Realist exploration of Emergency Nurses' role transition in a major Emergency Department in Indonesia

Abstract

INTRODUCTION: Advanced practice nurses’ roles in emergency departments (ED) have evolved, particularly in high-income countries. As these roles have developed, challenges such as resistance to change and a blurring of professional boundaries were met. In the later phases of role development, recognition and acceptance were achieved, although some disparities in standards still exist globally. New regulations, training, and education have been established alongside this emerging role. Previous studies into these roles have shown positive impacts on key performance indicators (KPIs) of the ED, such as decreased patient waiting times, increased levels of patient satisfaction, and cost-effectiveness.

However, there is little understanding of the complexity of these advanced practice nurses’ roles, how they work, for whom, and under what circumstances. In Indonesia, there is little evidence regarding the development of emergency nurses’ roles due to a lack of published studies. Therefore, this current research initiative was designed to understand the contributing factors that shape emergency nurses’ roles in Indonesia using a qualitative realist approach.

METHODS: The research was conducted in a major emergency department in Indonesia. Data were collected from non-participant observation of activities and interactions of thirteen participants in the ED, who consisted of nurses and physicians, eighteen interviews involving fourteen participants took place; the interviewees included emergency nurses, physicians, managers, and representatives of professional organisations. Data from policy documents also contributed. Realist data analysis was conducted to elicit realist programme theories (RPTs) and develop a middle-range theory (MRT) to identify and explain context-mechanism-outcome (CMO) interactions around the development of emergency nurses’ roles. Following data analysis, two realist programme theories, explaining what is happening around emergency nurses’ role shaping were developed: (1) knowledge brokering and (2) role-relationships.

Furthermore, the transition theory was configured as the middle-range theory grounded from the data.

FINDINGS: This study found that the emergency nurses’ roles in the ED are under transition. The findings suggest that there are two focused aspects of change in emergency nurses’ role transition: (a) transformation of knowledge and skill and (b) role-relationships of emergency nurses. Such transformation is influenced by various contexts existing at different system levels. The knowledge brokering process both at the individual and collective levels is revealed as the main underlying mechanism informing the emergency nurses’ role transition. This process is central in order to overcome disabling factors in the contexts and push forward the transition. Knowledge brokering operates within the engagement levels of involved individuals, departments, institutions, and wider organisations in emergency nurses’ role transition.

However, the role development in the current study was limited by a lack of collective knowledge brokering; a deficit which was reflected by the emergence of unintended outcomes, such as dissatisfaction of the role performance. As a result of limited collective brokering, important regulation and policies relevant to the role are yet to be established.

CONCLUSIONS: The study highlights the key importance of knowledge brokering both at the individual and collective levels as the factor required to move the professional role of emergency nurses forward in the ED.

Knowledge brokering interacted iteratively with the context. Such interactions made the context receptive to change. In return, it activated more mechanisms in producing expected outcomes of the transition. This study extracted a list of recommendations in the form of context-mechanism related interventions to support the development and transition process of emergency nurses’ roles.