A Position in the Making: A Bourdieusian Analysis of How RN Prescribing Influences Collaborative Team Practice in New Zealand
Background. In 2016, New Zealand introduced legislation enabling suitably qualified registered nurses the authority to prescribe from a limited formulary under the supervision of an authorised prescriber (doctor or nurse practitioner). Registered nurse prescribing is well established internationally and has been shown to enable the provision of quality, safe, and efficient health care. The Nursing Council of New Zealand stipulates that designated registered nurse prescribers are required to work collaboratively within the health care team. This study explored how registered nurse prescribers influence collaborative team practice. The research aimed to understand how registered nurse prescribers interact with other members of the health care team and to identify the social processes at play. Method. Bourdieu’s ‘Theory of Practice’ provided the methodological framework to explore health care teams as competitive social spaces where health professionals vie to establish social position and authority. Three health care teams, representing primary health and specialty practice, were recruited using purposive and snowball sampling. Individual participants included registered nurse prescribers, doctors, pharmacists, non-prescribing nurses, and a nurse practitioner. Data were collected through individual interviews and team meeting observation and analysed using reflexive thematic analysis informed by Bourdieu’s theoretical concepts. Findings. Three themes were identified. The first theme, ‘social topography’, positions team members in a social space, relevant to others, and according to their endowment of various forms of capital. A pervasive system of classification by professional discipline influences this established social order. The second theme is ‘working with a registered nurse prescriber’. Classification by discipline drives the way the teams work, informing the objective structures including the division of labour and the allocation of time and physical space. Team members internalise their experience of the objective organisational structures of the team. Registered nurse prescribers develop an embodied sense of opportunity which either limits or enables their ability to work collaboratively. The final theme, ‘patterns of communication’, addresses the way the team communicates including opportunities for shared clinical decision making. Prescribing authority signifies a greater level of responsibility for registered nurse prescribers, and they rely on their relationships with authorised prescribers to assist them to gain knowledge, confidence, and establish their new prescribing role. The patterns of communication evident in each team reflect the power dynamics at play and demonstrate authorised prescribers to hold a position of symbolic dominance over decision making. Conclusion. The propensity for the registered nurse prescriber to both realise the full potential of their prescriptive authority and to influence collaborative practice is determined by the organisational structure of the team and the relationships shared with authorised prescribers. The findings of this study build on an emerging body of research regarding the collaborative model of designated registered nurse prescribing in New Zealand. This research offers a unique and original contribution regarding how registered nurse prescribers work with others and influence collaborative team practice. These findings have relevance to those concerned with enabling and promoting registered nurse prescribing including postgraduate educators, health policy makers, and health care teams.