định của Bộ trưởng - Trưởng Ban Tổ chức- Cán bộ Chính phủ (Nay là Bộ Nội vụ) số 415/TCCB-VC ngày 29/05/1993 về việc ban hành tiêu chuẩn nghiệp vụ ngạch công chức ngành Y tế và căn cứ các văn bằng, chứng chỉ của các Trường Đại học và Trung học.
Đối với các bệnh viện thuộc khu vực miền núi, vùng sâu, vùng xa, biên giới, hải đảo:
Trình độ ngoại ngữ của cán bộ có thể được thay bằng biết một thứ tiếng dân tộc thiểu số.
4. Những điều kiện bắt buộc
Để được xếp hạng, bên cạnh tổng số điểm phải đạt theo nhóm tiêu chuẩn, một số tiêu chuẩn cụ thể bắt buộc phải đạt được số điểm tối thiểu đối với từng hạng bệnh viện.
APPENDICES 185
Các tiêu chuẩn và số điểm tối thiểu phải đạt của từng hạng bệnh viện như sau:.
Điều kiện phải đạt
TT Tiêu chuẩn Hạng I Hạng II Hạng III
1 Giám đốc và các Phó Giám đốc Trên 4 điểm Trên 3 điểm Trên 2 điểm
2 Các Trưởng phòng và Phó Trên 4 điểm Trên 3 điểm Trên 2 điểm trưởng phòng
3 Các Y tá điều dưỡng, NHS, Trên 4 điểm Trên 3 điểm Trên 2 điểm KTV trưởng khoa
4 Người bệnh nội trú thuộc diện Trên 4 điểm Trên 3 điểm Trên 2 điểm chăm sóc cấp một
5 Trưởng phòng y tá điều dưỡng Đại học Đại học Trung học
6 Trưởng phòng Tài chính - kế Đại học Đại học Trung học toán
7 Không có chức danh y sĩ làm + + công tác khám bệnh, chữa bệnh
II. Các tiêu chuẩn và bảng điểm A. Nhóm tiêu chuẩn I: Vị trí, chức năng và nhiệm vụ: 10 điểm 1. Chỉ đạo kỹ thuật tuyến dưới, chăm sóc sức khoẻ banđầu: 4 điểm a. Khu vực nhiều tỉnh, thành phố trực thuộc Trung ương 4điểm b. Tỉnh, thành phố trực thuộc Trung ương, ngành: 3 điểm c. Quận, huyện, thị xã, thành phố thuộc tỉnh: 2 điểm 2. Đào tạo cán bộ (là cơ sở thực hành): 3 điểm a. Đại học và sau đại học: 3 điểm b. Trung học: 2 điểm c. Sơ học: 1 điểm d. Thực hiện tự đào tạo liên tục trong bệnh viện: 0,5điểm 3. Nghiên cứu khoa học: 3 điểm a. Đề tài cấp Nhà nước: 3 điểm
APPENDICES 186 b. Đề tài cấp bộ, tỉnh, thành phố trực thuộc Trung ương: 2 điểm c. Đề tài cấp cơ sở: 1 điểm B. Nhóm tiêu chuẩn II: Quy mô giường bệnh và nội dung hoạt động : 1. Số giường bệnh theo kế hoạch: 10 điểm a. Từ 900 giường trở lên: 10 điểm b. Từ 500 đến dưới 900 giường: 7 điểm c. Từ 300 đến dưới 500 giường: 5 điểm d. Dưới 300 giường: 3 điểm 2. Công suất sử dụng giường bệnh: 4 điểm a. Đạt từ 80% trở lên và ngày điều trị trung bìnhphải:. - Dưới 7/11/14 ngày đối với BV huyện/tỉnh/trung ương: 4điểm - Từ 7-8/ 11-12/ 14- 15 ngày đối với BV huyện/ tỉnh/ trungương: 3 điểm - Trên 8/ 12/ 15 ngày đối với BV huyện/ tỉnh/ trung ương:2 điểm b. Đạt từ 60 đến dưới 80% và ngày điều trị trung bìnhphải dưới 7/ 11/ 14 ngày đối với BV huyện/ tỉnh/ trung ương: 1điểm (Ngày điều trị bình quân của các bệnh viện: Y học cổ truyền, Tâm thần, Điều dưỡng - PHCN thực hiện theo quy định riêng với mỗi loại bệnh viện tại Mục 2, 3 và 4 Phần E) 3. Số người bệnh nội trú thuộc đối tượng chăm sóc Cấp 1: 2 điểm a. Từ 25% số người bệnh nội trú trở lên: 2 điểm b. Từ 15 đến 24% số người bệnh nội trú: 1 điểm c. Dưới 15% số người bệnh nội trú: 0,5 điểm 4. Tổ chức chăm sóc người bệnh: 2 điểm a. Từ 50% số khoa trở lên tổ chức chăm sóc toàn diện: 2điểm b. Dưới 50% số khoa có tổ chức chăm sóc toàn diện: 1điểm
APPENDICES 187
5. Sấy hấp tiệt khuẩn tập trung: 2 điểm a. Thực hiện sấy hấp tiệt khuẩn tập trung toàn bệnh viện: 1 điểm b. Có khoa chống nhiễm khuẩn: 1 điểm C. Nhóm tiêu chuẩn III: Trình độ chuyên môn kỹ thuật,cơ cấu lao động: 35 điểm 1. Giám đốc và các Phó Giám đốc: 5 điểm a. 100% có trình độ đại học, trong đó có trên 60% có trình độ Tiến sĩ hoặc Chuyên khoa 2 (CK2): 2 điểm - 100% có trình độ đại học, trong đó dưới 60% có trình độ Thạc sĩ hoặc Chuyên khoa 1 (CK1) trở lên: 1,5 điểm - 100% có trình độ đại học, trong đó dưới 60% có trình độ Thạc sĩ hoặc CK1: 1 điểm b. 100% có bằng chính trị cử nhân, cao cấp hay trung cấp:1 điểm - Từ 60% trở lên có bằng chính trị cử nhân, cao cấp hay trung cấp: 0,5 điểm c. Trên 60% có chứng chỉ quản lý hành chính: 0,5 điểm d. Trên 60% có chứng chỉ quản lý bệnh viện: 0,5 điểm đ. Trên 60% có chứng chỉ ngoại ngữ trình độ C trở lên,còn lại là trình độ B: 1 điểm - Dưới 60% có chứng chỉ ngoại ngữ trình độ C trở lên,còn lại là trình độ B: 0,5 điểm 2. Các trưởng phòng và Phó trưởng phòng: 5 điểm. a. Trên 20% có trình độ sau đại học, còn lại là đại học: 3 điểm - 80% có trình độ đại học, còn lại là trung học: 2điểm - 50 % có trình độ đại học, còn lại là trung học: 1điểm b. 20 % có bằng chính trị từ trung cấp trở lên: 0,5 điểm c. 20% có chứng chỉ quản lý hành chính: 0,5 điểm d. 20% có chứng chỉ quản lý bệnh viện: 0,5 điểm
APPENDICES 188
đ. 20% có chứng chỉ ngoại ngữ trình độ B, còn lại là A0,5 điểm 3. Các trưởng khoa và phó trưởng khoa: 5 điểm a. Trên 60% có trình độ Tiến sĩ, CK2, còn lại là Đại học: 4 điểm - Dưới 60% có trình độ sau đại học, còn lại là đại học: 3 điểm - 100% có trình độ đại học: 2 điểm b. 20% có bằng chính trị từ trung cấp trở lên: 0,5 điểm c. 60% có chứng chỉ ngoại ngữ trình độ B trở lên, còn lại là trình độ A: 0,5 điểm 4. Các Y tá - ĐD, NHS, KTV trưởng khoa lâm sàng: 5 điểm a. Trên 15% có trình độ cao đẳng, đại học, còn lại là trung học: 4 điểm - Dưới 15% có trình độ CĐ, đại học, còn lại là trung học: 3 điểm - 100% có trình độ trung học: 2 điểm b. 10% có bằng chính trị trung cấp trở lên: 0,5 điểm c. 30% có chứng chỉ ngoại ngữ trình độ B trở lên, còn lại là trình độ A: 0,5 điểm. 5. Các thầy thuốc điều trị ở các khoa lâm sàng: 5 điểm a. Trên 50% có trình độ sau đại học, còn lại là đại học: 4 điểm - Từ 10% đến 50% có trình độ sau đại học, còn lại là đại học: 3 điểm - Dưới 10% có trình độ sau đại học, còn lại là đại học: 2 điểm - Trên 95% có trình độ đại học: 1 điểm b. 20 % có bằng chính trị trung cấp trở lên 0,5 điểm c. 60% có chứng chỉ ngoại ngữ B, còn lại là A 0,5 điểm 6. Y tá - ĐD, NHS, KTV thực hành ở các khoa lâm sàng: 5điểm a. Trên 10% có trình độ cao đẳng, đại học, còn lại là trung học: 4 điểm - Dưới 10% có trình độ cao đẳng, đại học, còn lại là trung học: 3 điểm - 100% có trình độ trung học: 2 điểm
APPENDICES 189
- 80 % có trình độ trung học, còn lại là sơ học: 1điểm b. 30 % có chứng chỉ ngoại ngữ A và B 1 điểm 7. Cơ cấu lao động: 5 điểm a. Tỉ lệ bác sĩ/ Y tá - ĐD ở các khoa lâm sàng: - <= 1/2 2 điểm - > 1/2 1 điểm.b. Số cán bộ chuyên môn về Lâm sàng,Cận lâm sàng và Dược: - > = 75% tổng số CC-VC 2 điểm - < 75% tổng số CC-VC 1 điểm c. Có cán bộ kỹ thuật bảo dưỡng máy, thiết bị y tế của BV: 1 điểm D. Nhóm tiêu chuẩn IV: cơ sở hạ tầng: 15 điểm Tiêu chuẩn Số điểm 1 Các khoa, buồng bệnh có hố xí tự hoại, nơi đi tiểu và buồng tắm 1 điểm 2 Khoa khám bệnh, Hồi sức cấp cứu, Ngoại sản, Truyền nhiễm, Xét nghiệm, Chẩn đoán hình ảnh xây dựng liên hoàn, có buồng vệ sinh,buồng tắm khép kín 1 điểm 3 Khoa Hồi sức cấp cứu, Phòng đẻ, Phòng phẫu thuật, Xét nghiệm, Chẩn đoán hình ảnh có điều hoà nhiệt độ 1 điểm 4 Buồng Hồi sức cấp cứu, Phòng đẻ, Phòng phẫu thuật có phương tiện gọi trực khẩn cấp 1 điểm 5 Có đủ quạt tại các buồng bệnh 0,5 điểm 6 Có đủ cơ số chiếu, chăn, màn, gối, quần áo cho người bệnh: - Đạt từ 2 cơ số trở lên cho một người bệnh 1 điểm - Đạt dưới 2 cơ số cho một giường bệnh 0,5 điểm 7 Trang phục nhân viên y tế thực hiện 100% theo quy chế 0,5điểm 8 100% CCVC đeo thẻ công chức theo quy chế 0,5 điểm 9 Thực hiện chế độ ăn bệnh lý 0,5 điểm
APPENDICES 190
10 Có hệ thống điện ưu tiên, an toàn 0,5 điểm 11 Có máy phát điện dự trữ 0,5 điểm 12 Có hàng rào, 2 cổng 0,5 điểm 13 Đường giao thông nội bộ BV đảm bảo vệ sinh, an toàn và thuận lợi khi vận chuyển 0,5 điểm 14 Có sơ đồ chỉ dẫn các khoa, phòng; Có bảng tên khoa, phòng, buồng viết đúng quy chế bệnh viện 0,5 điểm 15 Có bảng quy định y đức và quyền lợi nghĩa vụ của người bệnh treo ở vị trí quy định 0,5 điểm 16 Hệ thống cấp nước sạch 1 điểm 17 Có biện pháp xử lý chất thải rắn toàn bệnh viện đang hoạt động 1 điểm 18 Có hệ thống xử lý chất thải lỏng toàn bệnh viện đang hoạt động 1 điểm 19 Có hệ thống máy tính, có ứng dụng chương trình quản lý 1 điểm 20 Có hệ thống điện thoại nội bộ toàn bệnh viện, hệ thống phòng cháy, chữa cháy 1 điểm. E. Nhóm tiêu chuẩn V: Thiết bị y tế, kỹ thuật chẩn đoán và điều trị: 20điểm Mục 1. Bệnh viện đa khoa I. Thiết bị y tế: 5 điểm 1. Giường cấp cứu đa năng điện tử di động: 0,3 điểm 2. Máy X-quang công suất 125 KV-30mA 0,3 điểm 3. Máy X-quang cả sóng, tăng sáng truyền hình 0,4 điểm 4. Máy cộng hưởng từ 0,4 điểm 5. Máy CT Scaner 0,4 điểm 6. Máy nội soi ống mềm 0,4 điểm
APPENDICES 191
7. Máy siêu âm mầu 0,4 điểm 8. Máy siêu âm đen trắng 0,3 điểm 9. Monitoring 0,3 điểm 10. Máy theo dõi tim thai 0,3 điểm 11. Máy thở 0,3 điểm 12. Máy gây mê 0,3 điểm 13. Máy điện tim 0,3 điểm 14. Máy điện não 0,3 điểm 15. Kính hiển vi 2 mắt 0,3 điểm II. Kỹ thuật xét nghiệm huyết học đang thực hiện: 2điểm 1. Hồng cầu lưới 0,1 điểm 2. Các yếu tố đông máu 0,1 điểm 3. Huyết đồ 0,1 điểm 4. Tuỷ đồ 0,1 điểm 5. Thử nghiệm Coombs 0,1 điểm 6. Tìm kháng nguyên kháng thể 0,1 điểm 7. Tổng phân tích đông máu và cầm máu 0,1 điểm 8. Sinh thiết các cơ quan tạo máu 0,1 điểm 9. Phản ứng chéo ở 4 điều kiện 0,1 điểm 10. Đo đường kính hồng cầu 0,1 điểm 11. Co cục máu 0,1 điểm 12. Tìm tế bào trong các dịch sinh học 0,1 điểm 13. Số lượng hồng cầu 0,1 điểm 14. Công thức bạch cầu 0,1 điểm 15. Số lượng tiểu cầu 0,1 điểm 16. Tốc độ máu lắng 0,1 điểm
APPENDICES 192
17. Tỷ lệ huyết sắc tố 0,1 điểm 18. Dấu hiệu dây thắt 0,1 điểm 19. Thời gian máu chảy máu đông 0,1 điểm 20. Xác định nhóm máu ABO 0,1 điểm III. Kỹ thuật xét nghiệm hoá sinh đang thực hiện: 2 điểm 1. Cholesterol toàn phần 0,1 điểm 2. Bilirubin trực tiếp, gián tiếp 0,1 điểm 3. Protein toàn phần 0,1 điểm 4. Sợi huyết 0,1 điểm 5. Amylase pancreatic 0,1 điểm 6. Phosphatate kiềm 0,1 điểm 7. Điện giải đồ Na + ... 0,1 điểm 8. Xét nghiệm dịch não tuỷ 0,1 điểm 9. Xét nghiệm dịch màng phổi 0,1 điểm 10. Xét nghiệm dịch vị 0,1 điểm 11. Ure máu 0,1 điểm 12. Đường máu 0,1 điểm 13. Phản ứng Marlagan 0,1 điểm 14. Điện di protein lipoprotein, hemoglobine... 0,1 điểm 15. Protein nước tiểu 0,1 điểm 16. Đường nước tiểu 0,1 điểm 17. Thể cetonic 0,1 điểm 18. Urobilinogen 0,1 điểm 19. Tìm hồng cầu trong nước tiểu 0,1 điểm 20. Xác định tỷ trọng, pH nước tiểu 0,1 điểm IV. Kỹ thuật xét nghiệm vi sinh đang thực hiện: 2 điểm
APPENDICES 193
1. Nuôi cấu và phân lập vi khuẩn 0,2 điểm 2. Làm kháng sinh đồ 0,2 điểm 3. Viêm gan A, B, C, E (ELISA test) 0,2 điểm 4. HIV (ELISA test) 0,2 điểm 5. Cấy nấm nội tạng 0,2 điểm 6. Soi tươi tìm vi khuẩn 0,2 điểm 7. Nhuộm soi tìm vi khuẩn 0,2 điểm 8. Xét nghiệm ký sinh trùng đường ruột 0,2 điểm.9. Xét nghiệm ký sinh trùng sốt rét 0,2 điểm 10. Phản ứng Widal/VDRL 0,2 điểm V. Kỹ thuật chẩn đoán hình ảnh đang thực hiện: 2 điểm 1. Chụp động mạch vành 0,2 điểm 2. Chụp động mạch lớn qua ống thông 0,2 điểm 3. Chụp cộng hưởng từ 0,2 điểm 4. Chụp cắt lớp 0,2 điểm 5. Chụp đường mật qua ống dẫn lưu 0,1 điểm 6. Chụp dạ dày đối quang kép 0,1 điểm 7. Chụp thận ngược dòng 0,1 điểm 8. Chụp thận có cản quang 0,1 điểm 9. Chụp tử cung, buồng trứng có bơm hơi hay có cản quang 0,1 điểm 10. Chụp khung đại tràng có cản quang 0,1 điểm 11. Chụp thực quản có cản quang 0,1 điểm 12. Chụp lỗ dò cản quang 0,1 điểm 13. Chụp các xoang 0,1 điểm 14. Chụp cấp cứu ổ bụng 0,1 điểm 15. Siêu âm chẩn đoán (đen trắng hoặc mầu) 0,1 điểm 16. Nội soi chẩn đoán 0,1 điểm
APPENDICES 194
VI. Phẫu thuật do cán bộ bệnh viện đang thực hiện: 4điểm 1. Phẫu thuật loại đặc biệt 2 điểm 2. Phẫu thuật loại 1 (A, B, C) 1 điểm 3. Phẫu thuật loại 2 (A, B, C) 0,6 điểm 4. Phẫu thuật loại 3 0,4 điểm VII. Thủ thuật do cán bộ bệnh viện đang thực hiện: 2điểm 1. Thủ thuật loại đặc biệt 1 điểm 2. Thủ thuật loại 1 (A, B, C) 0,5 điểm 3. Thủ thuật loại 2 (A, B, C) 0,3 điểm 4. Thủ thuật loại 3 0,2 điểm VIII. Chuẩn đoán giải phẫu bệnh: 1 điểm 1. Sinh thiết hạch, u 0,5 điểm 2. Khám nghiệm tử thi 0,5 điểm. Mục 2- Bệnh viện y học cổ truyền I. Phần công tác cấp cứu, hồi sức đa khoa: 9 điểm 1. Thiết bị y tế: 2 điểm a. Máy X- quang công suất 125 KV - 300mA 0,4 điểm b. Máy điện tim 0,4 điểm c. Máy thở 0,4 điểm d. Máy siêu âm đen trắng 0,4 điểm đ. Kính hiển vi 2 mắt điện 0,4 điểm 2. Kỹ thuật xét nghiệm huyết học đang thực hiện: 1 điểm a. Số lượng hồng cầu 0,1 điểm b. Số lượng tiểu cầu 0,1 điểm c. Công thức bạch cầu 0,1 điểm
APPENDICES 195 d. Tỷ lệ huyết sắc tố 0,1 điểm đ. Thời gian máu chảy, máu đông 0,1 điểm e. Thể tích khối hồng cầu 0,1 điểm g. Huyết đồ 0,1 điểm h. Tốc độ máu lắng 0,1 điểm i. Dấu hiệu dây thắt 0,1 điểm k. Tế bào trong các dịch sinh vật 0,1 điểm 3. Kỹ thuật xét nghiệm hoá sinh đang thực hiện: 1 điểm a. Phản ứng Rivalta 0,1 điểm b. Dịch vị 0,1 điểm c. Bilirubin nước tiểu 0,1 điểm d. Urobilinogen nước tiểu 0,1 điểm đ. Đường nước tiểu 0,1 điểm e. Hồng cầu trong nước tiểu 0,1 điểm g. Cholesterol máu toàn phần 0,1 điểm h. Protein máu toàn phần 0,1 điểm i. Urê máu 0,1 điểm k. Đường máu 0,1 điểm 4. Kỹ thuật xét nghiệm vi sinh đang thực hiện: 1 điểm a. Ký sinh trùng đường ruột 0,2 điểm b. Soi tươi tìm vi khuẩn 0,2 điểm c. Nhuộm soi tìm vi khuẩn 0,2 điểm .d. Ký sinh trùng sốt rét 0,2 điểm đ. Soi tươi tìm nấm 0,2 điểm 5. Kỹ thuật chẩn đoán hình ảnh đang thực hiện: 1 điểm a. Chụp dạ dày cản quang 0,1 điểm
APPENDICES 196 b. Chụp xương 0,1 điểm c. Chụp các khớp xương 0,1 điểm d. Chụp khung đại tràng có cản quang 0,1 điểm đ. Chụp các xoang 0,2 điểm e. Chụp cấp cứu ổ bụng 0,2 điểm g. Siêu âm ổ bụng 0,2 điểm 6. Thủ thuật do cán bộ bệnh viện đang thực hiện: 1 điểm a. Thủ thuật loại 1 (A, B, C) 0,5 điểm b. Thủ thuật loại 2 (A,B, C) 0,3 điểm c. Thủ thuật loại 3 0,2 điểm 7. Kỹ thuật cấp cứu do cán bộ bệnh viện đang thực hiện: 2 điểm a. Suy hô hấp 0,4 điểm b. Ngừng tuần hoàn 0,4 điểm c. Choáng 0,4 điểm d. Hôn mê 0,4 điểm đ. Xử lý ngộ độc 0,4 điểm II. Phần đặc thù chuyên khoa: 11 điểm 1. Thiết bị y tế 4 điểm a. Máy điện châm 0,2 điểm b. Máy xoa bóp 0,2 điểm c. Máy chẩn mạch 0,2 điểm d. Máy cân bằng âm dương 0,2 điểm đ. Máy dò huyết 0,2 điểm e. Máy Laser châm cứu 0,2 điểm g. Thiết bị xông hơi YHCT 0,2 điểm h. Máy thái dược liệu 0,2 điểm
APPENDICES 197 i. Máy tán 0,2 điểm k. Máy bào 0,2 điểm l. Máy sao dược liệu 0,2 điểm m. Máy trộn dược liệu 0,2 điểm n. Máy bao viên 0,2 điểm o. Máy sát cốm 0,2 điểm.p. Máy quết tễ 0,2 điểm q. Tủ sấy dược liệu 0,2 điểm r. Thiết bị hệ thống sắc thuốc thang 0,2 điểm s. Dao cầu, thuyền tán 0,2 điểm t. Dụng cụ nấu cao 0,2 điểm u. Quầy thuốc YHCT 0,2 điểm 2. Châm tê để phẫu thuật do Bệnh viện thực hiện: 3điểm a. Phẫu thuật loại 1 (A, B, C) 1,2 điểm b. Phẫu thuật loại 2 (A, B, C) 1,0 điểm c. Phẫu thuật loại 3 0,8 điểm 3. Thủ thuật điều trị do bệnh viện thực hiện: 4 điểm a. Châm 0,2 điểm b. Cứu 0,2 điểm c. Thuỷ châm 0,2 điểm d. Điện châm 0,2 điểm đ. Giác 0,2 điểm e. Xông hơi thuốc YHCT 0,2 điểm g. Nhĩ châm 0,3 điểm h. Laser trên huyệt 0,3 điểm i. Thiệt châm 0,3 điểm k. Điều trị trĩ bằng thuốc YHCT 0,3 điểm
APPENDICES 198 l. Tắm nước thuốc YHCT 0,3 điểm m. Đắp, bó dán thuốc YHCT 0,3 điểm n. Xoa bóp, bấm huyệt 0,3 điểm o. Tập luyện dưỡng sinh 0,3 điểm p. Nắn bó gãy xương bằng phương pháp YHCT 0,3 điểm III. Phần bổ sung các nhóm chỉ tiêu khác đối với BVYHCT: 1. Nhóm tiêu chuẩn II: - Tiết a, điểm 2: Ngày điều trị trung bình được tínhlà 30 ngày. - Điểm 3: số người bệnh nội trú được chăm sóc Cấpmột: a. Từ 10% số người bệnh nội trú trở lên 2 điểm b. Từ 5% đến 9% số người bệnh nội trú 1 điểm c. Dưới 5% số người bệnh nội trú 0,5 điểm 2. Nhóm tiêu chuẩn III: - Mục 5: Thầy thuốc điều trị bao gồm: bác sĩ, lương y, y sĩ chuyên ngành YHCT 3. Nhóm tiêu chuẩn V:. - Điểm 2: được thay bằng: + Có buồng châm cứu nam, nữ riêng: 0,5 điểm + Có buồng luyện tập dưỡng sinh 0,5 điểm - Điểm 3: được thay bằng: + Khoa dược có buồng bào chế, buồng pha chế, sân phơi dược liệu, kho dược liệu 1 điểm Mục 3. Bệnh viện tâm thần I. Công tác cấp cứu, hồi sức đa khoa: 9 điểm 1. Thiết bị y tế: 2 điểm a. Máy X- quang công suất 125 KV - 300mA 0,4 điểm
APPENDICES 199 b. Máy điện tim 0,4 điểm c. Máy thở 0,4 điểm d. Máy siêu âm đen trắng 0,4 điểm đ. Kính hiển vi 2 mắt điện 0,4 điểm 2. Kỹ thuật xét nghiệm huyết học cơ bản BV thực hiện: 1điểm a. Số lượng hồng cầu 0,1 điểm b. Số lượng tiểu cầu 0,1 điểm c. Công thức bạch cầu 0,1 điểm d. Tỷ lệ huyết sắc tố 0,1 điểm đ. Thời gian máu chảy, máu đông 0,1 điểm e. Thể tích khối hồng cầu 0,1 điểm g. Huyết đồ 0,1 điểm h. Tốc độ lắng máu 0,1 điểm i. Dấu hiệu dây thắt 0,1 điểm k. Tế bào trong các dịch sinh vật 0,1 điểm 3. Kỹ thuật xét nghiệm hoá sinh cơ bản BV thực hiện: 1điểm a. Phản ứng Rivalta 0,1 điểm b. Dịch vị 0,1 điểm c. Bilirubin nước tiểu 0,1 điểm d. Urobilinogen nước tiểu 0,1 điểm đ. Đường nước tiểu 0,1 điểm e. Hồng cầu trong nước tiểu 0,1 điểm g. Cholesterol máu toàn phần 0,1 điểm h. Protein máu toàn phần 0,1 điểm i. Urê máu 0,1 điểm k. Đường máu 0,1 điểm.
APPENDICES 200
4. Kỹ thuật xét nghiệm vi sinh cơ bản BV thực hiện: 1điểm a. Ký sinh vật đường ruột 0,2 điểm b. Soi tươi tìm vi khuẩn 0,2 điểm c. Nhuộm soi tìm vi khuẩn 0,2 điểm d. Ký sinh vật sốt rét 0,2 điểm đ. Soi tươi tìm nấm 0,2 điểm 5. Kỹ thuật chẩn đoán hình ảnh do BV thực hiện: 1 điểm a. Chụp dạ dày 0,1 điểm b. Chụp xương 0,1 điểm c. Chụp các khớp xương 0,1 điểm d. Chụp khung đại tràng có cản quang 0,1 điểm đ. Chụp các xoang 0,2 điểm e. Chụp cấp cứu ổ bụng 0,2 điểm g. Siêu âm ổ bụng 0,2 điểm 6. Thủ thuật do cán bộ bệnh viện thực hiện: 1 điểm a. Thủ thuật loại 1 (A, B, C) 0,5 điểm b. Thủ thuật loại 2 (A,B, C) 0,3 điểm c. Thủ thuật loại 3 0,2 điểm 7. Kỹ thuật cấp cứu do bệnh viện thực hiện : 2 điểm a. Suy hô hấp 0,4 điểm b. Ngừng tuần hoàn 0,4 điểm c. Choáng 0,4 điểm d. Hôn mê 0,4 điểm đ. Xử lý ngộ độc 0,4 điểm II. Phần đặc thù chuyên khoa: 11 điểm 1. Thiết bị y tế 1 điểm
APPENDICES 201 a. Máy điện não 0,5 điểm b. Máy choáng (shock) điện 0,5 điểm 2. Kỹ thuật xét nghiệm hoá sinh đang thực hiện: 1 điểm Xác định chất gây nghiện 1 điểm 3. Kỹ thuật chẩn đoán hình ảnh đang thực hiện: 1 điểm a. Chụp tuỷ sống có cản quang 0,5 điểm b. Chụp hộp sọ thẳng, nghiêng 0,5 điểm 4. Chẩn đoán giải phẫu bệnh: 1 điểm a. Sinh thiết hạch, u 0,5 điểm b. Khám nghiệm tử thi 0,5 điểm. 5. Kỹ thuật chuyên khoa: 7 điểm a. Trắc nghiệm tâm lý 1 điểm b. Điều trị tâm lý 1 điểm c. Phục hồi chức năng 1 điểm d. Lao động liệu pháp 1 điểm đ. Điều trị giấc ngủ 1 điểm e. Choáng điện 1 điểm b. Giám định pháp y tâm thần 1 điểm III. Phần bổ sung các nhóm tiêu chuẩn khác: 1. Nhóm tiêu chuẩn II: - Tiết a, điểm 2: Ngày điều trị trung bình là 90 ngày. 2. Nhóm tiêu chuẩn V: Điểm 2: buồng điều trị thiết kế phù hợp với chăm sócngười bệnh tâm thần 1 điểm Điểm 3: có buồng điều trị bắt buộc bố trí riêng 1điểm Mục 4- Bệnh viện điều dưỡng - phục hồi chức năng
APPENDICES 202
I. Công tác cấp cứu, hồi sức đa khoa: 9 điểm 1. Thiết bị y tế: 2 điểm a. Máy X- quang công suất 125 KV - 300mA 0,4 điểm b. Máy điện tim 0,4 điểm c. Máy thở 0,4 điểm d. Máy siêu âm đen trắng 0,4 điểm đ. Kính hiển vi 2 mắt điện 0,4 điểm 2. Kỹ thuật xét nghiệm huyết học đang thực hiện: 1 điểm a. Số lượng hồng cầu 0,1 điểm b. Số lượng tiểu cầu 0,1 điểm c. Công thức bạch cầu 0,1 điểm d. Tỷ lệ huyết sắc tố 0,1 điểm đ. Thời gian máu chảy, máu đông 0,1 điểm e. Thể tích khối hồng cầu 0,1 điểm g. Huyết đồ 0,1 điểm h. Tốc độ lắng máu 0,1 điểm i. Dấu hiệu dây thắt 0,1 điểm k. Tế bào trong các dịch sinh vật 0,1 điểm 3. Kỹ thuật xét nghiệm hoá sinh đang thực hiện: 1 điểm. a. Phản ứng Rivalta 0,1 điểm b. Dịch vị 0,1 điểm c. Bilirubin nước tiểu 0,1 điểm d. Urobilinogen nước tiểu 0,1 điểm đ. Đường nước tiểu 0,1 điểm e. Hồng cầu trong nước tiểu 0,1 điểm g. Cholesterol máu toàn phần 0,1 điểm
APPENDICES 203 h. Protein máu toàn phần 0,1 điểm i. Urê máu 0,1 điểm k. Đường máu 0,1 điểm 4. Kỹ thuật xét nghiệm vi sinh đang thực hiện: 1 điểm a. Ký sinh vật đường ruột 0,2 điểm b. Soi tươi tìm vi khuẩn 0,2 điểm c. Nhuộm soi tìm vi khuẩn 0,2 điểm d. Ký sinh trùng sốt rét 0,2 điểm đ. Soi tươi tìm nấm 0,2 điểm 5. Kỹ thuật chẩn đoán hình ảnh đang thực hiện: 1 điểm a. Chụp dạ dày 0,1 điểm b. Chụp xương 0,1 điểm c. Chụp các khớp xương 0,1 điểm d. Chụp khung đại tràng có cản quang 0,1 điểm đ. Chụp các xoang 0,2 điểm e. Chụp cấp cứu ổ bụng 0,2 điểm g. Siêu âm ổ bụng 0,2 điểm 6. Thủ thuật do cán bộ bệnh viện đang thực hiện: 1 điểm a. Thủ thuật loại 1 (A, B, C) 0,5 điểm b. Thủ thuật loại 2 (A,B, C) 0,3 điểm c. Thủ thuật loại 3 0,2 điểm 7. Kỹ thuật cấp cứu do cán bộ bệnh viện đang thực hiện: 2 điểm a. Suy hô hấp 0,4 điểm b. Ngừng tuần hoàn 0,4 điểm c. Choáng 0,4 điểm d. Hôn mê 0,4 điểm
APPENDICES 204
đ. Xử lý ngộ độc 0,4 điểm II. Phần đặc thù chuyên khoa: 11 điểm 1. Thiết bị y tế 3 điểm.a. Máy điều trị tần số thấp 0,3 điểm b. Máy siêu âm điều trị 0,3 điểm c. Máy Laser điều trị 0,3 điểm d. Máy điều trị sóng ngắn 0,3 điểm đ. Máy kéo dãn cột sống 0,3 điểm e. Máy điều trị điện trường 0,3 điểm g. Máy điều trị bằng dòng giao thoa 0,3 điểm h. Máy chẩn đoán điện cơ 0,3 điểm i. Đèn hồng ngoại 0,3 điểm k. Đèn tử ngoại 0,3 điểm 2. Dụng cụ chuyên ngành phục hồi chức năng: 4 điểm a. Xưởng sản xuất dụng cụ chỉnh hình thích ứng 1 điểm b. Dụng cụ lượng giá chức năng vận động: lực kế tay, chân, thân 0,5 điểm c. Dụng cụ vận động trị liệu: xe đạp, bậc gỗ, tạ, bóng, thang, ròng rọc 0,5 điểm d. Thuỷ trị liệu 0,5 điểm đ. Dụng cụ hoạt động trị liệu 0,5 điểm e. Dụng cụ ngôn ngữ trị liệu 0,5 điểm g. Nhiệt trị liệu 0,5 điểm 3. Các kỹ thuật Phục hồi chức năng: 4 điểm a. Tập đi nạng 0,4 điểm b. Xoa bóp bấm huyệt 0,4 điểm c. Kéo dãn phục hồi vận động các chi 0,4 điểm d. Tập xe lăn 0,4 điểm
APPENDICES 205
đ. Tập tạ, chuỳ các loại 0,4 điểm e. Tập kéo co dãn chủ động và thụ động 0,4 điểm g. Tập bóng các loại 0,4 điểm h. Tập leo thang 0,4 điểm i. Tập bàn tay và ngón tay 0,4 điểm k. Tập kéo nắn cột sống 0,4 điểm. III. Phần bổ sung các nhóm tiêu chuẩn khác: 1. Nhóm tiêu chuẩn II: - Tiết a, điểm 2: ngày điều trị trung bình được tính chuẩn là 30 ngày. - Điểm 4: Số người bệnh nội trú được chăm sóc cấp một; chỉ tiêu này được thay bằng: a. Từ 10% số người bệnh nội trú trở lên 2 điểm b. Từ 5 đến 9% số người bệnh nội trú 1 điểm c. Dưới 5% số người bệnh nội trú 0,5 điểm. Mục 5- Bệnh viện Tai Mũi họng, Răng hàm mặt, mắt I. Công tác cấp cứu, hồi sức đa khoa: 9 điểm 1. Thiết bị y tế: 2 điểm a. Máy X- quang công suất 125 KV - 300mA 0,4 điểm b. Máy điện tim 0,4 điểm c. Máy thở 0,4 điểm d. Máy siêu âm đen trắng 0,4 điểm đ. Kính hiển vi 2 mắt điện 0,4 điểm 2. Kỹ thuật xét nghiệm huyết học do BV thực hiện: 1 điểm a. Số lượng hồng cầu 0,1 điểm b. Số lượng tiểu cầu 0,1 điểm c. Công thức bạch cầu 0,1 điểm
APPENDICES 206 d. Tỷ lệ huyết sắc tố 0,1 điểm đ. Thời gian máu chảy, máu đông 0,1 điểm e. Thể tích khối hồng cầu 0,1 điểm g. Huyết đồ 0,1 điểm h. Tốc độ lắng máu 0,1 điểm i. Dấu hiệu dây thắt 0,1 điểm k. Tế bào trong các dịch sinh vật 0,1 điểm 3. Kỹ thuật xét nghiệm hoá sinh do BV thực hiện: 1 điểm a. Phản ứng Rivalta 0,1 điểm b. Dịch vị 0,1 điểm c. Bilirubin nước tiểu 0,1 điểm d. Urobilinogen nước tiểu 0,1 điểm đ. Đường nước tiểu 0,1 điểm e. Hồng cầu trong nước tiểu 0,1 điểm g. Cholesterol máu toàn phần 0,1 điểm h. Protein máu toàn phần 0,1 điểm i. Urê máu 0,1 điểm k. Đường máu 0,1 điểm 4. Kỹ thuật xét nghiệm vi sinh do BV thực hiện: 1 điểm a. Ký sinh vật đường ruột 0,2 điểm b. Soi tươi tìm vi khuẩn 0,2 điểm c. Nhuộm soi tìm vi khuẩn 0,2 điểm d. Ký sinh trùng sốt rét 0,2 điểm.đ. Soi tươi tìm nấm 0,2 điểm 5. Kỹ thuật chẩn đoán hình ảnh do BV thực hiện: 1 điểm a. Chụp dạ dày 0,1 điểm b. Chụp xương 0,1 điểm
APPENDICES 207 c. Chụp các khớp xương 0,1 điểm d. Chụp khung đại tràng có cản quang 0,1 điểm đ. Chụp các xoang 0,2 điểm e. Chụp cấp cứu ổ bụng 0,2 điểm g. Siêu âm ổ bụng 0,2 điểm 6. Thủ thuật do bệnh viện thực hiện: 1 điểm a. Thủ thuật loại 1 (A, B, C) 0,5 điểm b. Thủ thuật loại 2 (A,B, C) 0,3 điểm c. Thủ thuật loại 3 0,2 điểm 7. Kỹ thuật cấp cứu do bệnh viện thực hiện : 2 điểm a. Suy hô hấp 0,4 điểm b. Ngừng tuần hoàn 0,4 điểm c. Choáng 0,4 điểm d. Hôn mê 0,4 điểm đ. Xử lý ngộ độc 0,4 điểm II. Phần đặc thù chuyên khoa: 11 điểm 1. Bệnh viện Tai Mũi Họng 1.1. Thiết bị y tế 3 điểm a. Máy quay lắc thử nghiệm sóng 0,3 điểm b. Máy đo thính lực 0,3 điểm c. Kính hiển vi phẫu thuật 0,4 điểm d. Máy soi hoạt nghiệm thanh quản 0,4 điểm đ. Máy khám tai có truyền hình 0,4 điểm e. Máy nội soi khí phế quản 0,4 điểm g. Máy Optokinatic 0,4 điểm h. Khung dao động 0,4 điểm
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1.2. Kỹ thuật chẩn đoán hình ảnh do BV thực hiện 2 điểm a. Chụp Hirzt 0,2 điểm b. Chụp xương chũm 0,3 điểm c. Chụp Schuller 0,3 điểm d. Chụp Stenven 0,3 điểm đ. Chụp lỗ tai ngoài 0,3 điểm.e. Chụp lỗ rách sau 0,3điểm g. Chụp lỗ nền sọ 0,3 điểm 1.3. Phẫu thuật do cán bộ bệnh viện thực hiện: 4 điểm a. Phẫu thuật loại đặc biệt 2,0 điểm b. Phẫu thuật loại 1 (A, B, C) 1,0 điểm c. Phẫu thuật loại 2 (A,B, C) 0,6 điểm d. Phẫu thuật loại 3 0,4 điểm 1.4. Thủ thuật do bệnh viện thực hiện: 2 điểm a. Thủ thuật loại đặc biệt 1,0 điểm b. Thủ thuật loại 1 (A, B, C) 0,5 điểm c. Thủ thuật loại 2 (A,B, C) 0,3 điểm d. Thủ thuật loại 3 0,2 điểm 1.5. Phần bổ sung các nhóm tiêu chuẩn khác: - Nhóm tiêu chuẩn IV: cơ sở hạ tầng - Điểm 2: Được thay bằng các khoa: Khám bệnh, Hồi sức cấp cứu, Chẩn đoán hình ảnh, Thính học, Thanh học, được xây dựng liên hoàn có buồng vệ sinh, buồng tắm khép kín 1 điểm - Điểm 3: được thay bằng: Khoa hồi sức cấp cứu, Phòng phẫu thuật, phẫu tích xương chũm, buồng khám chức năng tiền đình có điều hoà nhiệt độ 1 điểm. 2. Bệnh viện Răng Hàm Mặt: 2.1. Thiết bị : 3 điểm a. Ghế răng 0,4 điểm
APPENDICES 209 b. Máy đúc sứ 0,4 điểm c. Máy khoan cắt xương 0,4 điểm d. Máy cắt quay tiêu bản 0,4 điểm đ. Máy mài cao tốc 0,4 điểm e. Máy đúc cao tần 0,5 điểm g. Kính hiển vi kèm TV và Camera 0,5 điểm 2.2. Kỹ thuật chẩn đoán hình ảnh do BV thực hiện: 2điểm a. Chụp Panorama 0,4 điểm b. Chụp Hirts 0,4 điểm c. Chụp Blondeaux 0,4 điểm d. Chụp Schuller 0,4 điểm đ. Chụp ổ răng 0,4 điểm 2.3. Phẫu thuật do bệnh viện thực hiện: 4 điểm. a. Phẫu thuật loại đặc biệt 2,0 điểm b. Phẫu thuật loại 1 (A, B, C) 1,0 điểm c. Phẫu thuật loại 2 (A,B, C) 0,6 điểm d. Phẫu thuật loại 3 0,4 điểm 2.4. Thủ thuật do bệnh viện thực hiện: 2 điểm a. Thủ thuật loại đặc biệt 1,0 điểm b. Thủ thuật loại 1 (A, B, C) 0,5 điểm c. Thủ thuật loại 2 (A,B, C) 0,3 điểm d. Thủ thuật loại 3 0,2 điểm 3. Bệnh viện Mắt: 3.1. Thiết bị y tế 3 điểm a. Đèn soi đáy mắt cầm tay 0,1 điểm b. Máy đo Javal 0,1 điểm
APPENDICES 210 c. Máy làm nhuyễn thuỷ tinh thể 0,2 điểm d. Máy đo khúc xạ tự động 0,2 điểm đ. Máy đo nhãn áp tự động 0,2 điểm e. Máy đo thị trường tự động 0,2 điểm g. Máy sinh hiển vi đèn khe khám mắt 0,2 điểm h. Máy sinh hiển vi phẫu thuật mắt 0,2 điểm i. Máy đo thị trường không tự động 0,2 điểm k. Bộ thử kính có gọng kính 0,2 điểm l. Bộ thử thị lực điện 0,2 điểm m. Bộ đo nhãn áp Maclakov 0,2 điểm n. Hộp đo nhãn áp tiếp xúc Goldman-Shiotz 0,2 điểm o. Máy mổ Pharco 0,3 điểm p. Laser excimer 0,3 điểm 3.2. Kỹ thuật chẩn đoán hình ảnh do BV thực hiện: 2điểm a. Chụp hốc mắt 0,2 điểm b. Chụp trần hốc mắt 0,3 điểm c. Chụp lỗ thị giác 0,3 điểm d. Chụp khu trú Baltin, xác định dị vật nhãn cầu 0,3điểm đ. Chụp khu trú phương pháp Vogt, xác định dị vật bán phần trước nhãn cầu 0,3 điểm e. Chụp khung xương Baltin phát hiện dị vật nhãn cầu 0,3điểm b. Chụp túi lệ có bơm thuốc cản quang 0,3 điểm 3.3. Phẫu thuật do bệnh viện thực hiện: 4 điểm. a. Phẫu thuật loại đặc biệt 2,0 điểm b. Phẫu thuật loại 1 (A, B, C) 1,0 điểm c. Phẫu thuật loại 2 (A,B, C) 0,6 điểm d. Phẫu thuật loại 3 0,4 điểm
APPENDICES 211
3.4. Thủ thuật do bệnh viện thực hiện: 2 điểm a. Thủ thuật loại đặc biệt 1,0 điểm b. Thủ thuật loại 1 (A, B, C) 0,5 điểm c. Thủ thuật loại 2 (A,B, C) 0,3 điểm d. Thủ thuật loại 3 0,2 điểm
APPENDICES 212
Appendix B Nursing Competency Standards (Vietnamese) BỘ Y TẾ
CHUẨN NĂNG LỰC CƠ BẢN CỦA ĐIỀU DƯỠNG VIỆT NAM (Ban hành kèm theo Quyết định số: 1352/QĐ-BYT ngày 21 tháng4 năm 2012 của Bộ Y tế)
Hà Nội, tháng 4 năm 2012
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Phần Một
Giới thiệu chung
Mở đầu
Từ năm 1990 đến nay, ngành Điều dưỡng Việt Nam được sự hỗ trợ của chính phủ và Bộ Y tế đã phát triển nhanh chóng trên các lĩnh vực về quản lý, đào tạo, thực hành và nghiên cứu Điều dưỡng. Trong xu hướng hội nhập khu vực và quốc tế, chính phủ đã ký Thỏa thuận khung về thừa nhận lẫn nhau với 10 quốc gia ASEAN về việc công nhận dịch vụ Điều dưỡng trong khu vực. Để tăng cường chất lượng nguồn nhân lực điều dưỡng làm cơ sở cho việc xây dựng chương trình đào tạo và sử dụng nhân lực điều dưỡng có hiệu quả và đáp ứng yêu cầu hội nhập của các nước trong khu vực, Bộ Y tế phối hợp với Hội Điều dưỡng Việt Nam đã xây dựng Bộ Chuẩn năng lực cơ bản của Điều dưỡng Việt Nam với sự hỗ trợ của Hội Điều dưỡng Canada và chuyên gia điều dưỡng của Đại học Kỹ thuật Queensland – Úc. Tài liệu này đã được các chuyên gia điều dưỡng trong nước, các nhà quản lý y tế và giáo dục điều dưỡng tham gia biên soạn trên cơ sở tham khảo Tiêu chuẩn năng lực điều dưỡng của các nước trong khu vực và trên thế giới. Trên cơ sở kết luận thẩm định của Hội đồng chuyên môn được thành lập theo Quyết định số 3602/QĐ-BYT ngày 04 tháng 10 năm 2011, Bộ Y tế ban hành Bộ Chuẩn năng lực cơ bản của Điều dưỡng Việt Nam để các cơ sở đào tạo, sử dụng điều dưỡng nghiên cứu áp dụng và để thông tin cho các nước trong khu vực và Thế giới về chuẩn năng lực điều dưỡng Việt Nam.
Bối cảnh chung về điều dưỡng 1.1.1 Bối cảnh quốc tế về điều dưỡng Chuyên ngành điều dưỡng đã và đang phát triển thành một ngành học đa khoa, có nhiều chuyên khoa sau đại học và song hành phát triển với các chuyên ngành Y, Dược, Y tế Công cộng trong Ngành y tế. Nghề điều dưỡng đã phát triển thành một ngành dịch vụ công cộng thiết yếu, cần cho mọi người, mọi gia đình. Nhu cầu về dịch vụ chăm sóc có chất lượng ngày càng gia tăng ở mọi quốc gia, đặc biệt là các quốc gia phát triển, do sự gia tăng dân số già làm tăng nhu cầu chăm sóc điều dưỡng tại nhà và tại các cơ sở y tế.
APPENDICES 214
Trình độ điều dưỡng viên xu thế cao đẳng và đại học hóa đang trở thành yêu cầu tối thiểu để được đăng ký hành nghề và được công nhận là điều dưỡng chuyên nghiệp giữa các quốc gia khu vực ASEAN và trên toàn Thế giới. Thiếu điều dưỡng xuất hiện ở nhiều quốc gia, đặc biệt là tại các nước phát triển. Những nguyên nhân dẫn đến thiếu điều dưỡng bao gồm: dân số già làm gia tăng nhu cầu chăm sóc; điều dưỡng viên bỏ nghề sớm do công việc nặng nhọc, có nhiều áp lực về tâm lý và thời gian làm việc; các nghề khác hấp dẫn điều dưỡng viên chuyển nghề (thư ký các văn phòng, nhân viên các công ty..); nhiều điều dưỡng viên chỉ muốn làm việc bán thời gian (part time) để có thời gian chăm sóc gia đình và con nhỏ. Nhiều nước như Mỹ, Canada, Anh, Nhật Bản khi mở ra các cơ sở y tế không có điều dưỡng để tuyển, vì vậy các nước này đưa ra chính sách thu hút về lương và gia hạn thị thực để tuyển điều dưỡng viên có trình độ ở các quốc gia đang phát triển. Di cư điều dưỡng đang diễn ra trên phạm vi toàn cầu. Các dòng di cư điều dưỡng viên từ những nước kém phát triển sang nước đang phát triển và từ nước đang phát triển sang nước phát triển. Các Thỏa thuận thừa nhận lẫn nhau (Mutual Recognition Agreement-MRA) để hỗ trợ cho sự di cư điều dưỡng trên phạm vi khu vực và toàn cầu đã trở thành mối quan tâm của các chính phủ, được đặt ra trong tiến trình hội nhập và đã trở thành cam kết của các chính phủ. Mười quốc gia ở khu vực Đông Nam Á đã ký kết các thỏa thuận khung về công nhận dịch vụ Y, Điều dưỡng và Nha khoa, theo đó tiến tới cho phép công dân của các nước thành viên có chứng chỉ hành nghề hợp pháp được hành nghề Y, Điều dưỡng, Nha khoa ở các nước thành viên. Ủy ban Điều phối ASEAN về dịch vụ điều dưỡng đang thảo luận Tiêu chuẩn năng lực cốt lõi của cử nhân điều dưỡng làm cơ sở cho việc công nhận điều dưỡng viên giữa các nước và đang xây dựng Website Điều dưỡng ASEAN để theo dõi sự di chuyển thể nhân người nước ngoài hành nghề Điều dưỡng ở mỗi nước. Sự phát triển không đồng đều và đa dạng của ngành Điều dưỡng trong tiến trình hội nhập khu vực và quốc tế tất yếu sẽ dẫn đến nhu cầu chuẩn hóa hệ thống đào tạo, chuẩn hóa trình độ điều dưỡng viên để tạo điều kiện cho việc di chuyển thể nhân điều dưỡng và sự công nhận lẫn nhau về trình độ điều dưỡng giữa các nước khu vực ASEAN.
1.1.2 Chuyên ngành Điều dưỡng trong bối cảnh chung của hệ thống y tế Hiện nay, cả nước có 75891 điều dưỡng, chiếm 45% nhân lực chuyên môn của ngành y
APPENDICES 215
tế (Niên giám thống kê Y tế năm 2009). Dịch vụ chăm sóc do điều dưỡng cung cấp là một trong những trụ cột của hệ thống dịch vụ y tế, đóng vai trò rất quan trọng trong việc nâng cao chất lượng dịch vụ y tế. Được sự quan tâm của Bộ Y tế, ngành Điều dưỡng đã có sự phát triển nhanh chóng trên các lĩnh vực sau: Thiết lập hệ thống quản lý điều dưỡng từ Bộ Y tế đến các Sở Y tế và các bệnh viện và hệ thống tổ chức Hội Điều dưỡng ở các cấp đã phối hợp song hành, hỗ trợ lẫn nhau và cùng phát huy hiệu quả. Hệ thống điều dưỡng trưởng đã phát huy được vai trò quản lý chăm sóc và tham gia xây dựng các chính sách liên quan đến công tác điều dưỡng trong chăm sóc người bệnh. Vị trí và vai trò của điều dưỡng trưởng được khẳng định, điều dưỡng trưởng đã có phụ cấp nghề nghiệp tương đương phó khoa, phó phòng; một số điều dưỡng trưởng đã được bổ nhiệm phó phòng nghiệp vụ y, phó giám đốc bệnh viện. Điều dưỡng đã trở thành một ngành học với nhiều cấp trình độ, từ trung cấp lên cao đẳng, đại học điều dưỡng và thạc sỹ điều dưỡng. Hệ thống đào tạo điều dưỡng đến nay đã có nhiều cơ sở đào tạo, trong đó có các cơ sở đào tạo cao đẳng, đại học và sau đại học.
Các chính sách về điều dưỡng viên và các chuẩn mực hành nghề điều dưỡng đang được bổ sung, hoàn thiện: Bộ Y tế đã ban hành các văn bản quy phạm pháp luật, hướng dẫn quốc gia về thực hành chăm sóc điều dưỡng; Nhà nước đã có quyết định công nhận danh hiệu Thầy thuốc ưu tú, Thầy thuốc nhân dân cho điều dưỡng viên, hộ sinh viên. Với những chính sách hiện hành đã mở ra tương lai cho ngành điều dưỡng phát triển và người điều dưỡng có thể yên tâm phấn đấu và tiến bộ trong nghề nghiệp. Chất lượng chăm sóc người bệnh đã có nhiều chuyển biến rõ rệt thông qua việc đổi mới các mô hình phân công chăm sóc, tổ chức chăm sóc người bệnh toàn diện, chuẩn hoá các kỹ thuật điều dưỡng. Vai trò và vị thế nghề nghiệp của điều dưỡng viên đã có những thay đổi cơ bản. Tuy nhiên, ngành điều dưỡng đang đứng trước nhiều thách thức của sự phát triển: thiếu đội ngũ giáo viên và thiếu chuyên gia đầu ngành về Điều dưỡng nên phải sử dụng tới gần 70% đội ngũ giáo viên giảng dạy Điều dưỡng là bác sĩ; khoa học Điều dưỡng chưa phát triển kịp với những tiến bộ của Điều dưỡng thế giới trong đào tạo Điều dưỡng; người điều dưỡng chưa được đào tạo để thực hiện thiên chức chăm sóc mang tính chủ động và chuyên nghiệp; nguồn nhân lực điều dưỡng mất cân đối về cơ cấu dẫn đến sử dụng chưa phân biệt rõ trình độ đào tạo, kỹ năng, kỹ xảo; vị thế và hình ảnh người điều dưỡng trong xã hội tuy đã có thay đổi nhưng chưa được định hình rõ ràng.
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Sự cần thiết Việc xây dựng và ban hành Bộ Chuẩn năng lực cơ bản cho điều dưỡng Việt Nam có ý nghĩa rất quan trọng bởi các lý do cơ bản sau đây: Đối với cơ sở đào tạo - phân biệt năng lực giữa Cử nhân điều dưỡng với các cấp đào tạo điều dưỡng khác (Cao đẳng, trung học); - xây dựng chương trình và nội dung đào tạo đảm bảo cho sinh viên điều dưỡng sau khi tốt nghiệp có được các năng lực theo quy định; - giảng viên điều dưỡng xác định mục tiêu và nội dung đào tạo cho Cử nhân điều dưỡng; - sinh viên điều dưỡng phấn đấu học tập và tự đánh giá năng lực nghề nghiệp của bản thân; so sánh năng lực đầu ra của điều dưỡng Việt Nam với điều dưỡng của các nước, thúc đẩy quá trình hội nhập và công nhận trình độ đào tạo giữa các nước trong khu vực và trên thế giới.
Đối với cơ sở sử dụng nhân lực điều dưỡng - xác định phạm vi hành nghề giữa các cấp điều dưỡng; - phân công nhiệm vụ và trách nhiệm cho từng cấp điều dưỡng; - xây dựng tiêu chuẩn thực hành nghề nghiệp cho các cấp điều dưỡng; - xác định trách nhiệm và nghĩa vụ nghề nghiệp của người Điều dưỡng và giải quyết các sai phạm về đạo đức và hành nghề Điều dưỡng.
Đối với các cơ quan quản lý điều dưỡng - các quốc gia công nhận sự tương đương về trình độ Điều dưỡng giữa các quốc gia; - hợp tác và trao đổi Điều dưỡng giữa các quốc gia; - xây dựng chương trình đào tạo Điều dưỡng quốc tế; - xác định năng lực, chuẩn mực điều dưỡng ở mỗi quốc gia và khu vực.
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Cơ sở xây dựng chuẩn năng lực cỏa bản điều dưỡng - Luật Khám bệnh, chữa bệnh số 40/QH 12 ngày 23 tháng 11 năm 2009 của Quốc Hội khóa XII nước Cộng hòa xã hội chủ nghĩa Việt Nam.
- Thỏa thuận khung thừa nhận lẫn nhau về dịch vụ điều dưỡng giữa các nước trong khu vực ASEAN do Chính phủ Việt Nam ký kết với các nước thành viên khối ASEAN ngày 8 tháng 12 năm 2006. - Tiêu chuẩn nghiệp vụ Ngạch công chức điều dưỡng theo Quyết định số 41/2005/QĐ-BNV, ngày 22 tháng 4 năm 2005 của Bộ Nội vụ. - Chuẩn Năng lực chung của cử nhân điều dưỡng do Tổ chức Y tế thế giới khu vực Tây Thái Bình Dương khuyến cáo.
- Chuẩn “Năng lực điều dưỡng chuyên nghiệp - Professional Nurse” của Hội đồng Điều dưỡng thế giới (ICN - 2003). - Chuẩn năng lực cho Điều dưỡng của Philippines.
Qúa trình xây dựng Quá trình chuẩn bị của Hội Điều dưỡng Việt Nam - Thành lập Ban biên soạn Tiêu chuẩn năng lực điều dưỡng Việt Nam, gồm các nhà đào tạo, quản lý và xây dựng chính sách y tế, có sự tham gia tư vấn của các chuyên gia điều dưỡng quốc tế. - Ban biên soạn đã tiến hành dịch và nghiên cứu tài liệu trong nước và tài liệu quốc tế về chuẩn năng lực điều dưỡng
- Ban biên soạn đã xây dựng các bản thảo tiêu chuẩn năng lực để xin ý kiến góp ý trong các hội thảo điều dưỡng tại các vùng, miền.
- Tổ chức lấy ý kiến góp ý của các cơ sở đào tạo điều dưỡng, các bệnh viện và đăng trên website của Hội Điều dưỡng để tham khảo ý kiến của Hội viên. - Ban chấp hành Hội Điều dưỡng Việt Nam đã họp thông qua. Chủ tịch Hội Điều dưỡng Việt Nam đã ký ban hành về phương diện Hội nghề nghiệp để sử dụng làm tài liệu tham khảo và đã trình Bộ Y tế lần một vào năm 2009. Lần thứ 2 Hội Điều dưỡng Việt Nam tiếp tục bổ sung cập nhật và trình Bộ Y tế vào tháng 10 năm 2011.
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Quá trình phê duyệt của Bộ Y tế - Trên cơ sở đề xuất của Hội Điều dưỡng Việt Nam, sau khi có ý kiến chỉ đạo của Bộ trưởng Bộ Y tế, Vụ Tổ chức Cán bộ - Bộ Y tế đã đảm nhiệm vai trò đầu mối để tiếp tục hoàn chỉnh Chuẩn năng lực điều dưỡng Việt Nam theo các quy định của Bộ Y tế. - Bộ trưởng Bộ Y tế đã thành lập Hội đồng chuyên môn thẩm định Tài liệu chuẩn năng lực cơ bản của điều dưỡng Việt Nam. Hội đồng do PGS.TS Nguyễn Viết Tiến, Thứ trưởng Bộ Y tế là Chủ tịch Hội đồng và có 15 thành viên. - Hội đồng đã họp thẩm định tài liệu và đã có ý kiến góp ý bổ sung về nội dung và thể thức văn bản.Tổ Thư ký Hội đồng đã tiếp thu ý kiến của Hội đồng đẻ tiếp tục hoàn thiện Tài liệu. - Vụ Tổ chức Cán bộ - Bộ Y tế đã có văn bản xin góp ý lần cuối của các Vụ, Cục của Bộ Y tế để hoàn thiện.
- Bộ Trưởng Bộ Y tế đã ký Quyết định ban hành Chuẩn năng lực cơ bản của điều dưỡng Việt Nam tại Quyết định số ….. ngày …. tháng ….. năm 2012.
Tóm tắt nội dung tài liệu
Bộ Chuẩn năng lực cơ bản của điều dưỡng Việt Nam được cấu trúc theo khuôn mẫu chung của điều dưỡng khu vực Châu Á Thái Bình Dương và ASEAN để đáp ứng yêu cầu của khu vực và để dễ so sánh với chuẩn năng lực điều dưỡng các nước. Tài liệu chuẩn năng lực cơ bản điều dưỡng Việt Nam được cấu trúc thành 3 lĩnh vực, 25 tiêu chuẩn và 110 tiêu chí. Mỗi lĩnh vực thể hiện một chức năng cơ bản của người điều dưỡng. Trong tài liệu này được chia thành 3 lĩnh vực là: năng lực thực hành, quản lý chăm sóc và phát triển nghề, luật pháp và đạo đức điều dưỡng. Mỗi tiêu chuẩn thể hiện một phần của lĩnh vực và bao hàm một nhiệm vụ của người điều dưỡng. Mỗi tiêu chí là một thành phần của tiêu chuẩn. Một tiêu chí có thể áp dụng chung cho các tiêu chuẩn và các lĩnh vực.
Bộ Chuẩn năng lực cơ bản cho Điều dưỡng Việt Nam được biên soạn công phu, tham khảo nhiều nguồn tài liệu có giá trị, thông qua nhiều kênh thông tin để lấy ý kiến góp ý
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và điều chỉnh cho phù hợp với hiện trạng chuyên ngành Điều dưỡng Việt Nam và xu thế hội nhập.
Phần Hai
Chuẩn năng lực cơ bản của điều dưỡng Việt Nam
Lĩnh vực 1: Năng lực thực hành chăm sóc
Tiêu chuẩn 1: Thể hiện sự hiểu biết về tình trạng sức khỏe, bệnh tật của các cá nhân, gia đình và cộng đồng
1. Tiêu chí 1: Xác định nhu cầu về sức khỏe và tình trạng sức khỏe của các cá nhân, gia đình và cộng đồng. 2. Tiêu chí 2: Giải thích tình trạng sức khỏe của các cá nhân, gia đình và cộng đồng.
Tiêu chuẩn 2: Ra quyết định chăm sóc phù hợp với nhu cầu của các cá nhân, gia đình và cộng đồng
3. Tiêu chí 1: Thu thập thông tin và phân tích các vấn đề về sức khỏe, bệnh tật để xác định các vấn đề về sức khỏe và bệnh tật của cá nhân, gia đình và cộng đồng. 4. Tiêu chí 2: Ra các quyết định về chăm sóc cho người bệnh, gia đình và cộng đồng an toàn và hiệu quả. 5. Tiêu chí 3: Thực hiện các can thiệp điều dưỡng để hỗ trợ cá nhân, gia đình và cộng đồng đáp ứng với các vấn đề về sức khỏe/bệnh tật phù hợp với văn hóa, tín ngưỡng của người bệnh, gia đình người bệnh. 6. Tiêu chí 4: Theo dõi sự tiến triển của các can thiệp điều dưỡng đã thực hiện.
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Tiêu chuẩn 3: Xác định ưu tiên chăm sóc dựa trên nhu cầu của người bệnh, gia đình và cộng đồng
7. Tiêu chí 1: Phân tích và xác định được những nhu cầu chăm sóc ưu tiên của cá nhân, gia đình và cộng đồng. 8. Tiêu chí 2: Thực hiện các can thiệp chăm sóc đáp ứng nhu cầu chăm sóc ưu tiên của cá nhân, gia đình và cộng đồng.
Tiêu chuẩn 4: Sử dụng quy trình điều dưỡng để lập kế hoạch chăm sóc và can thiệp điều dưỡng
9. Tiêu chí 1: Thực hiện nhận định người bệnh toàn diện và có hệ thống. 10. Tiêu chí 2: Tập hợp và ghi đầy đủ thông tin thích hợp vào hồ sơ điều dưỡng. 11. Tiêu chí 3: Phân tích và diễn giải các thông tin về người bệnh một cách chính xác.
12. Tiêu chí 4: Lập kế hoạch chăm sóc điều dưỡng dựa trên nhận định người bệnh và có sự thống nhất với đồng nghiệp, người nhà người bệnh về các vấn đề ưu tiên, sự mong muốn và kết quả mong đợi cho người bệnh. 13. Tiêu chí 5: Giải thích các can thiệp điều dưỡng cho người bệnh, gia đình người bệnh và thực hiện các can thiệp theo kế hoạch chăm sóc điều dưỡng, bảo đảm an toàn, thoải mái, hiệu quả cho người bệnh. 14. Tiêu chí 6: Hướng dẫn người bệnh, gia đình người bệnh các phương pháp tự chăm sóc một cách phù hợp. 15. Tiêu chí 7: Đánh giá kết quả của quá trình chăm sóc và điều chỉnh kế hoạch chăm sóc dựa vào tình trạng sức khỏe người bệnh và kết quả mong đợi. 16. Tiêu chí 8: Thực hiện các công việc cần thiết để hỗ trợ người bệnh xuất viện. 17. Tiêu chí 9: Tuyên truyền giáo dục sức khỏe và hướng dẫn cách phòng bệnh cho người bệnh.
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Tiêu chuẩn 5: Tạo sự an toàn, thoải mái và kín đáo cho người bệnh
18. Tiêu chí 1: Thực hiện các biện pháp an toàn trong chăm sóc cho người bệnh. 19. Tiêu chí 2: Tạo môi trường chăm sóc thoải mái trong khi chăm sóc cho người bệnh. 20. Tiêu chí 3: Bảo đảm sự kín đáo trong khi chăm sóc cho người bệnh.
Tiêu chuẩn 6: Tiến hành các kỹ thuật chăm sóc đúng quy trình
21. Tiêu chí 1: Tuân thủ các bước của quy trình điều dưỡng trong phạm vi chuyên môn. 22. Tiêu chí 2: Thực hiện thành thạo kỹ thuật điều dưỡng. 23. Tiêu chí 3: Tuân thủ các quy định về vô khuẩn và kiểm soát nhiễm khuẩn.
Tiêu chuẩn 7: Dùng thuốc đảm bảo an toàn hiệu quả
24. Tiêu chí 1: Khai thác tiền sử dị ứng thuốc của người bệnh. 25. Tiêu chí 2: Tuân thủ quy tắc khi dùng thuốc. 26. Tiêu chí 3: Hướng dẫn người bệnh dùng thuốc đúng và an toàn. 27. Tiêu chí 4: Phát hiện và xử trí ban đầu các dấu hiệu của phản ứng có hại của thuốc và báo cáo kịp thời cho bác sĩ và điều dưỡng phụ trách. 28. Tiêu chí 5: Nhận biết sự tương tác giữa thuốc với thuốc và thuốc với thức ăn. 29. Tiêu chí 6: Đánh giá hiệu quả của việc dùng thuốc. 30. Tiêu chí 7: Ghi chép và công khai việc sử dụng thuốc cho người bệnh.
Tiêu chuẩn 8: Đảm bảo chăm sóc liên tục 31. Tiêu chí 1: Bàn giao tình trạng của người bệnh với nhóm chăm sóc kế tiếp một cách cụ thể, đầy đủ và chính xác.
APPENDICES 222
32. Tiêu chí 2: Phối hợp hiệu quả với người bệnh, gia đình và đồng nghiệp để đảm bảo chăm sóc liên tục cho người bệnh. 33. Tiêu chí 3: Thiết lập các biện pháp để thực hiện chăm sóc liên tục cho người bệnh.
Tiêu chuẩn 9: Sơ cứu và đáp ứng khi có tình huống cấp cứu
34. Tiêu chí 1: Phát hiện sớm những thay đổi đột ngột về tình trạng sức khỏe người bệnh. 35. Tiêu chí 2: Ra quyết định xử trí sơ cứu, cấp cứu kịp thời và phù hợp. 36. Tiêu chí 3: Phối hợp hiệu quả với các thành viên nhóm chăm sóc trong sơ cứu, cấp cứu. 37. Tiêu chí 4: Thực hiện sơ cứu, cấp cứu hiệu quả cho người bệnh.
Tiêu chuẩn 10: Thiết lập được mối quan hệ tốt với người bệnh, gia đình và đồng nghiệp
38. Tiêu chí 1: Tạo dựng niềm tin đối với người bệnh, người nhà và thành viên trong nhóm chăm sóc. 39. Tiêu chí 2: Dành thời gian cần thiết để giao tiếp với người bệnh, người nhà và thành viên trong nhóm chăm sóc. 40. Tiêu chí 3: Lắng nghe và đáp ứng thích hợp những băn khoăn, lo lắng của người bệnh và người nhà người bệnh.
Tiêu chuẩn 11: Giao tiếp hiệu quả với người bệnh và gia đình người bệnh
41. Tiêu chí 1: Nhận biết tâm lý và nhu cầu của người bệnh qua những biểu hiện nét mặt và ngôn ngữ cơ thể của người bệnh. 42. Tiêu chí 2: Giao tiếp hiệu quả với các cá nhân, gia đình, cộng đồng có các trở ngại về giao tiếp do bệnh tật, do những khó khăn về tâm lý.
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43. Tiêu chí 3: Thể hiện lời nói, cử chỉ động viên, khuyến khích người bệnh an tâm điều trị. 44. Tiêu chí 4: Thể hiện sự hiểu biết về văn hóa, tín ngưỡng trong giao tiếp với người bệnh, gia đình và nhóm người.
Tiêu chuẩn 12: Sử dụng hiệu quả các kênh truyền thông và phương tiện nghe nhìn trong giao tiếp với người bệnh và gia đình người bệnh
45. Tiêu chí 1: Sử dụng các phương tiện nghe nhìn sẵn có để truyền thông và hỗ trợ giao tiếp với người bệnh, người nhà và cộng đồng. 46. Tiêu chí 2: Sử dụng các phương pháp, hình thức giao tiếp hiệu quả và thích hợp với người bệnh, người nhà người bệnh.
Tiêu chuẩn 13: Cung cấp thông tin cho người bệnh, người nhà về tình trạng sức khỏe hiệu quả và phù hợp
47. Tiêu chí 1: Xác định những thông tin cần cung cấp cho người bệnh và gia đình. 48. Tiêu chí 2: Chuẩn bị về tâm lý cho người bệnh và gia đình trước khi cung cấp những thông tin “xấu”.
Tiêu chuẩn 14: Xác định nhu cầu và tổ chức hướng dẫn, giáo dục sức khỏe cho cá nhân, gia đình và cộng động
49. Tiêu chí 1: Thu thập và phân tích thông tin về nhu cầu hiểu biết của cá nhân, gia đình, và cộng đồng về hướng dẫn, giáo dục sức khỏe. 50. Tiêu chí 2: Xác định nhu cầu và những nội dung cần hướng dẫn, giáo dục sức khỏe cho cá nhân, gia đình và cộng đồng. 51. Tiêu chí 3: Xây dựng kế hoạch giáo dục sức khỏe phù hợp với văn hóa, xã hội và tín ngưỡng của cá nhân, gia đình và cộng đồng.
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52. Tiêu chí 4: Xây dựng tài liệu giáo dục sức khỏe phù hợp với trình độ của đối tượng. 53. Tiêu chí 5: Thực hiện tư vấn, truyền thông giáo dục sức khỏe phù hợp, hiệu quả. 54. Tiêu chí 6: Đánh giá kết quả giáo dục sức khỏe và điều chỉnh kế hoạch giáo dục sức khỏe dựa trên mục tiêu và kết quả mong chờ.
Tiêu chuẩn 15: Hợp tác với các thành viên nhóm chăm sóc
55. Tiêu chí 1: Duy trì tốt mối quan hệ với các thành viên trong nhóm, coi người bệnh như một cộng sự trong nhóm chăm sóc. 56. Tiêu chí 2: Hợp tác tốt với các thành viên trong nhóm chăm sóc để đưa ra các quyết định phù hợp nhằm cải thiện chất lượng chăm sóc. 57. Tiêu chí 3: Hợp tác tốt với các thành viên nhóm chăm sóc trong việc theo dõi, chăm sóc, điều trị người bệnh và thực hiện nhiệm vụ được giao. 58. Tiêu chí 4: Tôn trọng vai trò và quan điểm của đồng nghiệp. 59. Tiêu chí 5: Chia sẻ thông tin một cách hiệu quả với các thành viên trong nhóm chăm sóc. 60. Tiêu chí 6: Thực hiện vai trò đại diện hoặc biện hộ cho người bệnh để bảo đảm các quyền, lợi ích và vì sự an toàn của người bệnh.
Lĩnh vực 2: Năng lực quản lý và phát triển nghề nghiệp
Tiêu chuẩn 16: Quản lý, ghi chép và sử dụng hồ sơ bệnh án theo quy định
61. Tiêu chí 1: Thực hiện các quy chế quản lý, lưu giữ hồ sơ bệnh án theo quy định luật pháp và của Bộ Y tế. 62. Tiêu chí 2: Bảo mật thông tin trong hồ sơ bệnh án và Phiếu chăm sóc của người bệnh. 63. Tiêu chí 3: Ghi chép hồ sơ điều dưỡng bảo đảm tính khách quan, chính xác, đầy đủ và kịp thời. 64. Tiêu chí 4: Sử dụng các dữ liệu thu thập được về tình trạng sức khỏe người bệnh
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làm cơ sở để xây dựng chính sách và tạo thuận lợi cho việc chăm sóc người bệnh.
Tiêu chuẩn 17: Quản lý công tác chăm sóc người bệnh
65. Tiêu chí 1: Quản lý công việc, thời gian của cá nhân hiệu quả và khoa học. 66. Tiêu chí 2: Xác định các công việc hoặc nhiệm vụ cần hoàn thành theo thứ tự ưu tiên. 67. Tiêu chí 3: Tổ chức, điều phối, phân công và ủy quyền nhiệm vụ cho các thành viên của nhóm chăm sóc một cách khoa học, hợp lý và hiệu quả. 68. Tiêu chí 4: Thể hiện sự hiểu biết về mối quan hệ giữa quản lý và sử dụng các nguồn lực có hiệu quả để đảm bảo chất lượng chăm sóc và an toàn cho người bệnh. 69. Tiêu chí 5: Sử dụng công nghệ thông tin trong quản lý và chăm sóc người bệnh cũng như cập nhật kiến thức chuyên môn.
Tiêu chuẩn 18: Quản lý, vận hành và sử dụng các trang thiết bị y tế có hiệu quả
70. Tiêu chí 1: Thiết lập các cơ chế quản lý, phát huy tối đa chức năng hoạt động của các phương tiện, trang thiết bị phục vụ cho chăm sóc và điều trị. 71. Tiêu chí 2: Lập và thực hiện kế hoạch bảo trì phương tiện, trang thiết bị do mình phụ trách. 72. Tiêu chí 3: Vận hành các trang thiết bị, phương tiện sử dụng trong chăm sóc bảo đảm an toàn, hiệu quả và phòng tránh nhiễm khuẩn liên quan đến chăm sóc y tế.
Tiêu chuẩn 19: Sử dụng nguồn tài chính thích hợp để chăm sóc người bệnh hiệu quả
73. Tiêu chí 1: Nhận biết được hiệu quả kinh tế khi sử dụng các nguồn lực sẵn có tại nơi làm việc để sử dụng thích hợp, hiệu quả.
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74. Tiêu chí 2: Xây dựng và thực hiện kế hoạch sử dụng các nguồn lực trong chăm sóc người bệnh thuộc phạm vi phân công hiệu quả.
Tiêu chuẩn 20: Thiết lập môi trường làm việc an toàn và hiệu quả
75. Tiêu chí 1: Tuân thủ các tiêu chuẩn và quy tắc về an toàn lao động. 76. Tiêu chí 2: Tuân thủ các chính sách, quy trình về phòng ngừa cách ly và kiểm soát nhiễm khuẩn. 77. Tiêu chí 3: Tuân thủ các quy định về kiểm soát môi trường chăm sóc (tiếng ồn, không khí, nguồn nước…). 78. Tiêu chí 4: Tuân thủ quy định về quản lý, xử lý chất thải. 79. Tiêu chí 5: Tuân thủ các bước về an toàn phòng cháy chữa cháy, động đất hoặc các trường hợp khẩn cấp khác. 80. Tiêu chí 6: Thể hiện sự hiểu biết về những khía cạnh có liên quan đến sức khỏe nghề nghiệp và luật pháp về an toàn lao động.
Tiêu chuẩn 21: Cải tiến chất lượng chăm sóc và quản lý nguy cơ trong môi trường chăm sóc
81. Tiêu chí 1: Nhận thức được sự cần thiết về các hoạt động bảo đảm chất lượng, cải tiến chất lượng thông qua sự nghiên cứu, phản hồi và đánh giá thực hành thường xuyên. 82. Tiêu chí 2: Phát hiện, báo cáo và đưa ra các hành động khắc phục phù hợp các nguy cơ trong môi trường chăm sóc người bệnh 83. Tiêu chí 3: Nhận phản hồi từ người bệnh, gia đình và các đối tượng liên quan để cải tiến chất lượng các hoạt động chăm sóc. 84. Tiêu chí 4: Áp dụng các phương pháp cải tiến chất lượng phù hợp. 85. Tiêu chí 5: Tham gia các hoạt động cải tiến chất lượng tại cơ sở. 86. Tiêu chí 6: Chia sẻ các thông tin liên quan đến tình trạng người bệnh với các thành viên trong nhóm chăm sóc. 87. Tiêu chí 7: Bình phiếu chăm sóc để cải tiến và khắc phục những tồn tại về chuyên môn và thủ tục hành chính.
APPENDICES 227
88. Tiêu chí 8: Đưa ra những đề xuất phù hợp về các biện pháp chăm sóc và phòng ngừa bệnh. 89. Tiêu chí 9: Sử dụng bằng chứng áp dụng vào thực hành chăm sóc để tăng cường sự an toàn trong chăm sóc người bệnh.
Tiêu chuẩn 22: Nghiên cứu khoa học và thực hành dựa vào bằng chứng
90. Tiêu chí 1. Xác định và lựa chọn các lĩnh vực và vấn đề nghiên cứu phù họp, cần thiết và khả thi. 91. Tiêu chí 2: Áp dụng các phương pháp phù hợp để tiến hành nghiên cứu những vấn đề đã lựa chọn. 92. Tiêu chí 3: Sử dụng phương pháp thống kê thích hợp để phân tích và diễn giải dữ liệu thu thập được.
93. Tiêu chí 4: Đề xuất các giải pháp thích hợp dựa trên kết quả nghiên cứu.Tiêu chí 5: Trình bày, chia sẻ kết quả nghiên cứu với đồng nghiệp, người bệnh và những người có liên quan. 94. Tiêu chí 6: Ứng dụng kết quả nghiên cứu khoa học vào thực hành điều dưỡng. Sử dụng các bằng chứng từ nghiên cứu khoa học để nâng cao chất lượng thực hành chăm sóc điều dưỡng.
Tiêu chuẩn 23: Duy trì và phát triển năng lực cho bản thân và đồng nghiệp 95. Tiêu chí 1: Xác định rõ mục tiêu, nguyện vọng phát triển nghề nghiệp, nhu cầu học tập, điểm mạnh, điểm yếu của bản thân. 96. Tiêu chí 2: Học tập liên tục để cập nhật kiến thức, kỹ năng và ứng dụng kiến thức đã học để nâng cao chất lượng thực hành chăm sóc điều dưỡng. 97. Tiêu chí 3: Tham gia vào các hoạt động của tổ chức nghề nghiệp. 98. Tiêu chí 4: Quảng bá hình ảnh của người điều dưỡng, thể hiện tác phong và tư cách tốt, trang phục phù hợp, lời nói thuyết phục và cách cư xử đúng mực. 99. Tiêu chí 5: Thể hiện thái độ tích cực với những đổi mới và những quan điểm trái chiều, thể hiện sự lắng nghe các kiến nghị và đề xuất, thử nghiệm những phương pháp mới và thích nghi với những thay đổi.
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100. Tiêu chí 6: Thực hiện chăm sóc theo các tiêu chuẩn thực hành điều dưỡng. 101. Tiêu chí 7: Đóng góp vào việc đào tạo nâng cao trình độ và phát triển nghề nghiệp cho đồng nghiệp. 102. Tiêu chí 8: Đóng góp vào việc nâng cao vai trò, vị thế của người điều dưỡng, ngành điều dưỡng trong ngành y tế và trong xã hội.
Lĩnh vực 3: Năng lực hành nghề theo pháp luật và đạo đức nghề nghiệp
Tiêu chuẩn 24: Hành nghề theo quy định của pháp luật
103. Tiêu chí 1: Hành nghề theo quy định của pháp luật liên quan đến y tế, quy định của Bộ Y tế và thực hành điều dưỡng. 104. Tiêu chí 2: Tuân thủ các quy định của cơ sở nơi làm việc. 105. Tiêu chí 3: Thực hiện tốt quy tắc ứng xử của đơn vị/tổ chức và luật định. 106. Tiêu chí 4: Ghi chép và bảo quản hồ sơ chăm sóc và tài liệu liên quan đến người bệnh, các vấn đề sức khỏe của người bệnh phù hợp với các tiêu chuẩn thực hành chăm sóc.
Tiêu chuẩn 25: Hành nghề theo tiêu chuẩn đạo đức nghề nghiệp
107. Tiêu chí 1. Chịu trách nhiệm cá nhân khi đưa ra các quyết định và can thiệp chăm sóc. 108. Tiêu chí 2: Tuân thủ Tiêu chuẩn đạo đức nghề nghiệp của quốc gia và quốc tế trong thực hành điều dưỡng. 110. Tiêu chí 3: Báo cáo các hành vi vi phạm với cơ quan có thẩm quyền và chịu trách nhiệm cá nhân với báo cáo đó.
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Appendix C Synthesised documents Organisations Names Dated Description MOH • Decision No 19 September Nursing responsibilities in hospitals are 1895/1997/QD 1997 presented as one part in the decision. These -BYT responsibilities are materialized for every position of nurses, from head nurses to nursing staffs. • Decision No 24 April 2012 The Decision declares approval for the 1352/QD-BYT Vietnamese Nursing Competency Standards • Circular No 26 January This Circular describes nursing roles and 07/2011/TT- 2011 functions to guide nursing care in hospitals. BYT This guidance provides an abstract description which covers nursing responsibilities presented in the national hospital regulation. • Circular No 09 August The Circular provides instruction for 22/2013/TT- 2013 Continuous Medical Education (CME) of BYT medical healthcare workforce including nursing • Decision No 03 December The Decision declares the trialed evaluation 4858/QD-BYT 2013 standards for hospital quality including evaluation of nursing practice • Decision No 20 May 2014 The Decision declares the curriculum of CME 64/QD-K2DT for healthcare workforce • Decision No 17 July 2015 The Decision declares the approval for action 2992/QD-BYT plan of healthcare workforce development including nursing professional from 2015 to 2020 • Joint Circular 07 October The Circular provides codes of conduct for No 2015 healthcare professional including nursing 26/2015/TTLT -BYT-BNV
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• Action plan 01 March 2016 The MOH presents the action plan for No 139/KH- healthcare quality improvement from 2016 to BYT 2020 including plan to improve quality of nursing workforce • Decision No 06 March 2018 The Decision declares the approval to 1624/QD-BYT implement the action plan No 139/KH-BYT MOE • Circular No 27 December The Circular provides instruction to change 57/2012/TT- 2012 curriculum from traditional to credit-based BDDT including nursing curriculum • Circular No 02 October The Circular provides national criteria to 33/2014/TT- 2014 evaluate higher education curriculum BGDDT including nursing curriculum MOHA • Joint Circular 07 October The Joint Circular provides codes of conduct No 2015 for healthcare professional including nursing 26/2015/TTLT -BYT-BNV Vietnam • Law No 18 June 2012 Law on Higher Education National 08/2012/QH13 Assembly • Law No 27 November Law on Vocational Education 74/2014/QH13 2014 • Law No 18 June 2018 Revised Law on Higher Education 34/2018/QH18 Government of • Resolution No 21 August The resolution provides policies for oriented - the Socialist 90/1997/NQ- 1997 socialised education and healthcare system Republic of CP Vietnam • Resolution No 19 August The Resolution provides policies to encourage (GOV) 73/1999/NQ- 1999 socialization in higher education and CP healthcare system • Decision No 28 December The Decision declares the educational 201/2001/QD- 2001 development strategies from 2001 to 2010 TTg
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• Decree No 14 February The Decree provides instruction on wages for 204/2004/NQ- 2004 employees who work in governmental CP institutions including public hospitals and universities • Resolution No 02 November The Resolution provides policies for 14/2005/NQ- 2005 comprehensive renovation in higher education CP from 2006 to 2020 • Decision No 20 June 2006 The Decision provides approval of 145/2006/QD- internationalization in universities TTg • Decree No 30 May 2008 The Decree declares policies to encourage 69/2008/ND- socialization in higher education and CP healthcare • Decision No 19 April 2011 The Decision declares approval for National 579/QD-TTg Strategy of Human Resource Development • Decision No 13 June 2012 The Decision declares the educational 711/QD-TTg development strategies from 2011 to 2020 • Decree No 15 October The Decree declares financial mechanism of 85/2012/Nd- 2012 public health institutions including hospitals CP • Decision No 09 January The Decision declares schemes to build a 89/QD-TTg 2013 learning society for 2012 – 2020 period • Decision No 09 January The Decision declares the approval of action 92/2013/QD- 2013 plan to decrease overload in public hospitals TTg • Decision No 07 November The Decision declares approval of the HPET 2054/QD-TTg 2013 project • Resolution No 24 October The Resolution provides policies that allows 77/NQ-CP 2014 trial of renovation in higher education • Resolution No 15 December The Resolution provides policies to develop 93/NQ-CP 2014 healthcare system
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• Decree No 14 February The Decree provides instructions for financial 16/2015/ND- 2015 autonomisation in public institutions CP including public hospitals and universities • Decree No 08 September The Decree declares regulating standards in 73/2015/ND- 2015 stratification and ranking framework for CP institutions in higher education • Decree No 01 February The Decree provides working mechanisms of 10/2016/ND- 2016 governmental institutions including public CP hospitals and universities • Resolution No 25 October The Resolution provides policies to improve 20-NQ/TW 2017 healthcare quality which includes competency improvement of nursing professional • Decree No 07 December The Decree provides instruction of minimum 141/2017/ND- 2017 wage for employees who work in CP governmental institutions including public hospitals and universities VNA • Vietnamese 24 April 2012 This document presents competencies which nursing nurses are required to work in Vietnamese competency health care system standards
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Appendix D The ethics approval of the University of Medicine and Pharmacy
D
APPENDICES 234
APPENDICES 235
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Appendix E Information sheet PARTICIPANT INFORMATION FOR QUT RESEARCH PROJECT
– Interview – Observation –
Nurses’ decision making around physical assessment: A symbolic interactionist exploration
QUT Ethics Approval Number XXXXXX
RESEARCH TEAM Name: Thuy Phuong Hong Huynh – PhD Candidate
School of Nursing
Faculty of Health, QUT
Phone: (+84) 8 3 8570760
Email: [email protected]
Name: Karen Theobald – Principal Supervisor
School of Nursing
Faculty of Health, QUT
Phone: (+61) 7 3138 3904
Email: [email protected]
Name: Carol Windsor – Associate Supervisor
School of Nursing
Faculty of Health, QUT
Phone: (+61) 7 3138 3837
Email: [email protected]
DESCRIPTION This project is being undertaken as part of a PhD study for Thuy Phuong Hong Huynh.
The purpose of this project is to explore decision making by registered nurses around physical assessment.
APPENDICES 237
You are invited to participate in this project because you are Registered Nurse who has at least 3-year experience of working in a clinical area.
PARTICIPATION Your participation will involve informal interviews (conversations) and a more formal interview. Your clinical work area will be observed. The observational session will be of approximately a 2-hour period. The informal interviews (conversations) will be conducted throughout the observational sessions to explore further what is being observed. These informal interviews will be recorded through field notes. The observations and conversations will in no way interfere with your work in clinical areas. The formal interview will be undertaken outside working hours and will be negotiated between the researcher and you. This audio recorded interview will take place in a private room in your department. It will take approximately 60 minutes of your time to complete. Questions for the formal interview will include:
1. What are the patient assessment skills that you think every nurse should perform on every patient? 2. Can you talk about what you do with information from patient assessment?
Your participation in this project is entirely voluntary. If you do agree to participate you can withdraw from the project without comment or penalty. If you withdraw, on request any identifiable information already obtained from you will be destroyed. Your decision to participate or not participate will in no way impact upon your current or future relationship with QUT or with the Cho Ray hospital.
EXPECTED BENEFITS It is expected that this project will not benefit you directly. However, it may inform nursing practice around physical assessment in hospitals in Vietnam. Nurses will have the opportunity to reflect on their practice of physical assessment. Findings from the study are expected to be used by universities in Vietnam in reviewing teaching curricula for nurses. Moreover, hospitals can use these findings to conduct and/or to implement training programs in the future to develop nurses’ physical assessment skills. Vietnamese patients will indirectly benefit from the study as they may receive improved nursing care, particularly around nursing physical assessment.
To recognise your contribution should you choose to participate, the research team is offering each participant 5 Australia dollars
RISKS Risks associated with this research are minimal. If you experience any distress as a direct result of your participation, a support team is available to provide free counselling services (face-to-face only) for research participants of this project. Should you wish to access this service please call the Nursing Department of Cho Ray Hospital 1 216 (Monday–Friday only 9am – 2pm) and indicate that you are a research participant.
PRIVACY AND CONFIDENTIALITY
APPENDICES 238
All comments and responses will be treated confidentially and following transcription anonymously unless required by law. • The audio recording will be destroyed after 5 years of the research publication • The observational and informal interview field notes will be destroyed after the research is completed • The audio recording will not be used for any other purpose • Only the researcher, the transcriber and two supervisors will have access to the audio recording. The transcriber will have to sign into an agreement of confidentiality
CONSENT TO PARTICIPATE We would like to ask you to sign a written consent form (enclosed) to confirm your agreement to participate.
QUESTIONS / FURTHER INFORMATION ABOUT THE PROJECT If you have any questions or require further information please contact one of the research team members below.
Name: Thuy Phuong Hong Huynh – PhD Candidate Name: Karen Theobald – Principal Supervisor
School of Nursing School of Nursing
Faculty of Health, QUT Faculty of Health, QUT
Phone: (+84) 8 3 8570760 Phone: (+61) 7 3138 3904
Email: [email protected]/ Email: [email protected] [email protected]
Name: Carol Windsor – Associate Supervisor
School of Nursing
Faculty of Health, QUT
Phone: (+61) 7 3138 3837
Email: [email protected]
CONCERNS / COMPLAINTS REGARDING THE CONDUCT OF THE PROJECT QUT is committed to research integrity and the ethical conduct of research projects. However, if you do have any concerns or complaints about the ethical conduct of the project you may contact the QUT Research Ethics Unit on [+61 7] 3138 5123 or email [email protected] or the Research Office of University of Medicine and Pharmacy on [+84 8] 38556284. The QUT Research Ethics Unit is not connected with the research project and can facilitate a resolution to your concern in an impartial manner.
Thank you for helping with this research project. Please keep this sheet for your information.
APPENDICES 239
CONSENT FORM FOR QUT RESEARCH PROJECT
– Interview – Observation –
Nurses’ decision making around physical assessment: A symbolic
interactionist exploration
QUT Ethics Approval Number XXXXXX
RESEARCH TEAM CONTACTS Name: Thuy Phuong Hong Huynh – PhD Candidate Name: Karen Theobald – Principal Supervisor
School of Nursing School of Nursing
Faculty of Health Faculty of Health
Phone: (+84) 8 3 8570760 Phone: (+61) 7 3138 3904
Email: [email protected]/ Email: [email protected] [email protected]
Name: Carol Windsor – Associate Supervisor
School of Nursing
Faculty of Health
Phone: (+61) 7 3138 3837
Email: [email protected]
STATEMENT OF CONSENT By signing below, you are indicating that you:
• Have read and understood the information document regarding this project. • Have had any questions answered to your satisfaction. • Understand that if you have any additional questions you can contact the research team. • Understand that you are free to withdraw at any time without comment or penalty. • Understand that you can contact the Research Ethics Unit in Australia on [+61 7] 3138 5123 or email [email protected] or the Research Office of University of Medicine and Pharmacy on [+84 8] 38556284 if you have concerns about the ethical conduct of the project. • Understand that the project will include an audio recording. • Understand that the project will include observation • Agree to participate in the project. Please tick the relevant box below:
APPENDICES 240
I agree for the interview to be audio recorded.
I agree for the observation to be conducted.
Name
Signature
Date
Please return this sheet to the investigator.
APPENDICES 241
Appendix F The Research Poster
Nursing research on patient assessment Queensland University of Technology PhD candidate: Thuy Phuong Hong, will be undertaken in the department. Huynh Email: [email protected]/ The researcher is observing [email protected] nursing practice in this Principal Supervisor: Dr. Karen Theobald Email: [email protected] department for 2-hour Associate Supervisor: Associate Prof. periods Carol Windsor Email: [email protected]
Time: 7:30am – 7:30pm Nursing Faculty – Department of Nursing and Medical Technology Place:APPENDICES University of Medicine and Pharmacy242 – Duration: January 2016 – July 2016 Ho Chi Minh City Appendix G Bachelor of Science Nurse Curricula
ĐỀ CƯƠNG CHI TIẾT
- Tên học phần: ĐIỀU DƯỠNG CƠ SỞ 1
- Mã học phần:
- Thuộc khối kiến thức/ kỹ năng: ☐ Kiến thức cơ bản ☐ Kiến thức cơ sở ngành
Kiến thức chuyên ngành ☐ Kiến thức khác ☐ Học phần chuyên về kỹ năng ☐ Học phần đồ án/ luận văn tốt nghiệp
- Số tín chỉ: 3 tín chỉ (2 lý thuyết + 1 thực hành)
+ Số lý thuyết/ số buổi: 30 tiết lý thuyết ( 8 buổi)
+ Số tiết thực hành/ số buổi: 45 tiết thực hành ( 12 buổi)
- Học phần tiên quyết: Giải phẫu, Sinh lý
- Học phần song hành: Kỹ năng giao tiếp
1. Mô tả học phần: Học phần này thuộc nhóm học phần kiến thức cơ sở ngành. Học phần giới thiệu những kiến thức cơ bản về lịch sử điều dưỡng, hệ thống tổ chức ngành điều dưỡng, vai trò chức năng của người điều dưỡng và vị trí của điều dưỡng trong hệ thống tổ chức ngành y tế Việt Nam tạo điều kiện cho sinh viên có nhận thức đúng về nghề nghiệp điều dưỡng và những định hướng của điều dưỡng trong tương lai. Ngoài ra học phần này còn cung cấp cho sinh viên các kiến thức về những nguyên tắc chăm sóc cơ bản, nhu cầu cơ bản của con người, và các kỹ năng điều dưỡng cơ sở trong chăm sóc người bệnh. Bên cạnh đó sinh viên cũng được ứng dụng các
APPENDICES 243 kiến thức từ những môn khoa học cơ sở vào thực hành điều dưỡng. Kỹ năng nhận định, giải quyết vấn đề được phát triển qua học phần này sẽ là nền tảng cho việc chăm sóc dựa vào chứng cứ.
2. Nguồn học liệu Giáo trình:
[1] Giáo trình Điều dưỡng cơ sở do Phân môn Điều dưỡng cơ sở biên soạn
[2] Đoàn Thị Anh Lê (2014). Kỹ thuật Điều dưỡng cơ sở dựa trên chuẩn năng lực. Thành phố Hồ Chí Minh: Nhà xuất bản Y học.
[3] Trần Thị Thuận (2008). Điều dưỡng cơ bản 1. Hà Nội: Nhà xuất bản Y học.
Tài liệu khác:
[1] Bộ Y Tế (2012). Bộ chuẩn năng lực của Điều dưỡng Việt Nam.
[2] Bộ Y tế (2002). Hướng dẫn quy trình chăm sóc người bệnh.
[3] Bộ Y tế - Hội Điều dưỡng Việt Nam (2010). Tài liệu Đào tạo Phòng ngừa chuẩn.
[4] Crisp, J, & Taylor, C. (2009). Potter & Perry's fundamentals of nursing (3rd Australian ed.). Chatswood, NSW, Australia: Mosby Elsevier.
[5] Perry, A.G, Potter, P.A. (2014). Clinical Nursing Skills and technique. 8th edition, Mosby Elsevier.
[6] Perry, A.G, Potter, P.A. (2010). Clinical Nursing Skills and technique. 7th edition, Mosby Elsevier
[7] Perry, A.G, Potter, P.A. (2005). Fundamental of Nursing. 6th ed Evolve.
[8] Seidel, H.M, Ball, J.W. Dains, J.E., Flynn, J.A, Soloman, B.S, & Stewart, R. W. (2011). Guide to Physical Examination.7th ed. Mosby’s.
APPENDICES 244
[9] Bickley, L.S. & Szilagyi, P.G. (2009). Bates Guide to Physical Examination and History Taking. 10th ed.
3. Mục tiêu học phần Mục CĐR của Mô tả mục tiêu tiêu CTĐT
Thảo luận về vai trò và trách nhiệm của người điều dưỡng MT1 khi chăm sóc cho người bệnh và gia đình của họ trong các C31 hệ thống chăm sóc sức khỏe
Sử dụng những kiến thức đã học để nhận định được nhu MT2 C11 cầu cơ bản của người bệnh và gia đình của họ.
Thảo luận về các tiêu chuẩn luật pháp và đạo đức người MT3 điều dưỡng cần khi chăm sóc sức khoẻ cho con người, gia C31 đình, các nhóm dân tộc thiểu số và cộng đồng
Phát triển kế hoạch chăm sóc sử dụng những chứng cứ tốt MT4 nhất cũng như có sự trao đổi tham khảo ý kiến từ người C12 bệnh và gia đình của họ.
Lựa chọn các can thiệp chính xác để thực hành chăm sóc người MT5 C12, C14 bệnh được thoải mái và an toàn trong một số tình huống.
Trình bày các yếu tố môi trường ảnh hưởng đến tình trạng sức khỏe MT6 C18 người bệnh
Nhận định và đánh giá tình trạng tổng quát của người bệnh một MT7 C12 cách an toàn và chính xác
Bàn giao bằng lời nói và văn bản viết đối với các thành viên trong MT8 nhóm chăm sóc về những vấn đề chăm sóc và hiệu quả chăm sóc C20 trên người bệnh
APPENDICES 245
Mục CĐR của Mô tả mục tiêu tiêu CTĐT
Áp dụng các nguyên lý về an toàn môi trường, kiểm soát nhiễm MT9 khuẩn và phòng ngừa thương tổn trong suốt quá trình chăm sóc C19 cho người bệnh.
Thực hiện các kỹ năng chăm sóc cơ bản trong việc đáp ứng nhu cầu MT10 C14 cơ bản cho người bệnh
Lập kế hoạch xuất viện, đặc biệt là trong lãnh vực giáo MT11 dục sức khỏe cho người bệnh một cách toàn diện và hiệu C30 quả
MT12 Thể hiện sự hiểu biết và tự hào về nghề nghiệp điều dưỡng C27, C37
Thận trọng khi đưa ra các quyết định, kế hoạch chăm sóc đảm bảo MT13 C32, C36 an toàn cho người bệnh.
MT14 Tôn trọng quyền lợi của người bệnh và người thân C33
MT15 Trung thực khi làm việc nhóm, khi chăm sóc người bệnh. C33
4. Đánh giá học phần Thành phần đánh giá Bài đánh giá MT học phần Tỷ lệ (%)
Tham gia hoạt động, A1. Đánh giá thường đóng góp ý kiến trong 10% xuyên lớp học
MT9 MT10 A2. Đánh giá giữa kỳ Thực hành các kỹ năng 30% MT14
Bài kiểm tra cuối kỳ (trắc MT1 MT2 MT3 A3. Đánh giá cuối kỳ 60% nghiệm) MT4 MT5 MT6 MT7 MT8 MT11
APPENDICES 246
Thành phần đánh giá Bài đánh giá MT học phần Tỷ lệ (%)
MT12 MT13 MT14 MT15
- Sinh viên phải tham dự đầy đủ các bài thực hành. - Học viên đủ điều kiện dự thi cuối kỳ khi không vắng quá 20% tổng số tiết lý thuyết của học phần và hoàn thành các bài đánh giá giữa kỳ - Điểm đánh giá bộ phận và điểm thi kết thúc học phần được chấm theo thang điểm 10 (từ 0 đến 10), làm tròn đến một chữ số thập phân. - Điểm học phần được tính bằng tổng các điểm đánh giá quá trình ( A 1 + A 2 = 40%) và đánh giá cuối kỳ/ thi kết thúc học phần (60%). - Điểm thi kết thúc học phần là bắt buộc cho mọi đối tượng. - Điểm học phần làm tròn đến một chữ số thập phân, sinh viên được đánh giá: + Đạt khi điểm tổng kết học phần > 4.0
+ Không đạt nếu < 4,0.
5. Nội dung giảng dạy Lý thuyết
Số tiết Mục Nội dung Bài đánh giá Lên Tự tiêu lớp học
Đánh giá thường MT1 1. Lịch sử điều dưỡng 1 2 xuyên MT12 Đánh giá cuối kỳ
1.1 Điều dưỡng ở các nước phát triển
APPENDICES 247
1.2 Điều dưỡng thế giới, ĐD Việt Nam
1.3 Vai trò của người ĐD theo quan điểm mới
1.4 Phẩm chất của ĐD
1.5 Chuẩn mực đạo đức của ĐD viên phản ánh
các giá trị của nghề nghiệp
1.6 Trách nhiệm của người ĐD
1.7 Lĩnh vực cơ bản của Ngành ĐD
Đánh giá thường MT1 2. Định hướng nghề nghiệp điều dưỡng 1 2 xuyên MT12 Đánh giá cuối kỳ
2.1 Hướng đi mới của ĐD quốc tê
2.2 Sự thay đổi về nhu cầu chăm sóc sức khỏe
người bệnh
2.3 Đặc điểm hiện tại ĐD Việt Nam
2.4 Thành tựu, tồn tại, thách thức và giải pháp
Đánh giá thường 3. Tiêu chuẩn năng lực của người điều dưỡng 1 2 MT3 xuyên chuyên nghiệp Đánh giá cuối kỳ
3.1 Bối cảnh chung
3.2 Sự cần thiết của bộ tiêu chuẩn năng lực
3.3 Nội dung chuẩn năng lực
APPENDICES 248
Đánh giá thường 4. Vai trò, chức năng và nhiệm vụ của điều 1 2 MT1 xuyên dưỡng chuyên nghiệp Đánh giá cuối kỳ
4.1 Lĩnh vực cơ bản của ngành ĐD
4.2 Giáo dục ĐD
4.3 Thực hành ĐD
4.4 Vai trò thực hành
Đánh giá thường
5. Quản lý điều dưỡng 1 2 MT1 xuyên
Đánh giá cuối kỳ
5.1 Vai trò quản lý
5.2 Nghiên cứu ĐD
5.3 Vai trò nghiên cứu
Đánh giá thường 6. Học thuyết điều dưỡng và thực hành điều 1 2 MT2 xuyên dưỡng Đánh giá cuối kỳ
6.1 Tầm quan trọng của học thuyết ĐD
6.2 Các thành phần trong học thuyết
6.3 Các thành phần trong mối quan hệ thực
hành ĐD
6.4 Mô hình học thuyết
6.5 Giới thiệu một số học thuyết
APPENDICES 249
Đánh giá thường 7. Nhu cầu cơ bản của con người: của Virginia 1 2 MT2 xuyên Henderson, Gordon, Maslow Đánh giá cuối kỳ
7.1 Nhu cầu cơ bản và nguyên tắc ĐD
7.2 Nhu cầu cơ bản theo học thuyết Maslow,
Gordon và Virginia Henderson
7.3 Nhận định nhu cầu cơ bản và sự đáp ứng
Đánh giá thường
8. Sự ảnh hưởng của môi trường đến sức khỏe 1 2 MT6 xuyên
Đánh giá cuối kỳ
8.1 Các yếu tố ảnh hưởng đến sức khỏe
8.2 Các phương pháp giữ gìn sức khỏe
8.3 Nâng cao sức khỏe
8.4 Xu hướng trong tương lai
MT4 MT5 Đánh giá thường
9. Qui trình APIE và ứng dụng qui trình APIE MT12 xuyên vào qui trình chăm sóc người bệnh 4 8 MT13 MT14 Đánh giá cuối kỳ
MT15
9.1 Lịch sử quy trình ĐD
9.2 Ý nghĩa của quy trình ĐD
9.3 Lợi ích của quy trình ĐD
APPENDICES 250
9.4 Các bước quy trình ĐD
MT2 Đánh giá thường 10. Vệ sinh cá nhân 3 6 MT4 xuyên
MT5 Đánh giá cuối kỳ
10.1 Cấu tạo, chức năng, đặc điểm da
10.2 Các yếu tố, nguy cơ làm ảnh hưởng đến
chức năng da
10.3 Chăm sóc da, tắm bệnh tại giường
10.4 Chăm sóc tóc, gội tóc tại giường
10.5 Chăm sóc răng miệng
10.6 Chăm sóc móng
10.7 Vệ sinh bộ phận sinh dục
10.8 Vệ sinh vùng phụ cận
10.9 Vệ sinh ăn uống, vệ sinh tâm thần
10.10 Quy trình chăm sóc vệ sinh cá nhân
MT2 Đánh giá thường 11. Chăm sóc ngừa loét 1 2 MT4 xuyên
MT5 Đánh giá cuối kỳ
11.1 Yếu tố ảnh hưởng đến quá trình hình
thành vết loét
11.2 Các vị trí dễ bị đè cấn
11.3 Các giai đoạn
APPENDICES 251
11.4 Các loại loét
11.5 Quy trình chăm sóc
MT2 Đánh giá thường 12. Chăm sóc giấc ngủ và nghỉ ngơi hợp lý 2 4 MT4 xuyên
MT5 Đánh giá cuối kỳ
12.1 Nguyên nhân gây mất ngủ
12.2 Sự ngủ và nghỉ ngơi bình thường
12.3 Phương diện điện sinh lý học
12.4 Giai đoạn không cử động mắt nhanh
12.5 Giấc ngủ và nghỉ ngơi bình thường
12.6 Quy trình chăm sóc
MT2 Đánh giá thường 13. Chăm sóc người bệnh giai đoạn cuối 2 4 MT4 xuyên
MT5 Đánh giá cuối kỳ
13.1 Chăm sóc NB giai đoạn cuối
13.2 Các triệu chứng thường gặp ở NB giai
đoạn cuối
13.3 Những biểu hiện ở giai đoạn cuối dấu
hiệu của sự chết
13.4 Quy trình chăm sóc
14. Nhận định đánh giá tình trạng tổng quát Đánh giá thường 3 6 MT7 của NB: Đánh giá chức năng sinh lý xuyên
APPENDICES 252
Đánh giá cuối kỳ
14.1 Yêu cầu khi lấy dấu hiệu sinh tồn
14.2 Thân nhiệt, mạch, hô hấp, huyết áp
14.3 Quy trình chăm sóc NB có DSH bất
thường
Đánh giá thường
15. Patient assessment 4 8 MT7 xuyên
Đánh giá cuối kỳ
15.1 History taking
15.2 Interviewing techniques
15.3 Mind map of health
15.4 Physical examination techniques
15.5 Examination of systems
16. Cách tiếp nhận người bệnh vào viện, Đánh giá thường
chuyển viện 2 4 MT11 xuyên
Chuẩn bị thủ tục cho người bệnh xuất viện Đánh giá cuối kỳ
16.1 Quy trình tiếp đón NB
16.2 Thủ tục hành chánh khi NB vào viện
16.3 Thủ tục hành chánh khi NB chuyển khoa,
phòng, chuyển viện
16.4 Quy trình cho NB xuất viện
APPENDICES 253
Đánh giá thường 17. Hồ sơ chăm sóc người bệnh và cách ghi 1 2 MT8 xuyên chép Đánh giá cuối kỳ
17.1 Tầm quan trọng của ghi chép hồ sơ
17.2 Nguyên tắc ghi chép hồ sơ
17.3 Thành phần hồ sơ NB
17.4 Ghi chép phiếu chăm sóc
17.5 Bảo quản hồ sơ
17.6 Quản lý và lưu trữ hồ sơ
Tổng 30 60
Thực hành
Số tiết Mục Nội dung Bài đánh giá Lên Tự tiêu lớp học
MT9 Đánh giá thường 1. Thiết lập môi trường chăm sóc an toàn và tạo MT10 xuyên sự thoải mái cho người bệnh: MT14 Đánh giá giữa kỳ
1.1 Chuẩn bị giường bệnh 4 4
1.2 Các tư thế nghỉ ngơi trị liệu thông thường, 2 2 các tư thế khám bệnh
1.3 Vận chuyển, nâng đỡ người bệnh 2 2
APPENDICES 254
Số tiết Mục Nội dung Bài đánh giá Lên Tự tiêu lớp học
1.4 Cố định giữ an toàn cho người bệnh 1 1
MT9 Đánh giá thường
2. Vệ sinh cá nhân: MT10 xuyên
MT14 Đánh giá giữa kỳ
2.1 Tắm bệnh tại giường 4 4
2.2 Chăm sóc ngừa loét, mang tả, mang 4 4 uridom, sử dụng bô tiêu, tiểu
2.3 Gội tóc tại giường 4 4
2.4 Săn sóc răng miệng 4 4
Đánh giá thường MT9 3. Vital signs 4 4 xuyên MT10 Đánh giá giữa kỳ
3.1 Temperature
3.2 Pulse
3.3 Breathing rates
3.4 Blood pressure
Đánh giá thường MT9 4. Physical examination xuyên MT10 Đánh giá giữa kỳ
APPENDICES 255
Số tiết Mục Nội dung Bài đánh giá Lên Tự tiêu lớp học
4.1 Examination of head, face, lymph nodes, 4 4 thyroid gland, ENT
4.2 Examination of respiratory system, 4 4 circulatory system, digestive system
4.3 Examination of musculoskeletal system 4 4
4.4 Neurological examination, cerebellum, 4 4 sensory
Tổng 45 45
6. Quy định của học phần
- Học viên đi học đầy đủ và đúng giờ. - Học viên vắng mặt quá 20% tổng số buổi học lý thuyết sẽ không được tham dự kiểm tra tổng kết cuối kỳ. - Sinh viên phải xem video kỹ năng trước khi tham dự buổi học thực hành - Sinh viên phải tham gia phát biểu, hoạt động thường xuyên trong lớp. - Sinh viên phải hoàn thành đủ 100% tổng số bài tập được giao và nộp đúng thời hạn. Không hoàn thành phần nào thì phần đó được đánh giá là không điểm (0đ) - Sinh viên vắng mặt trong kỳ thi kết thúc học phần, nếu không có lý do chính đáng coi như đã dự thi lần một và phải nhận điểm 0 ở kỳ thi chính. Những sinh viên này khi được trưởng khoa cho phép được dự thi một lần ở kỳ thi phụ ngay sau đó (nếu có). - Sinh viên vắng mặt có lý do chính đáng ở kỳ thi chính, nếu được trưởng khoa cho phép, được dự thi ở kỳ thi phụ ngay sau đó (nếu có), điểm thi kết thúc học phần được coi là điểm thi lần đầu. Trường hợp không có kỳ thi phụ hoặc thi không đạt trong kỳ thi phụ,
APPENDICES 256
những sinh viên này sẽ phải dự thi tại các kỳ thi kết thúc học phần ở các học kỳ sau hoặc học kỳ phụ.
7. Phụ trách học phần
- Khoa/ Bộ môn: Khoa Điều Dưỡng – Kỹ Thuật Y Học/ Đơn vị Huấn Luyện Kỹ Năng Điều Dưỡng – Kỹ Thuật Y Học - Địa chỉ liên hệ: 217 Hồng Bàng, Q.5, Tp.HCM (Tầng 11, tòa nhà 15 tầng) - Điện thoại liên hệ: 083.952.6020
APPENDICES 257