Role conflict

The theme of role conflict was multifaceted, relating to both personal and professional perspectives. The subthemes which underpin this theme were identified during the inductive analysis, and consist of conflicting priorities, role duality, personal versus professional identity, and making the wrong decisions.

Conflicting priorities: The first sub-theme was not unexpected and related to the conflicting priorities resulting from service demands. Additional requests from children, patients or parents demonstrated role conflict and frustration resulting from competing demands:

…'have you got some biscuits for them?' And it's, 'Actually no, we're not here for that. We're here to look after your poorly mum or your poorly dad.' It is difficult (P-AN29 - FG2A Lines 45 – 48).

157 The dilemma of the extent to which caring for relatives is a nursing role was also evident when talking about children visiting. Despite the growing promotion of family centred care (Clarke and Guzzetta, 2017; NMC, 2015), family presence (American Association of Critical Care Nurses (AACN), 2016) and holistic assessment (NMC, 2015), adult nurse participants did not consider that they had any role in providing any care or support to children visiting. The patient was seen as not only their priority, but also as the sole focus of care:

As long as the patient's safe and I suppose - because we're here for the patients. We're not here for the kids at all (P-AN27 - FG2A Lines 291-292).

This total concentration upon the patient to the exclusion of the family and children may link with the fears expressed about responsibility for children and child abandonment.

Role duality: Role conflict was also found in relation to personal and professional roles boundaries. In action research role duality is associated with the researchers differing roles, and the challenges of valuing each role whilst managing the differing demands particularly if there are conflicts between them (Coghlan and Shani, 2008). Role duality had been considered from a personal perspective as my role as researcher and my organisational role as ANP could have resulted in conflicting priorities. I had not considered the potential for role duality in the daily lives of the participants. However, it was identified that a similar conflict in roles was felt between the role as a parent and the role as a professional nurse. Within the clinical environment, this type of conflict was also identified when roles changed from day to day, such as between working on the ward within the nursing team and then taking the role of nurse-in-charge of that team.

158 Several participants discussed the experience of being a parent who wanted to allow their child to visit a hospital with them:

…on a personal point of view I’ve had my husband in hospital and a young baby and I wanted that baby near me at all times he came to the hospital to visit his Dad and he was only 6 months but I needed him there (P-AN01 - FG1A Lines 21-23).

Personal versus professional identity: In discussing their experiences and role as a parent, the theme of personal professional role conflict began to emerge. The idea that as a parent you wanted your child to be able to visit, but that without having had these types of experiences, consideration for other patients visiting may be side-lined to fall in line with management decisions:

This is it, this is it if you’ve had like a personal experience of it you want your children there from the word go (Lots of Erm, yea – in the background) but if you haven’t you’ll go with what the majority and what your management are saying no no no they can’t come in (P-AN01 - FG1A Lines 146-149)

This may also be representative of the switch from personal identity to social identity.

The social identity (the sense of being a member of a group) is perhaps considered most appropriate (Dickerson, 2012) when a nurse is lacking in experience and so defaults to the group perception and behaviours.

There was appreciation from those participants that are parents that this role may bias views and responses towards other parents in the clinical environment:

159

…'oh no, no. This is wrong. This shouldn't be happening.' But why? Do you know what I mean? I don't know, sometimes being a parent can make you a bit more biased to say, 'You shouldn't be doing that. (P-AN10 - FG4 Lines 139-141).

There was recognition that feelings and responses in their professional role of the nurse were often different than the responses they would give out in the community in their personal lives. This linked with what was seen as professional behaviour and acceptability. The quote below again demonstrates the potential conflict between the personal identity and the social identity (Dickerson, 2012) of being a professional nurse

…they'll say to you, 'Oh, look at the baby in the bed.' You feel actually really horrible because in normal life without the job I'd be, 'Oh, that's really nice. The baby's nice.' But actually that's not professional. Within the hospital setting it's not acceptable. So it can be quite difficult because then you upset relatives.

So I think it's quite a difficult place. (P-AN27 - FG2A Lines 31-35).

Nurse professional identity is defined by the “values and beliefs held by nurses that guide his/her thinking, actions and interactions with the patients” (Fagermoen, 1997, p435). It is also influenced by opinions of the general public, the work environment, education and culture (Ten Hoeve, Jansen and Roodbol, 2014). There was evidence of a clash of these different influences in the adult nurse participants where some expressed that their actions in work did not reflect their personal views. There was a perception that the public may find certain socially accepted behaviours, such as admiring a new baby, unacceptable in the clinical area.

160 Making the wrong decisions: Conflicting thoughts around decision making were evident with adult nurse participants expressing that they were not sure if they were doing the right thing; whether that was restricting visitors, allowing a visit or being asked for advice:

Sometimes we’re withdrawing treatment erm and when there’s younger kiddies especially like toddler age we don’t really know as a professional what the best thing to do is. The family tend to be asking your viewpoint on whether or not the kids should come in and from a personal point of view you’re saying yes yes yes bring them in you know but from a professional point of view you’re thinking well how much information would they take from this experience being so little seeing all the machinery if they can see every other patient on the unit as well (P-AN01 - FG1A Lines 12-18).

This concern that inadequate support or information will be provided to children and their families due to a lack of knowledge and understanding about appropriate methods to support them is well recognised within the literature (Gibson et al, 2012).

Nurses dissuading families from bringing children to visit due to a desire to protect themselves from additional trauma was also reported in the literature (Clarke, 2000). It was unclear in this PAR study whether this was the case with the adult nurse participants, although there was evidence that children visiting did cause additional stresses relating to decision making.

Families’ transferring the responsibility for decision making to nursing staff at times of stress had been experienced and again there was conflict about making the right decision in relation to allowing children to visit:

161

…it’s one of those very vague areas where you don’t know if you’re doing the right or wrong thing and because of the stress of what the family are going through it tends to get put on the nursing staff the decision of whether or not they come on to see their loved one (P-AN01 - FG1A Lines 23-27)

When children did visit, one particular stressor for the adult nurse participants was how to deal with any challenging situations arising which involved the families with the children:

I think it's the difficulty of not knowing where we stand when it comes to telling parents about children that are running round (P-AN28 - FG2A Lines 189-190)

This was raised a number of times with adult nurse participants expressing concern about approaching parents if there was any disruptive behaviour from the children. In contrast, the same adult nurse participants were not concerned about approaching adult visitors in relation to any disruptive behaviour from them:

In summary, the theme of role conflict included the subthemes conflicting priorities, role duality, personal versus professional identity, and making the wrong decisions. Conflicting priorities linked to the earlier subtheme of responsibility. It was felt that the patient was the priority and that was no responsibility to care for any children visiting. Despite this, there was conflict for some between their personal identity and their social identity as a professional nurse. It was acknowledged that practices in the clinical area towards child visitors did not always reflect how they felt on a personal level, and that there was concern about the professional image portrayed to the public. There was also an element of role duality, with participants

162 explaining that their actions may be different depending upon their role on any given shift; between being a member of the nursing team and being the designated nurse-in-charge of the ward.