Refining Nursing Practice: A Grounded Theory of How Nurses Learn to Nurse Well in the Current Health Care Milieu

Abstract

Continuing to provide high-quality care to patients in the present health care system is challenging. As with many contemporary organizations, health care is characterized by change. This grounded theory study examined nurses’ workplace learning, with a particular focus on the role of the workplace in improving nursing practice. The data comprised semi-structured interviews of nominated nurses from diverse areas of practice and participant observation on two units in acute care. Nurses with more than ten years’ experience working in direct patient care who were known for nursing well were recruited to the study initially, followed by theoretical sampling of nurses at diverse stages. Constant comparison, grounded theory coding, theoretical sensitivity, and memos were used to analyze the data. Nurses’ workplace learning is an essential process in the career-long process of refining nursing practice. Refining processes begin with a trigger for learning. These triggers include patient-specific concerns, changes in the workplace, and self-awareness of a learning gap. In the workplace nurses respond to the resulting need to know by engaging in puzzling and inquiring, an iterative process that involves deliberation and drawing on other nurses, physicians, and other accessible resources. Everyday workplace learning and the career-long process of refining nursing practice are dependent on the quality of nursing education and early work experience. Germane conceptual, procedural, and dispositional knowledge and four capabilities, which nurses utilize throughout their careers to discriminate learning demands and develop wisdom, constitute a necessary foundation for nursing practice. These capabilities are (a) setting and maintaining high standards, (b) having a healthy apprehension, (c) seeing the whole patient picture, and (d) being self-aware. Refining nursing practice is facilitated by mentor-guides, workplace camaraderie, and functional teams. The pressures of globalization, neoliberalism, technical rationality, and managerialism place demands on nurses working in health care. The professionalization agenda, with related decisions to promote academic nursing education and with responsibilities related to ensuring continuing competence, has created preparation practice gaps. Based on this theory, I propose that existing approaches for preparing and supporting nurses for practising nursing in current health care require complementary efforts to accomplish the goal of excellent patient care.

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