Grace E Scrimgeour | University of Bristol (original) (raw)

Uploads

Drafts by Grace E Scrimgeour

Research paper thumbnail of How cross-training of hospital-based nursing assistants provides a flexible workforce while maintaining professional nursing boundaries.

Over the last century there have been major changes in the division of nursing labor in hospitals... more Over the last century there have been major changes in the division of nursing labor in hospitals, focusing on the proportions of Registered Nurses and auxiliaries (Licensed Practical Nurses and Nursing Assistants) on the nursing team. Changes have been driven by the interests of two major stakeholders; health provision institutions, who have pursued policies of cost containment and professional nursing leaders, who prioritized professional status for Registered Nurses. The status project for RNs has been strengthened by the large-scale removal of LPNs from hospitals, since their ability to substitute for RNs made it difficult for graduate nurses to achieve social closure. This loss of LPNs in hospitals has created a binary split in the division of nursing labor between RNs and CNAs, who perform much of the personal care of patients but are prohibited from delivering medical and skilled nursing tasks. However, to increase flexibility in work teams, CNAs are increasingly being cross-trained to replace the work of other technical and clerical workers within the hospital. Based on semi-structured interviews with nursing assistants at a large Midwestern hospital, this paper examines the cross-training of nursing assistants. The research found that cross training does not breach the scope of work of RNs, keeping occupational boundaries within the nursing team intact, and maintaining the status of RNs while reducing costs for the institution. While cross-training does provide some job enrichment for CNAs, the institutional expectation that most CNAs undertake some form of cross training suggests that it may be an informal requirement to maintain employment. This training is not accredited, so is not transferrable if workers move to other workplaces or to higher education.

Research paper thumbnail of ‘Killing Them with Kindness’ and ‘Being Professional’: Strategies of Hospital-Based CNAs for Dealing with Difficult Patients.

This paper examines two strategies that Certified Nursing Assistants who work in hospitals use to... more This paper examines two strategies that Certified Nursing Assistants who work in hospitals use to deal with difficult patients. This research is the first to study hospital-based CNAs, although there is an extensive literature on CNAs in nursing homes. CNAs are the workers seen most often by patients, since they perform most of the personal care at the bedside. While the “professional” approach to healthcare provision demands a detached, depersonalizing view of patients, CNAs reject this by prioritizing what they define as ‘real’ care; providing individualized and personalized care to each patient, care which is both instrumental and affective. However, this may be challenged when they are faced with difficult, abusive and even violent patients. CNAs use one of two strategies, invoking Hochschild’s opposing ideas of the ‘toe’ and the ‘heel’ of emotional labor. “Killing them with kindness” involves ramping up affective care, with the hope that this invokes a positive change in the patient’s attitude. The other strategy is “being professional,” which means delivering instrumental care only, and spending little time with the patient. Unlike the boundary work identified in nursing homes, where individual patients are classified into durable categories as “lovelies” or “the disliked” by staff, these strategies tend to be adopted by individual CNAs towards individual patients. Male CNAs are more likely to use “being professional” and female CNAs “killing them with kindness.” However, as in nursing homes, in situations where patients are actually violent, their violence is minimized in a number of different ways.

Research paper thumbnail of Technological expertise or supervisory responsibilities? Problems of social closure in nurses’ struggle for professional recognition.

While nursing is seen as the paradigmatic ‘women’s profession’, it has failed to gain full profes... more While nursing is seen as the paradigmatic ‘women’s profession’, it has failed to gain full professional status. While it has met many of the milestones that are accepted as steps in the process of professionalization, it has failed to establish a bounded core set of practices and skills that are unique to registered nurses, and to restrict other workers from these practices. One major reason for this can be found in the gendered assumptions about caring work, which is seen as an essentialist trait of women, rather than a set of learned skills. While nursing has become increasingly technological, and nurses are often removed from routine bedside care, public perceptions about nursing are still rooted in common ideas about femininity. While graduate nursing has improved in status, it has failed in establishing some of the core characteristics of professions, namely autonomous practice and social closure. Nursing leaders have largely failed in gaining professional acceptance for nursing as caring, and instead have followed two strategies; establishing professional nursing as supervision and management of other nursing and auxiliary workers in hospitals, and promoting specialization in nursing. In the first case, institutional constraints limit the autonomy of nurses, and the use of auxiliaries has meant that the possibility of substitution has undermined their authority and the legitimacy of the task subdivision. In the second, specialization has aligned nurses with the medical profession, where they are seen as inferior practitioners, since the knowledge base of nursing, unlike medicine, is seen as experiential, not theoretical.

Papers by Grace E Scrimgeour

Research paper thumbnail of General practitioner roles in emergency medical services: a systematic mapping review and narrative synthesis

BJGP open, Mar 17, 2023

BackgroundA significant proportion of emergency medical services (EMS) work is for problems that ... more BackgroundA significant proportion of emergency medical services (EMS) work is for problems that may be amenable to timely primary care management and could benefit from GP input. Utilising GPs in EMS may reduce avoidable emergency department (ED) conveyance, releasing emergency ambulances for higher-acuity care, and meeting patient needs earlier in the evolution of an emergency call.AimTo collate and summarise evidence on how GPs are utilised in EMS.Design & settingSystematic mapping review and narrative synthesis.MethodA systematic literature search was conducted using search terms for general practice and emergency care. Primary research articles investigating the utilisation of GPs in non-critical EMS were included. An inductive framework was used to structure the results alongside a narrative synthesis.ResultsTwenty-one articles were included. GPs were embedded in EMS for urgent management of high-acuity patients or used as an intervention to avoid unnecessary ED conveyance in selected lower-acuity patients. The importance of interprofessional relationships and training for GPs involved in EMS was highlighted. No studies explored patient-reported outcomes. Outcomes measured were predominantly ED non-conveyance and admission avoidance, with GP services as an intervention reducing the likelihood of these outcomes.ConclusionEmbedding GPs in EMS might service different purposes depending on context. There is some evidence that GP EMS services may reduce the likelihood of ED conveyance and hospital admission in selected cases; it is unclear whether this is owing to case selection or GP involvement. Future research should incorporate patients’ views and experiences.

Research paper thumbnail of GP roles in emergency medical services: a systematic mapping review and narrative synthesis

BJGP Open, 2023

Background: A significant proportion of emergency medical services (EMS) work is for problems tha... more Background: A significant proportion of emergency medical services (EMS) work is for problems that may be amenable to timely primary care management and could benefit from GP input. Utilising GPs in EMS may reduce avoidable emergency department (ED) conveyance, releasing emergency ambulances for higher- acuity care, and meeting patient needs earlier in the evolution of an emergency call. Aim: To collate and summarise evidence on how GPs are utilised in EMS. Design & setting: Systematic mapping review and narrative synthesis. Method: A systematic literature search was conducted using search terms for general practice and emergency care. Primary research articles investigating the utilisation of GPs in non- critical EMS were included. An inductive framework was used to structure the results alongside a narrative synthesis. Results: Twenty- one articles were included. GPs were embedded in EMS for urgent management of high- acuity patients or used as an intervention to avoid unnecessary ED conveyance in selected lower- acuity patients. The importance of interprofessional relationships and training for GPs involved in EMS was highlighted. No studies explored patient- reported outcomes. Outcomes measured were predominantly ED non- conveyance and admission avoidance, with GP services as an intervention reducing the likelihood of these outcomes. Conclusion: Embedding GPs in EMS might service different purposes depending on context. There is some evidence that GP EMS services may reduce the likelihood of ED conveyance and hospital admission in selected cases; it is unclear whether this is owing to case selection or GP involvement. Future research should incorporate patients’ views and experiences.

Research paper thumbnail of Who cares? The role of nursing assistants in the labor process of hospital nursing

This research, using the feminist methodology of "reading up the power structure," is the first s... more This research, using the feminist methodology of "reading up the power structure," is the first study of hospital-based Certified Nursing Assistants (CNAs). Through interviews with 21 CNAs in a large, independent, urban hospital in the Midwest, the study examines how two major institutions have impacted the labor process of CNAs and the division of labor between CNAs and RNs. These include historical changes in nurses' priorities in pursuing professional status, and the reconfiguration of healthcare provision in the United States. The removal of LPNs from hospital nursing creates a clear division of labor between RNs and auxiliaries since, unlike LPNs, CNAs are unable to substitute for RNs. CNAs have been cross-trained to replace clerical and technical workers, but this does not impinge on the labor process of RNs. CNAs perceive good care as incorporating both instrumental and affective elements, in opposition to detached, "professional" healthcare, and they take a holistic view of patient welfare that corresponds with Foucault's "pastoral power." When dealing with difficult patients, CNAs choose alternate strategies; "killing them with kindness," or "being professional" (withholding affective care.) There is a limited career ladder for CNAs, but many create their own dynamic ladder by combining work and study, gaining higher education incrementally over many years. Hospitals support this in formal and informal ways that are not available in other healthcare settings, such as nursing homes. 1 CHAPTER ONE 5 Association of Colleges of Nursing 2012; Institute of Medicine 2011), and to encourage nurses working in acute care to upgrade their training, particularly as research suggests a link between the proportion of nurses holding lower qualifications of nurses and higher mortality rates in hospitals (Aiken et al.. 2003). The most popular route to basic RN certification is the Associate of Science in Nursing (ASN) degree, also known as an Associate Degree in Nursing (ADN). This is a two-year course that was introduced in the 1960s. It is offered mainly in community colleges and for-profit colleges (Bureau of Labor Statistics 2012a). Fifty eight percent of new nurses (2008 figures) graduate with an associates' degree (National League for Nursing 2009c) with 45% of currently registered nurses holding that qualification (U.S.

Research paper thumbnail of How cross-training of hospital-based nursing assistants provides a flexible workforce while maintaining professional nursing boundaries.

Over the last century there have been major changes in the division of nursing labor in hospitals... more Over the last century there have been major changes in the division of nursing labor in hospitals, focusing on the proportions of Registered Nurses and auxiliaries (Licensed Practical Nurses and Nursing Assistants) on the nursing team. Changes have been driven by the interests of two major stakeholders; health provision institutions, who have pursued policies of cost containment and professional nursing leaders, who prioritized professional status for Registered Nurses. The status project for RNs has been strengthened by the large-scale removal of LPNs from hospitals, since their ability to substitute for RNs made it difficult for graduate nurses to achieve social closure. This loss of LPNs in hospitals has created a binary split in the division of nursing labor between RNs and CNAs, who perform much of the personal care of patients but are prohibited from delivering medical and skilled nursing tasks. However, to increase flexibility in work teams, CNAs are increasingly being cross-trained to replace the work of other technical and clerical workers within the hospital. Based on semi-structured interviews with nursing assistants at a large Midwestern hospital, this paper examines the cross-training of nursing assistants. The research found that cross training does not breach the scope of work of RNs, keeping occupational boundaries within the nursing team intact, and maintaining the status of RNs while reducing costs for the institution. While cross-training does provide some job enrichment for CNAs, the institutional expectation that most CNAs undertake some form of cross training suggests that it may be an informal requirement to maintain employment. This training is not accredited, so is not transferrable if workers move to other workplaces or to higher education.

Research paper thumbnail of ‘Killing Them with Kindness’ and ‘Being Professional’: Strategies of Hospital-Based CNAs for Dealing with Difficult Patients.

This paper examines two strategies that Certified Nursing Assistants who work in hospitals use to... more This paper examines two strategies that Certified Nursing Assistants who work in hospitals use to deal with difficult patients. This research is the first to study hospital-based CNAs, although there is an extensive literature on CNAs in nursing homes. CNAs are the workers seen most often by patients, since they perform most of the personal care at the bedside. While the “professional” approach to healthcare provision demands a detached, depersonalizing view of patients, CNAs reject this by prioritizing what they define as ‘real’ care; providing individualized and personalized care to each patient, care which is both instrumental and affective. However, this may be challenged when they are faced with difficult, abusive and even violent patients. CNAs use one of two strategies, invoking Hochschild’s opposing ideas of the ‘toe’ and the ‘heel’ of emotional labor. “Killing them with kindness” involves ramping up affective care, with the hope that this invokes a positive change in the patient’s attitude. The other strategy is “being professional,” which means delivering instrumental care only, and spending little time with the patient. Unlike the boundary work identified in nursing homes, where individual patients are classified into durable categories as “lovelies” or “the disliked” by staff, these strategies tend to be adopted by individual CNAs towards individual patients. Male CNAs are more likely to use “being professional” and female CNAs “killing them with kindness.” However, as in nursing homes, in situations where patients are actually violent, their violence is minimized in a number of different ways.

Research paper thumbnail of Technological expertise or supervisory responsibilities? Problems of social closure in nurses’ struggle for professional recognition.

While nursing is seen as the paradigmatic ‘women’s profession’, it has failed to gain full profes... more While nursing is seen as the paradigmatic ‘women’s profession’, it has failed to gain full professional status. While it has met many of the milestones that are accepted as steps in the process of professionalization, it has failed to establish a bounded core set of practices and skills that are unique to registered nurses, and to restrict other workers from these practices. One major reason for this can be found in the gendered assumptions about caring work, which is seen as an essentialist trait of women, rather than a set of learned skills. While nursing has become increasingly technological, and nurses are often removed from routine bedside care, public perceptions about nursing are still rooted in common ideas about femininity. While graduate nursing has improved in status, it has failed in establishing some of the core characteristics of professions, namely autonomous practice and social closure. Nursing leaders have largely failed in gaining professional acceptance for nursing as caring, and instead have followed two strategies; establishing professional nursing as supervision and management of other nursing and auxiliary workers in hospitals, and promoting specialization in nursing. In the first case, institutional constraints limit the autonomy of nurses, and the use of auxiliaries has meant that the possibility of substitution has undermined their authority and the legitimacy of the task subdivision. In the second, specialization has aligned nurses with the medical profession, where they are seen as inferior practitioners, since the knowledge base of nursing, unlike medicine, is seen as experiential, not theoretical.

Research paper thumbnail of General practitioner roles in emergency medical services: a systematic mapping review and narrative synthesis

BJGP open, Mar 17, 2023

BackgroundA significant proportion of emergency medical services (EMS) work is for problems that ... more BackgroundA significant proportion of emergency medical services (EMS) work is for problems that may be amenable to timely primary care management and could benefit from GP input. Utilising GPs in EMS may reduce avoidable emergency department (ED) conveyance, releasing emergency ambulances for higher-acuity care, and meeting patient needs earlier in the evolution of an emergency call.AimTo collate and summarise evidence on how GPs are utilised in EMS.Design & settingSystematic mapping review and narrative synthesis.MethodA systematic literature search was conducted using search terms for general practice and emergency care. Primary research articles investigating the utilisation of GPs in non-critical EMS were included. An inductive framework was used to structure the results alongside a narrative synthesis.ResultsTwenty-one articles were included. GPs were embedded in EMS for urgent management of high-acuity patients or used as an intervention to avoid unnecessary ED conveyance in selected lower-acuity patients. The importance of interprofessional relationships and training for GPs involved in EMS was highlighted. No studies explored patient-reported outcomes. Outcomes measured were predominantly ED non-conveyance and admission avoidance, with GP services as an intervention reducing the likelihood of these outcomes.ConclusionEmbedding GPs in EMS might service different purposes depending on context. There is some evidence that GP EMS services may reduce the likelihood of ED conveyance and hospital admission in selected cases; it is unclear whether this is owing to case selection or GP involvement. Future research should incorporate patients’ views and experiences.

Research paper thumbnail of GP roles in emergency medical services: a systematic mapping review and narrative synthesis

BJGP Open, 2023

Background: A significant proportion of emergency medical services (EMS) work is for problems tha... more Background: A significant proportion of emergency medical services (EMS) work is for problems that may be amenable to timely primary care management and could benefit from GP input. Utilising GPs in EMS may reduce avoidable emergency department (ED) conveyance, releasing emergency ambulances for higher- acuity care, and meeting patient needs earlier in the evolution of an emergency call. Aim: To collate and summarise evidence on how GPs are utilised in EMS. Design & setting: Systematic mapping review and narrative synthesis. Method: A systematic literature search was conducted using search terms for general practice and emergency care. Primary research articles investigating the utilisation of GPs in non- critical EMS were included. An inductive framework was used to structure the results alongside a narrative synthesis. Results: Twenty- one articles were included. GPs were embedded in EMS for urgent management of high- acuity patients or used as an intervention to avoid unnecessary ED conveyance in selected lower- acuity patients. The importance of interprofessional relationships and training for GPs involved in EMS was highlighted. No studies explored patient- reported outcomes. Outcomes measured were predominantly ED non- conveyance and admission avoidance, with GP services as an intervention reducing the likelihood of these outcomes. Conclusion: Embedding GPs in EMS might service different purposes depending on context. There is some evidence that GP EMS services may reduce the likelihood of ED conveyance and hospital admission in selected cases; it is unclear whether this is owing to case selection or GP involvement. Future research should incorporate patients’ views and experiences.

Research paper thumbnail of Who cares? The role of nursing assistants in the labor process of hospital nursing

This research, using the feminist methodology of "reading up the power structure," is the first s... more This research, using the feminist methodology of "reading up the power structure," is the first study of hospital-based Certified Nursing Assistants (CNAs). Through interviews with 21 CNAs in a large, independent, urban hospital in the Midwest, the study examines how two major institutions have impacted the labor process of CNAs and the division of labor between CNAs and RNs. These include historical changes in nurses' priorities in pursuing professional status, and the reconfiguration of healthcare provision in the United States. The removal of LPNs from hospital nursing creates a clear division of labor between RNs and auxiliaries since, unlike LPNs, CNAs are unable to substitute for RNs. CNAs have been cross-trained to replace clerical and technical workers, but this does not impinge on the labor process of RNs. CNAs perceive good care as incorporating both instrumental and affective elements, in opposition to detached, "professional" healthcare, and they take a holistic view of patient welfare that corresponds with Foucault's "pastoral power." When dealing with difficult patients, CNAs choose alternate strategies; "killing them with kindness," or "being professional" (withholding affective care.) There is a limited career ladder for CNAs, but many create their own dynamic ladder by combining work and study, gaining higher education incrementally over many years. Hospitals support this in formal and informal ways that are not available in other healthcare settings, such as nursing homes. 1 CHAPTER ONE 5 Association of Colleges of Nursing 2012; Institute of Medicine 2011), and to encourage nurses working in acute care to upgrade their training, particularly as research suggests a link between the proportion of nurses holding lower qualifications of nurses and higher mortality rates in hospitals (Aiken et al.. 2003). The most popular route to basic RN certification is the Associate of Science in Nursing (ASN) degree, also known as an Associate Degree in Nursing (ADN). This is a two-year course that was introduced in the 1960s. It is offered mainly in community colleges and for-profit colleges (Bureau of Labor Statistics 2012a). Fifty eight percent of new nurses (2008 figures) graduate with an associates' degree (National League for Nursing 2009c) with 45% of currently registered nurses holding that qualification (U.S.