The intraprofessional and interprofessional relations of neurorehabilitation nurses: a negotiated order perspective

ORIGINAL RESEARCH

The intraprofessional and interprofessional relations of

neurorehabilitation nurses: a negotiated order perspective

Karen-Lee Miller & Pia C. Kontos

Accepted for publication 6 October 2012

Correspondence to K.-L. Miller:

e-mail: [email protected]

Karen-Lee Miller BA MA MSW

Research Associate

Toronto Rehabilitation Institute - University

Health Network, Ontario, Canada

and

PhD Candidate

Dalla Lana School of Public Health,

University of Toronto, Ontario, Canada

Pia C. Kontos BA MA PhD

Research Scientist

Toronto Rehabilitation Institute - University

Health Network, Ontario, Canada

MILLER K . - L . & KONTOS P .C . ( 2 0 1 3 ) The intraprofessional and interprofession-

al relations of neurorehabilitation nurses: a negotiated order perspective. Journal

of Advanced Nursing 69(8), 1797–1807. doi: 10.1111/jan.12041

AbstractAims. To report a study of the negotiation practices of neurorehabilitation nurses

with one another and with allied health professionals to understand nursing

relations.

Background. Negotiated order theory offers a promising theoretical lens with

which to explore negotiation between nurses and other professionals. This study

is the first to apply the perspective to nurse–nurse and nurse–allied health

professional relations.

Design. The study is a secondary analysis of findings from a multi-site arts-based

intervention to improve patient-centred neurorehabilitation practice.

Methods. Interviews and ethnographic observations were conducted (2008–2011)

in two neurorehabilitation units in Ontario, Canada. Participants (n = 31)

included registered and practical nurses, nurse leaders, and allied health

professionals from physical, occupational, and recreational therapy, speech

language pathology, and social work.

Findings. Neurorehabilitation nursing is characterized by heavy workload, high

patient acuity, and poor interprofessional collaboration. This practice context was

negotiated by nurses through two strategies: (1) intraprofessional collegialism,

accomplished through tactics including task and knowledge sharing, emotional

support, coercive threats, and suppression of dissension; and (2) vying for an

autonomous essential nursing role in interprofessional practice, accomplished by

claiming unique nursing knowledge based on 24/7 nursing proximity, the

expansion of the division of professional labour with allied health professionals

and modifying physical therapy care plans.

Conclusion. The intraprofessional context and negotiations therein were linked in

significant ways to interprofessional negotiations. Understanding this complexity

has important implications for improving patient safety and interprofessional

practice interventions.

Keywords: allied health, collaboration, interprofessional practice, intraprofessional

practice, negotiated order theory, nursing, traumatic brain injury

© 2012 Blackwell Publishing Ltd 1797

JAN JOURNAL OF ADVANCED NURSING

Introduction

Micro and macro characteristics of nursing’s intraprofes-

sional and interprofessional practices have long been of

interest to scholars. Interactions have been typically exam-

ined via a conflict lens such as lateral violence amongst

nurses (Embree & White 2010) or the doctor–nurse game

(Stein 1967) that provides important insight into antagonis-

tic relations. Yet, this implicitly valorizes collaboration and

underexamines interaction complexities. Negotiated order

theory (Strauss et al. 1963, Strauss 1966, 1978) instead

stresses dynamic appraisal and negotiation processes in

healthcare relations.

Negotiated order theory has been touted as a ‘helpful

agency-based path’ to explore negotiation between nurses

and other professionals (Reeves et al. 2008, p. 2). It has

been applied to nurse–physician (Svensson 1996, Allen

1997) and interprofessional relations (Evans 2007, Reeves

et al. 2009, Nugus et al. 2010). To date, it has not been

used to examine intraprofessional nursing interactions, nor

specifically applied to nurses’ interprofessional relations

with allied health professionals (AHPs). Given that these

comprise the majority of nurses’ daily interactions in hospi-

tals, redressing this limitation is critical. We draw on this

theory to provide novel examination of nurse–nurse and

nurse–AHP negotiations in inpatient traumatic brain injury

(TBI) rehabilitation settings.

Background

Intraprofessional nursing practice

Nursing has become increasingly stratified with registered

nurses (RNs) providing supervision to licensed practical

nurses (Huynh et al. 2011) and unlicensed auxiliaries

(Daykin & Clarke 2000, Rheaume 2003). While increased

credentialism and skill-mix have had positive patient

impacts (McGillis Hall et al. 2003), effects have been more

negative for intraprofessional functioning (Strauss 1966,

Cohen 1981, Witz 1990, McPherson 1996, Huynh et al.

2011). Differences in education and scope of practice

may make some nurses more akin to interprofessional col-

leagues (Huynh et al. 2011). Intraprofessional hostility,

poor co-worker support, and lack of help-giving behaviour

cause significant psychological stress and poor workplace

retention (McKenna et al. 2003, Embree & White 2010)

and contribute to perceptions of suboptimal care (Kenasz-

chuk et al. 2010).

Nonetheless, nurses have been identified as having a

unique, binding professional identity (Briskin 2011) based

on patient proximity and the intimacy of bedside nursing

(Barker 2000, Peter & Liaschenko 2004). Nursing identity

is associated with feelings of group belonging and solidarity

(Briskin 2011) originating from the collective position

nurses occupy as subordinates in the healthcare system,

feelings which, in turn, may negatively affect how they

engage as a group with others (Miller et al. 2008). Examin-

ing the ‘special features’ (Strauss 1978, p. 105) of how and

why nurses negotiate with one another and other profes-

sions is critical to understanding nursing relations.

Allied health professionals and interprofessional practice

As nursing moved from occupation to profession, so too did

multiple non-medical groups such as physical therapists and

speech language pathologists (Colyer 2004), which comprise

some of approximately 200 specialty disciplines known as

‘allied health professionals’ or AHPs (Balogun et al. 2006).

The rise of AHPs has prompted a new decision-making

model based on demands for equal professional status,

shared treatment goals, and joint decision-making (Colyer

2004). Such interprofessional practice (IPP) is characterized

by highly integrated intervention whereby professionals

develop common objectives while still providing specific

contributions (Geva et al. 2000).

Barriers to IPP stem from difficulties establishing commu-

nication, trust, and mutual respect among autonomous pro-

fessionals (Colyer 2004, Conn et al. 2009). Nurses are

cautious of the new disciplinary alignment with AHPs

(McCallin & Bamford 2007), given pursuit of their own

professionalization project (Salhani & Coulter 2009). While

nurse–AHP conflicts are said to result from AHPs’ focus on

physical functioning (Sinclair et al. 2009, Koyama 2011),

which diminishes the psychosocial concerns and emotion

work which underpins holistic nursing (Miller et al. 2008),

much remains unknown about how nurses negotiate these

conflicts as a means of ‘getting things accomplished’

(Strauss 1978, p. 11).

Negotiated order theory

During patient care, negotiation involves ‘the continual

working out, together, of who [is] to do what, how and

with whom’ (Strauss 1978, p. 107) among professionals.

Negotiations may be co-operative or conflictual (Strauss

1978) and involve tactics such as ‘making trade offs,

obtaining kickbacks, compromising toward the middle,

paying off debts and reaching negotiated agreements’

(Strauss 1978, p. 237). Negotiations more commonly occur

when rules and policies are not definitive (Svensson 1996),

1798 © 2012 Blackwell Publishing Ltd

K.-L. Miller and P.C. Kontos

such as the introduction of a new staff member or care

ideology.

Negotiations cannot be divorced from the structural and

social conditions under which they are made and settings

where they occur (Strauss 1978). The ‘structural context’ –

‘that “within which” negotiations take place, in the largest

sense’ (Strauss 1978, p. 98) – includes healthcare system

properties and professional specializations. ‘Negotiation

context’ refers to properties that enter directly ‘as condi-

tions into the course of the negotiation itself’ (Strauss 1978,

p. 238) through personal awareness; that is, ‘the context

within which people interact while taking cognizance of it’

(Glaser & Strauss 1965 cited in Strauss 1978, p. 99).

Repetitive and entrenched outcomes are relevant to future

negotiations and may have an impact on social conditions

(Strauss 1978).

Negotiated order theory has not been applied to intrapro-

fessional nursing relations. However, IPP negotiated order

studies have identified important ways nurses and physicians

interact, including direct negotiations, which can end in

compromise (Svensson 1996), or those where physicians

exercise competitive power (Nugus et al. 2010). The absence

of negotiation, or ‘non-negotiation’, has been observed where

nurses undertake activities that fall outside their formal

jurisdiction (Allen 1997) and in disproportionately one-way

interactions from physicians to nurses and AHPs (Reeves

et al. 2009). Where communication between RNs and AHPs

has been examined, it has been characterized as the mutual

exchange of clinical information (Reeves et al. 2009) involv-

ing collaborative power (Nugus et al. 2010). This emphasis

on collaboration has left unaddressed potentially negative

processes on which these negotiations rest.

The study

Aim

The aim of this study was to examine neurorehabilitation

nurses’ intra- and interprofessional negotiative practices.

Design

The study was a 3-year (2008–2011) interview- and ethnog-

raphy-based evaluation of an arts-based educational inter-

vention to improve patient-centred neurorehabilitation care

(Colantonio et al. 2008, Kontos et al. 2012). Postevalua-

tion, we conducted a secondary analysis (Gladstone et al.

2007) to examine nurse–nurse and nurse–AHP negotiations,

specifically: (1) the primary issues around which nurses

negotiate with each other and AHPs; and (2) the contexts,

strategies, tactics, and outcomes associated with these nego-

tiations.

Study settings

The study settings were neurorehabilitation units (Hospital

A, 32-bed; Hospital B, 27-bed) of two inpatient rehabilita-

tion hospitals in Ontario, Canada. Both units had an equal

female–male patient ratio with an average length of stay of

43–49 days. Patients incurred a TBI, ‘an alteration in brain

function, or other evidence of brain pathology, caused by

an external force’ (Menon et al. 2010, p. 1637).

Data collection

Naturalistic observations of structured and unstructured

interactions

At each site, one researcher undertook non-participant

naturalistic observations (Green & Thorogood 2004) of

structured and unstructured activities (Reeves et al. 2009) at

three time points: baseline, 3, and 12 months postinterven-

tion. Structured interactions included nursing rounds;

huddles (brief, informal team gatherings); interprofessional

rounds; case conference meetings; and family meetings.

Unstructured interactions included nurses and AHPs working

together in patients’ rooms, shared work spaces, or the

hallway. Observations occurred Monday–Friday from 8 AM

to 4 PM (Facility A, 97�75 hours; Facility B, 106�75 hours).

Fieldnotes documented setting (e.g. location), participant(s)

(e.g. profession), event/activity (e.g. huddles), communica-

tion (e.g. verbal), and outcome (e.g. education).

Interviews

Semi-structured interviews lasting approximately 60 minutes

each were conducted at the same time points. Interviews

explored clinical practice(s); institutional practice(s); and

patients’ experiences. Postintervention interviews examined

intervention impacts. Interview guides reflected intervention

objectives. Research assistants were trained to explore new

avenues of interest in response to participant answers. Loss

to follow-up occurred in eight cases (1 RN, 7 AHPs).

Ethical consideration

Participating hospital research ethics boards approved the

study. Each practitioner approached for study enrolment

provided informed consent, as did each Substitute Decision

Maker approached to obtain consent by proxy for TBI

clients with impaired cognition.


JAN: ORIGINAL RESEARCH Intraprofessional and interprofessional negotiations

Participants

A literature search identified nurses and AHPs as the most

common neurorehabilitation professionals. This formed cri-

terion-based selection (Le Compte & Preissle 1993) to pur-

posively sample (Patton 1990) 31 licensed practitioners

with the most and least years’ experience from nursing

(RN; and registered practical nurse [RPN]; n = 11), occupa-

tional therapy (OT; n = 5), physical therapy (PT; n = 5),

speech language pathology (SLP; n = 6), social work (SW;

n = 3), and recreational therapy (RT; n = 1). Also included

were nurses who managed RNs, but did not have a clinical

role (RN leader n = 4). Participants consented to the inter-

vention and data collection. Seventy-one per cent of partici-

pants had worked in the facility for 4 years or more.

Participants ranged in age from 27 to 58 years with a mean

of 38�93 (SD 9�14).

Analysis

All data pertaining to nurses’ activities and intra- or interpro-

fessional engagement were analysed using a modified directed

content analysis approach (Hsieh & Shannon 2005) where

code development is guided by sensitizing concepts (Bowen

2006), in this case, negotiated order theory. This involved

analytical expansion of the data to investigate negotiation,

which was not central to the original study. It is appropriate

where secondary research questions can be traced back to the

original data (Medjedovic &Witzel 2007).

We first identified negotiation examples. Next, we

grouped examples into categories and identified salient sub-

categories. These were then condensed, investigated for

interrelationships and organized according to thematic con-

tent, moving from lower order to higher order themes.

Through an iterative process, higher order themes were

developed to capture intraprofessional and interprofessional

negotiative activities (e.g. a singular, repeated activity such

as refraining from challenging other nurses was conceptual-

ized as one component of the suppression of dissension and

later linked to other behaviours associated with intraprofes-

sional collegialism as a strategy of negotiation). Identified

themes did not include practices impacted by the interven-

tion (see Kontos et al. 2012, for intervention evaluation).

Rigour

At present, consensus does not exist on how best to specify

quality in qualitative research (Mays & Pope 2000, Tracy

2010). We implemented Lincoln and Guba’s (1985) four-

point criterion: credibility, dependability, confirmability,

and transferability. Their approach to trustworthiness

emphasizes the establishment of clarity regarding judge-

ments and methodological decisions made throughout the

study. Credibility was ensured by decreasing potential ‘reac-

tivity’ during observations by acclimatizing staff to

researcher presence and establishing good rapport (Gold

1997, Spano 2005). Dependability and confirmability were

established through a dependability audit (Miyata & Kai

2009) that involved a methodologically self-critical account

of research conduct. Transferability was addressed through

sufficient detail that evaluators could assess applicability of

findings (Miyata & Kai 2009) vis-a-vis ‘fittingness’ or

‘degree of concurrence between sending and receiving con-

texts’ (Lincoln & Guba 1985, p. 124).

Findings

Intraprofessional and interprofessional findings are sepa-

rately organized by negotiation context, strategy, and tac-

tics. Data are drawn predominantly from interviews with

support from observations.

Intraprofessional negotiation: context, strategy, and

tactics

Patient acuity is an important component of the negotiation

context (Nugus et al. 2010) and nurses value workload shar-

ing (Pryor 2007). At both sites, acuity and heavy workload

contexts were negotiated through a strategy of collegialism:

I’ve heard a lot of other nurses that come from [non-rehabilitation]

units say the teamwork there is not the greatest. There if a patient

is buzzing [the call buzzer], it’s only the nurse that has that patient

assigned who is going to answer. We’re lucky enough that our unit

[is] pretty teamwork oriented, because there are a lot of things that

we wouldn’t be able to do if we weren’t. Because we have a lot of

patients who need to be two-man transfers, you need assistance

with repositioning…and it’s like you can count on [co-workers] if

you need something, you know?… [Interview, RPN]

Collegialism was negotiated through tactics such as task

and knowledge sharing and emotional support across

licensure levels. In Facility A, RNs initiated in-hospital train-

ing sessions on RN–RPN co-operation. In both facilities, task

sharing overtures were observed and also extended to tempo-

rary agency nurses. Collegialism was a strategy, rather than

friendship and familiarity amongst established co-workers:

An agency nurse was hired for the day to cover on the unit…An

RPN said, ‘Wow, that’s a long shift’. The agency nurse just

shrugged. One RN sat at the head of the table and looked at the



agency nurse, then down at her notes and around the table. She

said to the agency nurse, ‘So you’re doing two RNs work?’ ‘Yes’,

replied the agency nurse without appearing worried about it. The

RN raised her eyebrows in surprise. Another RPN said, ‘we’ll all

help out’. [Observation, Nursing Report]

Collegialism was further negotiated through opportunistic

knowledge sharing and positive feedback:

The RN reads her nursing report. After she finishes, an RPN asks,

‘Do you find that she fights with you about pills?’ The RN replies

yes and recounts how yesterday the patient had been demanding

that she be permitted to keep her pills at her bedside. The RN

relays that she told the patient that it is against hospital rules to do

so, even if the patient is a pharmacist. The RPN laughs and says

that she told her the ‘exact same thing’, and that ‘it’s a wonder that

the patient just keeps at it’…Another RN appears to provide logical

context for the patient’s persistence by explaining, ‘[Patient] doesn’t

actually remember, even a few minutes later’. She further explains

that the patient is compliant with the hospital’s protocol that she

ask for her own medication but she cannot recall when she has

already done so. [Observation, Nursing Report]

…(T)he [less experienced nurses] are coming up and saying, ‘Oh,

I like how you handled that’…as they watch us, how we deal

with certain scenarios or patients. We often get the comment,

‘I wouldn’t have thought of doing that’. [Interview, RPN]

Collegialism commonly included emotional support:

An RN and an RPN are discussing…[nursing] assignments. The

older RN encourages the young RPN, ‘You have to speak up!

You always get that patient!’ The young RPN replies calmly, ‘it’s

okay, we all have heavy shifts sometimes’. [Observation, Nursing

Report]

An interviewed nurse leader recounted the intervention of

RNs when RPNs were subject to a patient’s disinhibited

sexual behaviour:

[RNs] came to me and said, ‘…We need to counsel [the wife] that

it’s his brain injury [causing this behaviour] and…we really need to

help the RPNs who are really young and haven’t dealt with this’.

Intraprofessional collegialism was sometimes negotiated

through negative tactics, such as coercive threats. An inter-

viewed RPN spoke of threatened workplace ostracism

should newcomers not share tasks:

And a lot of the newer staff that comes to our unit it’s kind of like

[senior staff] give you that little speech like, ‘Okay, it’s like you

need to be a team player to work here. …(Otherwise) you’re going

to be pointed out and you’re not going to like it. Because if you’re

not going to help anyone else, nobody else is going to help you’.

Other negative tactics included the suppression of dissen-

sion, which occurred through the use of managers to

express complaints:

We had one situation where a nurse complained to the manager

that [a covering nurse from a different unit] who was having a

patient going sour, like the condition changed for the worse, hadn’t

called for assistance. She was angry that [covering nurse] hadn’t

called for assistance…[she wanted the manager to express to her],

‘You’re not an island. We’re here to support you. We work as a

team. You should have alerted us so we make sure your other

patients are being cared for’. [Interview, RN leader]

Suppression of dissension was also evident in unwilling-

ness to resolve disputes. During a nursing report, an RN

appears doubtful of her colleague’s problem-solving, yet

drops the matter:

The tape report by the day shift nurse relays that the client has

many complaints about stomach pain that the client attributes to

her prescription of Celexa [an anti-depressant, with a minor side

effect of stomach upset]. So, the client is going off Celexa and onto

Effexor [an anti-depressant]. The tape report continues that the cli-

ent slept most of the day, attended by her husband. The RN who

has been taking notes since this client is part of her assignment,

pauses the tape report. She questions aloud whether it is the Celexa

that is causing the stomach pain. The RPN interrupts her and says

since the Celexa was the last change to her medication, it therefore

is the most likely reason. The RN says that to her the symptoms

sound like side effects of the client’s prescription of Tegratol [an

anti-convulsant, with a minor side effect of stomach pain]. The RN

then restarts the tape report. [There is no further exchange nor

does the nurse indicate her concern in the client’s chart.]

Interprofessional negotiation context: poor IPP

Most IPP negotiated order studies perceive poor collabora-

tion solely as an outcome (Reeves et al. 2009, Nugus et al.

2010), which fails to recognize repeated outcomes can

inform future negotiations. We found ineffective RN–AHP

collaboration such a routinized feature of institutional life

that poor IPP was the context within which nurses negoti-

ated. Participants recognized patient complexity necessitated

interprofessional collaboration, ‘the more shared knowledge

you have as a team, the better’ [Interview, SLP]. Yet nurses

complained AHPs minimized nurses’ contributions:

I find that some of the other professions don’t value the nursing

aspect. [Interview, RN]

Some therapists it’s like well, until [patients] can do it all by them-

selves, they don’t want us to practice on the floor…[Therapists]



need to trust that we know what we’re doing with [patients].

[Interview, RPN]

AHPs appeared to confirm this undervaluing:

I’d say a lot of times in rounds…the whole team least values the

nursing opinions and reports just because nurses give sometimes

irrelevant information and don’t necessarily use a lot of clinical

judgment in the information they’re providing. [OT]

Observations of intraprofessional rounds supported this

opinion:

Next it was the RN’s turn to report. He speaks from his seat on

the periphery of the room from handwritten notes. He reports the

patient is independent with activities of daily living, that the wife

comes and feeds him and that when she is here the patient is settled

but when she is not here the patient often uses the call bell for

nurses and most of the time the patient eats food from home for

lunch so he does not eat much from the hospital kitchen. While the

RN is speaking, most [AHPs] are looking down and reading their

own notes.

The context of poor IPP was further characterized by

uniprofessional silos. Nurses often complained that AHPs

did not openly share knowledge:

(P)rofessions really guard their [expertise] so they don’t want to

give you too much information of what works. There’s a lot of ego

so they don’t want to give you too much information because then

all of a sudden, well, maybe you’re as smart as they are. They want

to be a little heads up on somebody. It’s too bad. [Interview, RN]

AHPs also differentiated nurses’ and AHPs’ responsibili-

ties in a way that inhibited IPP: ‘that’s a nursing issue.

Nurses need to deal with that on the unit’ [Interview, RT].

In addition to AHP-sourced IPP barriers, both nurses and

AHPs noted that nurses’ rotation and workload hampered

information sharing:

I find sometimes our nurse leader will have a lot of information

[from the interprofessional team], but she neglects to relay it …I

guess she forgets that in the middle of the week that we have new

[nursing] staff on. She might have relayed it Monday with that

group, but by Wednesday, it’s all a totally different group [of

nurses] on the floor. [Interview, RPN]

IPP negotiation strategy and tactics

Poor IPP context led nurses to vie for an autonomous

nursing role. This strategy was negotiated through various

tactics, including claiming unique nursing knowledge based

on patient proximity and intimacy:

We’re with these patients, not just one hour of the day like some

[therapist] sessions, we’re with them 24 hours a day pretty well.

[Interview, RN]

(Y)ou really get to know what works good with some of the

patients. So even some of those other professions can learn from

how [nurses] interact. [Interview, RN]

Knowledge was used to negotiate autonomous patient

decisions, including how ‘to cohort the noisy patients, to be

strategic in where we place a patient that’s got behavioural

issues’ [Interview, RN].

Another tactic was nurses’ use of after-hours and week-

end care periods to expand the division of labour when

AHPs were not present. Nurses often acted as social work-

ers to effectively manage patient or family outbursts

‘because a lot of this stuff doesn’t necessarily happen Mon-

day to Friday, 8:00 to 4:00 when AHPs work’ [RN]. In one

facility, nurses also facilitated weekend functional activities:

The nurses are carrying over [activities of daily living]…the

walking program and stuff…[Nurses] felt that [patients] needed

to be stimulated somehow [through] some kind of activity…And

also get [patients] into an activity that they would enjoy and

kind of, not doing therapeutic tasks, but doing functional tasks.

And it has been getting a lot of positive feedback from the

patients…They’re actually engaged, they’re doing things, they’re

walking more. They feel like…they’re getting some type of ther-

apy on the weekends…(I)t’s not considered therapy because

[nurses] are not considered therapists, but…as far as I’m con-

cerned, it is some type of functional therapy for the patient.

[Interview, RN leader]

AHPs supported nurses’ efforts regarding division of

labour expansion in terms of circumscribed ‘carry-on’ and

support roles (Pryor & Buzio 2010), which offloaded AHP

responsibilities such as replacing cancelled sessions, or

developing weekend routines:

(A) lot of stuff is dumped back [by AHPs] to nursing because the

patient lives on the nursing floor. So, if you’ve got a meeting,

you’ve got to cancel your patient, you don’t worry about it because

the nurses will handle it. [Another example], we had a [patient]

that needed a [structured] weekend [schedule] here at the hospital

just because he was difficult to manage. My assumption was that

that the primary therapist would talk to the team and try and pull

something together. Well, that didn’t happen. So…typically it’s

[left] to the nurses, um, how to structure [the weekend]. [Interview,

RT]

Nurses in both facilities also vied for autonomy by grant-

ing weekend discharges so patients could visit family or



dine at restaurants. However, AHPs engaged in ‘task strip-

ping’ (Strauss 1978), which involves denial by some profes-

sions to others’ claims to a particular task, arguing it is

more appropriate to be conducted by themselves (Strauss

1978, p. 113). An interviewed nurse leader describes typical

discharge tensions:

And so on the weekend, the nurse allowed the day pass, where

the [AHPs] hadn’t provided the education [to the patient]. Later

on in the week I received complaint emails [from AHPs], ‘Why

was this patient out on a pass? We didn’t provide education’…

[But] you know, [AHPs] aren’t here 24/7. And if you’re not gon-

na be here 24/7, the nurse is gonna be here and make the deci-

sions.

Nurses also vied for an autonomous role by modifying

PT orders. Modifications were justified through claims to

specialized nursing knowledge and nursing workload:

Like if [physical therapists are] saying, ‘no, transfer them on a slid-

ing board’, well I know this patient can stand and do it [so I let

them]… [Interview, RPN]

…(I)t’s [due to] the increase in beds that nurses are just trying to

make their workload a little bit easier. Sometimes you’ve got six

patients on [PT orders for mechanized lifts]…[but] the lift is not

always practical, so [RNs] will often try a two-person lift in the

bathroom. [Interview, RN]

In response, nurses experienced backlash from PTs:

RN: (I)t felt, all the time, that we were doing something illegal,

behind their back. We were always scared to get in trouble Mon-

day morning if the patient went to therapy and said, ‘[nurses] stood

me up’.

Interviewer: Oh, really? And did that ever happen?

RN: Oh yes.

Interviewer: Did you get reprimanded in any way?

RN: Well, yes. [PTs] weren’t happy about it. [RNs] would be told

that, ‘It’s this kind of a lift or a transfer. Don’t try anything else’.

Nurses negotiated backlash by indirectly criticizing thera-

pists’ assessments or treatments and referring to environ-

mental artefacts such as beds as the source of clinical

disagreements:

Some nurses were hurting their backs…with some transfers. And

the way the rooms are laid out, there is no option. And we were

trying to say that to the [physical] therapists, but they kept saying,

‘[Nurses] are doing it wrong…doing wrong body mechanics’. So

they watched us and then they tried to demonstrate and then they

couldn’t do the right manoeuvres in the [patient room] environ-

ment as well. So they’ve seen for themselves that it wasn’t possible.

[PTs] weren’t listening to us. [RN]

Ward] bed[s are] not quite the same as the mat [in the gym]…So

[patients] could push off that mat, but when they came to push off

the mattress [in their rooms], there’s no way. So we said to the [phys-

ical therapists], ‘you come and show us from the client’s bed how to

do this and how to do that’. They couldn’t [when they arrived]. [RN]

Nurses also used nurse leaders as mediators to express

criticism of PT orders. An interviewed PT explained:

I educated about 3 different nurses on the spot about what it

takes for [patient] to walk and what’s the supervision we have to

provide…And those nurses were fine but many of the others kept

saying, ‘he’s so unsafe’, and ‘he’s gonna fall’, and ‘I don’t want us

to get ourselves hurt’. Rather than first of all communicate with

me, they were just going to the nurse leader complaining. And so

the nurse leader’s saying, ‘we gotta take him off cuz he’s not

ready. He’s not ready. He’s not ready’. So it’s really poor commu-

nication despite my educating some of them and they should have

been educating their peers, to say exactly this is what they need

to do.

Discussion

This study examines intra- and interprofessional negotia-

tions by neurorehabilitation nurses. Findings may not be

relevant to settings where patient acuity, lengths of stay

and staff interactions differ. Studies which have examined

intraprofessional relations have demonstrated antagonistic

relations between RN and RPNs (McKenna et al. 2003)

and a cohesive esprit de corps fostered through a ‘siege

mentality’ by nurses holding negative stereotypes of others

(Miller et al. 2008, p. 5). In contrast, this study found that

collegial intraprofessional relations across licensure levels

were the norm, independent of xenophobia. The presumed

relationship between strong professional identify and poor

identification as a member of an interprofessional team

may require re-thinking (Sands et al. 1990, Miller et al.

2008).

Collegialism was a negotiation strategy to manage heavy

workload. Newcomers were initiated into a ‘standing

agreement (an agreement not made by them to but to

which they are expected to adhere)’ (Strauss 1978, p. 47)

for which positive practices such as task and knowledge

sharing, as well as negative practices such as threats of



ostracism and suppression of dissension were tactics that

‘pertained to the maintenance of the agreement’ (Strauss

1978, p. 47). Uncovering negative processes is an impor-

tant corrective to exclusive focus on collaboration’s posi-

tive dimensions (Reeves et al. 2009, Nugus et al. 2010).

Furthermore, nurses often privileged agreeability over clini-

cal education and problem-solving, potentially leading to

poorer care. This was poignantly illustrated when a

nurse’s attribution of stomach pain precluded a fuller dis-

cussion of medication side effects. Problematizing nurse

agreement makes an important contribution to understand-

ing links between professional development and patient

safety.

Poor IPP formed ‘salient properties of the overarching

negotiation context ‘within which’ the negotiations…occur’

(Strauss 1978, p. 140) and was evidenced by AHPs’ unipro-

fessional silos and undervaluing of nursing knowledge and

nurses’ inability to fully participate in IPP. Nurses ‘negoti-

ated around’ (Evans 2007) poor IPP through claiming an

essential role on the basis of round-the-clock care and

patient familiarity. While other studies found rehabilitation

nurses narrowly interpreting their 24-hour responsibility in

terms of co-ordinating input from the interprofessional

team (Pryor & Buzio 2010), we found nurses negotiating

an expanded division of labour vis-a-vis AHPs, including

weekend therapy and temporary discharges.

Nurses often engaged in overt and covert conflictual

relations with PTs, arguably the most prestigious profession

in rehabilitation next to medicine (Nugus et al. 2010).

Unco-ordinated treatment has been elsewhere attributed to

poor communication between PTs and nurses (Koyama

2011). Here, however, nurses chose to modify PT care plans

due to intraprofessional issues such as unique nursing

knowledge and workload. Demonstration of links between

intraprofessional context and interprofessional negotiations

is novel and contributes significantly to IPP studies.

Contrary to the view that nurses’ avoidance of direct

confrontation is a form of ‘non-negotiation’ (Allen 1997),

we argue such conceptualization forecloses analysis of the

complexities of negotiation in that the ‘interactional course

may not have been totally finished and indeed may be

re-opened’ (Strauss 1993, p. 38). Rather than characterizing

the modification of PT treatments and use of artefacts and

nurse leaders as non-negotiation, it is more accurate to treat

these interactions as skilful negotiation. By focusing on

artefacts, nurses achieved desired care modifications with-

out undermining physiotherapy’s claims of ownership of

the body (Norris 2001). Yet, such tactics are no less of the

negotiated order even if they did not succeed in garnering

AHP recognition of nursing’s mobility expertise, which

direct confrontation may have achieved. These ‘problematic

interactions’ (Strauss 1993, p. 43) entail a breakdown of

routinized action with the intent to establish a new effective

routine whilst requiring that actors ‘come to terms with the

goals and actions of others’ (Strauss 1993, p. 57). Recogniz-

ing negotiative nuance is crucial when examining nursing

interactions in the context of power and status struggles

and is suggestive of new avenues of research for interprofes-

sional nursing practice.

Conclusion

This article provides novel findings of nurse–nurse and nurse

–AHP negotiations in neurorehabilitation. Collegial intra-

professional negotiations were reinforced by co-operative

What is already known about this topic

● Nursing interactions have been typically examined via

a conflict lens, which provides important insight into

antagonistic relations in nursing.

● Nurses are often unenthusiastic about interprofessional

practice.

● The emphasis on antagonistic relations implicitly valo-

rizes collaboration and leaves underexamined the com-

plexities of intra- and interprofessional relations.

What this paper adds

● This study provides a novel examination of nurse–

nurse and nurse–allied health professional relations

using negotiated order theory.

● Nursing practice barriers are negotiated by nurses

through two strategies: intraprofessional collegialism;

and vying for an autonomous nursing role in interpro-

fessional practice.

● Intraprofessional collegialism was sometimes negoti-

ated through negative tactics such as suppression of

dissension and coercion in task sharing.

Implications for practice and/or policy

● Identifying the negative aspects of nursing collegialism

makes an important contribution to understanding

mentoring and other aspects of professional develop-

ment.

● Nurses’ desire for an autonomous professional role

challenges the central tenets of interprofessional prac-

tice and should be addressed in initiatives to improve

nurse–allied health collaboration.



and negative tactics that problematize agreement in relation

to patient safety. In a context of poor IPP, nurses attempted

an essential, autonomous nursing role and an expanded

division of labour. Negotiations with PTs were particularly

contentious. Understanding of the interrelationships between

intraprofessional context and interprofessional negotiations

is critical to improving IPP interventions.

Acknowledgements

We are greatly indebted to Romeo Colobong and Jessica

Neuman who collected the ethnographic and interview

data. We also thank the study participants who juggled

research participation with heavy patient caseloads.

Funding

The authors disclosed receipt of the following financial

support for the research and/or authorship of this article:

Canadian Institutes of Health Research Operating Grant

(2008–2011, MOP – 86624); Pia Kontos holds a Canadian

Institutes of Health Research New Investigator Award (2009

–2014, MSH – 87726). The authors acknowledge the support

of Toronto Rehabilitation Institute that receives funding

under the Provincial Rehabilitation Research Program from

the Ministry of Health and Long-Term Care in Ontario. The

views expressed do not necessarily reflect those of our

supporters or funders.

Conflict of interest

The authors declared no potential conflicts of interest with

respect to the research, authorship, and/or publication of

this article.

Author contributions

All authors meet at least one of the following criteria [recom-

mended by the ICMJE (http://www.icmje.org/ethical_1author.

html)] and have agreed on the final version:

� substantial contributions to conception and design, acqui-

sition of data, or analysis and interpretation of data;

� drafting the article or revising it critically for important

intellectual content.

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The intraprofessional and interprofessional relations of neurorehabilitation nurses: a negotiated order perspective