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 THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE ii 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. THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE iii 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 THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE iv 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 THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE v 5.1 Introduction ..................................................................................................................... 87 5.2 The process of negotiation and mediation .................................................................... 88 5.2.1 Understanding nursing practice in the world of