Nurses at the Nexus: A Case Study in Structurational Divergence

Abstract

Hospital-based nurses are institutionally positioned at a nexus where numerous social structures interpenetrate, compelling the individual to simultaneously fulfill obligations from multiple rules systems. When these rules systems are incompatible, the individual's position is untenable. This article describes the phenomenon of structurational divergence (SD) identified in our previous research, wherein the intersection of incompatible rules systems manifests as unresolved conflict that sets off a negative spiral of communication. To explore and illustrate SD in the nursing role, we present herein a case study of a geriatric care unit where the phenomenon is clearly visible. Using qualitative interviews and observation, we first look simply to identify the negative spiral that is the hallmark of SD. Once the instances of the negative spiral are identified, we explore the issues surrounding them to discover the underlying structurational incompatibilities, using sets of incompatible rules identified in previous research as a guide. Finally, we address the extent to which the SD in this case is particular to this situation or might be linked to nurses' unique institutional positioning, and we discuss our future research agenda.

ACKNOWLEDGMENTS

A previous version of this article was presented at the 10th biennial Kentucky Conference on Health Communication, University of Kentucky, 2008. The authors acknowledge Jordyn Lorenz in great appreciation for her assistance in recording and compiling our data; Dr. Lynn Harter for her impressively efficient, supportive, and helpful editorship; and our anonymous reviewers for their thoroughness, their insightful demands that we dig deeper, and their quick turnaround with critique.

Notes

In previous work, we coined the term “organizational divergence” for this phenomenon (Nicotera & Clinkscales, 2003). To avoid the confusion we then encountered with other uses of the term “divergence,” we herein refer to our construct as structurational divergence to specify our framing of the phenomenon with Giddens's notion of structural interpenetration.

² Sewell (1992) prefers the term “schemas,” pointing out that structures have a virtual rather than a real existence, and he provides a thoughtful theoretic explication of Giddens's notion of “structure.” However, although we recognize the value of such theoretic work, we find it of secondary importance here, given the very concrete and distressing outcomes experienced from SD by nurses and their patients. Our foremost concern, and where our energies are devoted, is in developing practical and socially relevant interventions that can be applied in the education and training of nurses and those who manage health care systems. SD has important implications for structuration theory, and vice versa. We are committed to building theory inductively, so a full theoretic treatment now is premature. We far prefer to document the experience, which is our current purpose; follow that up by documenting interventions, which we are currently designing in another project; and then use all those data to build theory informing and informed by structuration.

³In a separate private report, we offered recommendations to the director.