Table 2.

Contradictions analysis

Illustrative quotations and notes from the field study and the interviews	Interpretive remarks	Contradiction analysis
How often do you receive new guidelines? What do you think about that?
‘Every day. I think we receive 2–3 new or updated guidelines per day. I don't have any chance in daily practice to update my knowledge.’ (nurse 12)  ‘Every day. If guidelines are made to beat the staff over the head, then don't send them. They become a tool to increase the poor conscience.’ (nurse 3)  ‘I am not sure … maybe every day. It is difficult to find the time to look at all these guidelines. I now that I'm not up to date with a lot of guidelines.’ (doctor 2)  ‘Every day. I think it is a problem that we only receive an email as the only reminder that there are new guidelines. Nobody in this department can check emails during the day.’ (medical secretaries 2)  All guidelines were sent from the hospital's central quality department to a secretary in the department. She made sure that the guidelines were available in the central web portal and she also sent a message via email to all professions (field notes from researcher)	There appears to be a consensus across professional borders that everyone knows that they receive new or updated guidelines every day They also agree that time is a limiting factor for the opportunity to look at these new guidelines. And the method used is not deemed appropriate When the staff do not manage to look at the guidelines or perform actions similar to those in the guidelines, it is experienced as a tool that preys on the conscience	The amount of guidelines sent daily to the health professionals creates contradictions between community and rules. Lack of time and the methods used create contradictions between the subject and rules, which increase bad conscience. Simultaneously, the methodological approach is seen as a sign of a top‐down thinking thereby creating contradictions between different activity systems and their embedded cultural thinking about the use of guidelines and standards
Are there clinical guidelines you rarely use? And why?
‘If you call nutrition and pressure ulcer screenings standards, those screening tools I don't use. They don't fit within an emergency department’ (nurse 17)  ‘Nutrition screening is in contrast with acute treatment’ (nurse 1)  ‘If the guidelines are not FAM (emergency department) specified, then I do not use them. It is a waste of my time’ (nurse 22)  ‘I don't know, but I know that many of the nurses in the department do not prioritise screening for nutrition and pressure ulcers. They find that these screenings do not fit in. They (the screenings) don't support patients moving on in the hospital and that is very important in this department’ (doctor 3)  The researcher did not see many nurses do nutrition or pressure ulcer screenings. When some of the new nurses started to screen, they were asked to prioritise differently by their more experienced colleagues (field notes from researcher)  When some nurses did the nutrition screening, they felt tied to the patient. They began to sweat and became abrupt with the patients (field notes from the researcher)	There appears to be a consensus across all professions that screening for nutrition and pressure ulcers is not performed in the department The explanations were that the screenings do not fit within the emergency department – they are not FAM specified. They also do not help the staff to move patients on in the system and this is why the guidelines were not deemed useful Newcomers learned over time which actions were right in the department	Screening for nutrition and pressure ulcers creates contradictions between the nurses and the rules. At the same time, it is common knowledge in the community that these screenings do not fit into the department, which is represented by the activity system flow culture Instead, the screenings become a mediating sign of an embedded understanding of a professional identity that belongs in a medical department and not in a flow culture When newcomers began to screen, it created contradictions between the subject and the community
In what situations do you use clinical guidelines?
‘I use guidelines especially in unknown and acute situations.’ (doctor 1)  ‘I use guidelines when it helps my colleagues move on with their work and if the actions connected to the guidelines ensure that the patients move on into the hospital or home.’ (nurse 8)  ‘What is it that causes death in the first 24 hours? Not hunger but fluid! That is why I always give the highest priority to treatment with intravenous fluids. When a stable patient is transferred, then the medical department can do the nutrition screening. I think it is part of their job.’ (nurse 9) The researcher often experienced that guidelines that secured patient transfer were prioritised (field notes from the researcher)	Guidelines are used particularly in the case of acute care situations, but were also given priority if the guidelines supported moving the patient on to another department or home If the use of guidelines helped the professional to finish in the emergency department and go back to their specialised department (doctors), then the guidelines were prioritised Screenings for nutrition and pressure ulcers were perceived as not belonging to an emergency department but in a medical department. The health professionals found that only specific types of guidelines belong in the emergency department	Guidelines and screenings that do not support the creation of a continuous patient flow or do not ensure that the doctors can get back to their specialised department creates contradictions between rules, subject and community Another contradiction created between rules and community was that nutrition and pressure ulcer screening challenged the embedded common knowledge and understanding about being a professional, an understanding created in the flow culture