Good practice: how nurses in a rehabilitation unit are coping with

differing views on the nature of knowledge

Vestfold University CollegeMaster in health promotion

Lene Stavnar and Monica Vestå

Theoretical framework

• Bolman, Lee G. & Deal, Terrence E. Reframing organizations. Artistry, Choice and Leadership

• Hanson, Anders. Workplace health promotion • Green, Jackie & Tones, Keith. Health Promotion.

Planning and strategies• Grimen, Harald & Terum, Lars I. Evidence based

professional practice• Schön, Donald A. The reflective practitioner. How

professionals think in action

Research questions

• How can internal control systems and clinical judgements promote good nursing practice in a rehabilitation unit?

1. How is the internal control system in the unit organized?2. In what way do the nurses in the unit use their clinical

judgement? 3. How do the internal control system and the clinical

judgement interact?

Health promotion perspectives

The settings approachRe-orienting health service (Ottawa-charter)

Reseach setting

Sample:• A municipal rehabilitation centre for hospital patients• Informants: nurses, nurse assistants, physiotherapist,

occupational therapist, leader

Methods

• Observation • Interdisciplinary workshop• Individual interviews of six nurses

Data analysis

• Inductiv approach• Main categories: - Internal control system

- Clinical judgement

Codes

•Competance and experience•Comprehension of clinical judgement•Course of treatment•Documentation•Relatives and family•Decisions •Targets•Interdisiplinary collaboration•Patient in focus•Patient participation

• The nurse`s role • Time• Communication and

information• Leadership• Ethical perspectives• Culture• Quality• Good practice• Coordination reform• Correct patient group

Results. The internal control system

•Management ensured that employees had necessary knowledge and competence and that both employees and patients participated in practical work. Routines adapted to rehabilitation were used in daily activities

•The unit has systems for identifying possible failure, and the procedures were regularly evaluated. Targets were evaluated to initiate change

•Based on clear goals and role descriptions the activities in the rehabilitation unit were planned according to the directives in the Regulations of Internal Control

•Procedures were regularly adjusted according to the evaluations and improvement s were made

Acth

Plan a,b

Do c,d,e

Checkf,g

Results. The use of clinical judgement

• Comprehension: The combination of theoretical knowledge, experience and intuition

• Used continuously• Reflection in- and over- action, both

individually and together • Reflection on ethical values and dilemmas

Results. Good nursing practice based on the interaction between the internal control system and the nurses clinical judgement

The nurse`s role Organizational factors

• Primary contact

• Cooperation partner

• Coordinator

• The nurse`s basic values

• Leadership

• Decisions and targets

• Good routines

• Time and resources

Concluding remarks

• Structural balance : The internal control system included an appropriate distribution of top-down and bottom-up elements. Decisions based on experiences and clinical judgement could take place.

• Future challenge: The internal control system will determine the nature of the clinical judgements and the way health professionals develop their competence.

Workshop