Negotiating Quality: Everyday Practice & Self-Regulation

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DESCRIPTION (provided by applicant):Concerns about quality in clinical practice have become increasingly prominent in discussions of healthcare. Although excellence and expertise have been extensively studied, inferior or substandard nursing practice has received less scholarly attention. Professional self-regulation is commonly identified as a central strategy for the maintenance of professional standards. Neither the actual mechanisms of these processes, however, nor their efficacy in accomplishing the assigned purposes, have been well described or evaluated. Complicating this topic still further is the indeterminacy of the standards themselves: the tension between broad, general guidelines and specific situations, the inevitability of interpretation and translation, and the uncertainties inherent in clinical practice. The goal of the proposed training program is to enhance understanding of the everyday practices of professional self-regulation in nursing, and the negotiations of standards of practice, collegiality, and accountability. The proposed project will consist of an ethnographic inquiry into the symbolic order, routines of work, and communication patterns on an inpatient unit, as the nursing staff organizes, copes with, and accounts for normal variation, challenges and conflicts. This study will examine (1) the ways in which staff nurses and first-line managers negotiate the practical standards of quality, collegiality, and accountability, (2) the dynamic interactions between formal and informal rules, work-groups norms and institutional arrangements, in the routine definition and performance of collective nursing practice, and (3) the relation of these staff-level interactions to institutional, social, and professional structures, and cultural-historical discourses. Greater understanding of these interactive social processes will help to improve communication among staff and between staff and managers, and support the development of more effective strategies for the improvement of practice and enhanced protection of the public.