A grounded theory of directors' of nursing perceptions on caring: Post-Francis paradoxes

Abstract

This study explores the perceptions of Directors of Nursing from NHS acute Trusts in England, on caring practices. The aspiration of the NHS is to deliver good care to patients and their families. The NHS constitution states that the 'NHS is there to improve health and wellbeing, and it touches our lives at times of basic human need, when care and compassion are what matter most' (DH 2013:2). However, recent inquiries into poor care have created a searching debate regarding standards of nursing care, leadership, culture and practice. Directors of Nursing play a significant role in influencing care, as they are charged with responsibilities relating to providing assurance of standards of care within NHS Trusts. However, little is known about the perceptions of Directors of Nursing in NHS acute Trusts, on caring practices. The study aimed to construct a grounded theory of the perceptions of Directors of Nursing from NHS acute Trusts, on caring practices. The study also sought to understand the social, political, professional and organisational challenges facing Directors of Nursing. Twelve Directors of Nursing from NHS acute Trusts in England were interviewed between July 2013 and January 2014 using semi-structured questions. A constructivist grounded theory approach was adopted to support the co-construction of the theory by exploring how the participants construct their worlds or reality. Through the co-construction approach a theory of 'Directors of Nursing Perceptions on Caring: Post Francis Paradoxes' revealed that the participants are working within a paradoxical NHS system in response to findings from the Mid Staffordshire NHS Foundation Trust inquiry. The theory is supported by three categories of: 'trusting my senses'; 'avoiding becoming collateral damage'; and 'being in a different place'. The three paradoxes that emerged were: the need to produce reliable high-quality assurance about standards of care in the NHS which detracted from and impacted on the Directors of Nursing roles in supporting internal assurances processes. Secondly, external monitoring standards did not capture the 'real' warning signals of care failings as intended. Thirdly, the reliance on intuitive skills to give assurances of caring practices was considered necessary to support the demanding monitoring and assurance processes. This study captures a challenge, as perceived by Directors of Nursing, regarding how external regulatory demands can be accommodated alongside the internal organisational requirements to lead the improvement agenda of patient care standards. Directors of Nursing need then to balance the competing priorities in their roles whilst supporting and leading a nursing workforce to deliver ethical caring practices. Recommendations are made for research, education and practice.