Striving to be in close proximity to the patient: An interpretive descriptive study of nursing practice from the perspectives of clinically experienced registered nurses

Abstract

This paper explores essential characteristics of current nursing practice from the perspectives of clinically experienced registered nurses in various fields of health care in Sweden. Nursing practice has been the subject of much debate in the past and because of its complexity as well as continuous changes in society it is important to continue the debate. A qualitative study, including 16 group interviews with altogether 74 participants, was conducted. Nursing practice was viewed as a multifaceted field. The participants struggled to define nursing but were able to describe it using concrete examples. The analysis, using interpretive description, identified current practice as essentially consisting of: ‘A practice pervaded by comprehensive responsibility’, ‘A practice that recognises a patient's unique needs’, ‘A practice based on multifaceted knowledge’ and ‘A practice that mediates between traditional values and changing demands’. Current nursing practice can be understood as striving to be in close proximity to the patient, but in tension with pervasive requirements and societal changes. Going forward, it is necessary to continue to reflect on and discuss the nature of nursing practice in an interprofessional context. Studies from primary and home care are also needed to broaden the understanding of nursing practice.

1. INTRODUCTION

Nursing practice is the basis of how nurses perceive, understand, and interpret clinical situations for the benefit of others, namely the patients. It is a complex practice and encompasses several types of actions within a broad scope of complexity and seriousness (Kim, 2015). The wide range of nursing tasks, which are not always simple and predictable, can confuse nurses’ about their responsibility in practice (Bekker et al., 2015). Because of the complexity and also because of continuous changes in society, it is of significant importance to continue the debate around nursing practice, for the benefit of both nurses and other health professionals. In today's health care, nurses are expected to work interprofessionally. Interprofessional ways of working can lead to nurses struggling to define what nursing practice constitutes, particularly in the context of an expanding and constrained healthcare sector (Thorne, 2015; Thorne et al., 2012). This study examines essential characteristics of current nursing practice from the perspectives of clinically experienced registered nurses (RNs).

1.1. Background

It is emphasised that it is not merely the actions that nurses perform, that make nursing practice what it is. Rather, nursing practice is constituted by how the actions are put together in the specific context of a person, such as a patient, in need of help (Kim, 2015; Kirkevold, 1997). Kim (2015) presents a model with five essential components that shape nursing practice: perspective, knowledge, philosophy, dimension, and process. Risjord (2010) describes how nursing practice comprises at least two perspectives: knowledge about the care context, including the patient's specific health situation, and knowledge about moral questions such as what is good and valuable for a patient in a specific situation. Decision‐making is both an important and a complex concept and includes decisions within different areas, such as clinical, administrative, ethical, and moral (Johansen and O' Brien, 2016). Since the turn of the millennium (if not before), nurses have perceived their work in practice as comprehensive. One day can be filled with strain, the next can be stimulating, or both of these elements may be present (Hallin & Danielson, 2007). Emeghebo (2012) describes how nurses in practice identify their work as action‐oriented, with common nursing tasks including bathing and administrating medication, but also how nurses express frustration, especially regarding the paperwork that can prevent them from performing tasks they were educated for. Linked to Thorne’s (2015) statement that health care relies on interprofessional collaboration, nurses in Emeghebo’s (2012) study perceived that the expectations from other health care professionals affected the outcome of their work—especially when nurses were seen as doctors’ handmaidens. In Sweden, a model for nursing has been developed as a guide for practice, as well as for research and theory development. The model consists of different aspects, which affect nursing practice regardless of care contexts such as the society, care environment and ethics (Norberg et al., 1992; Ternestedt & Norberg, 2014).

Applying nursing theories in practice can help nurses gain a deeper understanding of patients’ well‐being (Doane & Varcoe, 2008; Meleis, 2018; Rega et al., 2017). The first serious and systematic attempt to conceptualise nursing practice was made by Florence Nightingale in the 19th century (Nightingale, 1860). Nightingale improved nursing knowledge based on actual nursing practice. In the mid‐1950s, nurses began to formulate and theorise nursing practice (Meleis, 2018). In general, nurses’ work has been grounded in a problem‐solving focus related to human health and illness, where knowledge is expected to reflect both abstract and concrete, contextualised knowledge based on specific care situations (Thorne & Sawatzky, 2014). However, critics argue that theories are increasingly being overlooked in favour of tasks and immediate effectiveness. This could result in a return to a more task‐oriented nursing practice focused on achieving cost‐effectiveness solutions for the healthcare sector (Rudge, 2013). Moving forward, Jairath et al. (2018) emphasise that future challenges include whether nurses and scholars can adapt past theories into today's challenges, and whether the theories per se are flexible enough for future health care.

Hoeck and Winther (2012) and Roy (2018) emphasised that modern societies, with new technical challenges for health care professionals and increased expectations from the public, have re‐ignited the debate regarding the nursing discipline and therefore, indirectly, nursing practice. In November 2018, the World Health Organization (WHO) held a global conference that focused on the development of primary healthcare and the importance of resuming attention on public health. At the conference, Rawaf (2018) highlighted the need to integrate public health into primary health care and support citizens in promoting and maintaining their health. Rawaf further emphasised the need to assess the patient as a whole person rather than view the patient ‘as a disease’. According to Rawaf (2018), health care should act before people become ill, by looking at the needs of populations and communities and then adapting the services around the population's needs. Person‐centred care (PCC), which aims to acknowledge and endorse patients’ resources and views patients as a co‐creators of their care, has been suggested as a possible solution to enhance quality of care in relation to current societal challenges (Lloyd et al., 2020). Person‐centred care has been shown to both improve health outcomes and increase patients’ satisfaction with their care (Fors et al., 2015; Jakobsson et al., 2019). Although care providers acknowledge PCC as a way forward, the importance of establishing routines to initiate and integrate PCC into practice is highlighted (Britten et al., 2017; Ekman et al., 2011). Kennedy (2018) discusses a model of care for non‐communicable diseases that can be used in many countries around the world. This model requires a rethinking of how the potentials of nursing practice can be used; it also requires a move into the community where the promotion and prevention and control of non‐communicable diseases are best managed. Healthcare reforms are over the last decade related to improved coordinated care between different health care institutions as well as to recognising the importance of being responsive to patients’ needs (Anell et al., 2012). In Sweden, as well as in other countries, health care is, however, experienced as scarcely accessible, with little, and ever‐decreasing continuity of care, and decreased influence in decision‐making (SOU2019:29).

According to Hoeck and Winther (2012), today's patients are knowledgeable and have expectations of up‐to‐date care. This requires nurses to acquire and process knowledge in order to be at the forefront of practice. Furthermore, nurses need to be able to work in environments that emphasise cross‐disciplinary work in an interprofessional context. The authors warn that there is a risk that nursing practice may lose its focus in a multidisciplinary setting (Hoeck & Winther, 2012). Consequently, in an increasingly interprofessional context in which nursing practice constitutes one part, it is important to continue to reflect on and discuss nursing practice and whether it meets the conditions for fulfilling the mandate of nursing.

1.2. Aim

This study aimed to explore essential characteristics of current nursing practice from the perspectives of clinically experienced RNs in various fields of health care.

2. METHOD

2.1. Study design

This study is part of a comprehensive nursing educational project, which aims to deepen the understanding of nursing as both a practice and a subject among clinically experienced RNs, nursing students and nursing educators. The study had an interpretive descriptive design, and an inductive analytical approach was used so as to create knowledge in collaboration with, and for the benefit of, clinical practice (Polit, 2016; Thorne et al., 1997).

2.2. Participants and settings

The inclusion criteria in this study were being a clinically experienced RN, and either presently working clinically or studying in higher education. For inclusion, different health care areas and different specialist nursing programmes were selected to obtain a broad material, covering, hospital inpatient care, community care and primary care. The RNs in higher education were in the process of completing nursing education at a university in Sweden, studying either for a 1‐ or 2‐year Master's degree in specialist nursing or for a 4‐year doctoral degree. In total, 74 participants aged 28–65 years were included (Table 1). The majority of the RNs in higher education worked in clinically positions while studying.

Table 1.

Participants’ gender and age

Gender	Clinically experienced RN (n)	Clinically experienced RN in higher education (n)
Male	19	1
Female	28	26
Age, years
28–35	12	13
36–45	12	6
46–55	15	4
56–65	8	4

Abbreviation: RN, registered nurse.

2.3. Data generation

The research team contacted directors from various health care areas by e‐mail. The e‐mail sought permission to invite clinically experienced RNs working in their health care area to participate, and asked for contact information for head nurses to help the research team identify RNs for participation. Registered nurses in higher education were informed on campus about the study and invited by e‐mail to participate. Data were collected through 16 group interviews held between October 2017 and March 2018. Ten group interviews included RNs and six included RNs in higher education (Tables 2 and 3). The size of the groups varied from two to eight participants. Allocation to the different groups depended on the workplace and preferred time for the interview. Group interviews were used as the data generation method because interviewing in groups involves a high degree of interaction between the participants and the interviewers, whose main task is to facilitate reasoning and reflections when a phenomenon is being discussed (Polit, 2016). The group interviews were held in either a room near the nurses’ workplaces or in a room at the university.

Table 2.

Work experience and field of work of clinically experienced RNs participating in group interviews

Group	Participants (n)	Work experience (yrs)	Clinical context
1	7	2–27	Cardiac, surgical, oncological, and thoracic care
2	2	12–31	Orthopaedic care
3	5	1–18	Psychiatric care, orthopaedics
4	4	8–28	Psychiatric care
5	7	4–39	Cardiac, emergency, oncological and intensive care
6	2	5–7	Orthopaedics
7	6	3–22	Pre‐hospital care
8	3	10–15	Diabetes, cardiac care, internal medicine
9	8	1–20	Palliative home care, community care
10	3	5–7	Community care

Abbreviation: RN, registered nurse.

Table 3.

Level of education of clinically experienced RNs in higher education, participating in group interviews

Group	Participants (n)	Level of nursing education	Specialist nursing programme
11	4	Master's level	Medical care; Care of older adults
12	5	Master's level	Master's programme in Nursing, Health care pedagogy
13	5	Master's level	Supplementary nursing education
14	7	Master's level	Psychiatric care; Care of children and adolescents
15	3	Master's level	District nurse
16	3	Doctoral level

Abbreviation: RN, registered nurse.

All 16 group interviews were recorded with the participants’ permission, and lasted 38–60 min. Before the interviews started, participants completed a short questionnaire concerning their gender, age, education, work experience and field of work. All participants were asked to specify their level of education and relevant specialist nursing programme. The main questions that guided the interviews were: What are the characteristics of nursing? Could you describe a situation that illustrates some of what you perceive as characteristic of nursing practice? And what knowledge is needed to practise it? All participants were encouraged to give concrete examples of nursing situations. The interviews were concluded by inviting participants to summarise the most important aspects, for them, of the discussion. Four different research assistants conducted the interviews in twos. At each interview, one research assistant acted as moderator and another as co‐moderator. To support the research assistants, two researchers in the project joined the first interviews and the research group supervised the research assistants throughout the data collection phase.

2.4. Data analysis

The group interviews were transcribed verbatim. The transcribed text was analysed using the interpretive descriptive approach described by Thorne (2016), as follows: in the first phase, data analysis started concurrently with the interviews, with the entire research group meeting repeatedly to generate a shared understanding of the data as a whole. In the second phase, the first author read all the transcriptions while listening to the recordings of the interviews to gain a deeper understanding of the data. Memos and preliminary ideas were examined. In the third phase, the first author strategically organised the transcripts. Key units containing descriptions relating to the purpose of the study were identified and marked. Consistent with the interpretive descriptive approach, the question that guided this step was: What is going on here? In the fourth phase, the inductive coding process started, which included broad coding of all text units. Broad codes were used to avoid narrowing the material and interpreting details too early in the analysis process. Throughout this process, all authors discussed the coding to validate and reach an agreement on the interpretation of the data. In the fifth phase, similar codes were sorted and collapsed into broad themes. All authors discussed the themes repeatedly to reach a consensus regarding the most fruitful interpretation of the findings. The themes were iteratively compared across transcripts to reflect the variety of the data. Moreover, the authors are from different fields of health care, which contributed to an open mind set in the analysis process. The data generation and data analysis phase were permeated by a reflective attitude. The authors had no relation with the participants before the study was conducted.

2.5. Ethical considerations

This study followed the ethical principles of the Declaration of Helsinki (World Medical Association, 1964). Ethical approval was obtained from a regional Research Ethics Committee (Dnr:677/17). All participants received verbal and written information about the study and were assured that their participation was voluntary, and that they could withdraw from the study at any time without giving a reason. Oral informed consent was obtained before data collection started.

3. RESULTS

Current nursing practice can be understood as striving to be in close proximity to the patient which is enacted in the context of a tension between individual needs of the patient and pervasive system requirements and uncertainties of what tasks a nurse should perform. Practice entails a broad comprehensive responsibility with unclear boundaries, interprofessional work demanding an extensive knowledge area and contextual differences. Furthermore, societal changes need to be considered in practice. The participants in this study described a constant struggle in finding the appropriate balance between working with the patients to meet their needs and, on the other hand, taking a stand on what a nurse should or should not do. In discussing features of current practice, participants elaborated on nursing practice needs to be: ‘A practice pervaded by comprehensive responsibility’, ‘A practice that recognises a patient's unique needs’, ‘A practice based on multifaceted knowledge’ and ‘A practice that mediates between traditional values and changing demands’. These features are presented below with participants' quotations.

3.1. A practice pervaded by comprehensive responsibility

It was apparent that the participants dealt with a variety of different tasks in practice, which suggests a broad practice role. They expressed that addressing the patients’ needs relies heavily on nurses, as nurses have the knowledge to carry out a broad range of tasks, such as administrating medication, dressing wounds and sometimes even acting as a nurse manager. The participants also emphasised a nursing coordinator role, described as being ‘leaders of the nursing care’. This role was associated with nurses having to prioritise and make decisions regarding nursing care. The broad practice role made it a struggle to determine how much responsibility a nurse had and it sometimes created difficulties in setting boundaries of what a nurse should or should not do. Participants described that often they could not decline to carry out care actions, while they perceived that other health care professionals could. This gave a sense of inequality between different care professions. Furthermore, the participants expressed difficulties in deciding whether the medical tasks a nurse performs are part of nursing practice. A participant from surgical care highlighted that much of her work was performed based on a medical perspective; for example, the practice focused on questions such as ‘What does the surgical wounds look like?’ instead of on the social situation and the patient's resources for regaining health. From the participants’ view, this led to tension regarding what to focus on. A nurse might be scheduled for a specific task, but other tasks take precedence, such as administration or having to act as the coordinator.

Nurses were described as working more closely with patients than other professions. Because of this proximity, other health care professions often instructed them to perform tasks not traditionally performed by nurses or not clearly perceived as nursing tasks. The participants emphasised that the ability to set boundaries in relation to the nurse's areas of responsibility evolved over time. Having longer work experience as a nurse helped develop the ability to evaluate different situations in terms of where the professional responsibility begins and ends, which, according to the participants, contributed to safety in practice. An example of crossing professional boundaries that was shared in the discussions was going to a patient's funeral. Because of blurred boundaries, nurses were sometimes ‘too kind’ to a patient or colleague, and as a result sometimes felt exploited.

It was suggested that, to find the appropriate balance, nurses need a wide set of skills, as one participant described in the following example: ‘It has a lot to do with the treatment that we talked about and making the patient feel safe. [Nurses have to] create an atmosphere [and] be good at their job and know what to do with medications and treatments, and so on. That is the main thing on the whole’. Some skills including empathy skills advance through professional experience, according to the participants: ‘I would like to say empathy too… is a huge part of nursing, and that is nothing you can learn [in school], but something you develop over the years’. Other required skills are difficult to describe and are ‘more of a talent’: You just have it in you or you don't. The participants related that, since nurses are considered to work closely with their patients, some traits such as communication skills and being a good listener, as well as having ‘a bit of humour’, are important.

3.2. A practice that recognises a patient's unique needs

The participants emphasised that in practice, nurses tend to work from a holistic perspective. However, what this entails varies from situation to situation and depends on the clinical practice field. For example, one participant said that nurses need to ‘see the patient as a whole—[and to] look at all aspects. Not just the physical [health], but also the mental health of the patient and what the patient wants from us or the care. That is good nursing!’. The holistic perspective was described as contextually dependent. For example, in orthopaedics, nurses focused on falls risk assessments, while nurses in psychiatry focused on creating a good daily rhythm for patients. Working close to the patient included not only planned specific nursing interventions such as administrating medication, but also other aspects such as assessing and observing care. This meant that nurses had to focus on specific tasks, but at the same time their attention was on additional work that needed to be done. Furthermore, some participants described the social aspects of having a holistic perspective. For instance, they were offering coffee to visiting relatives. The social aspects in practice were expressed as context‐dependent; for example, a psychiatric nurse explained that it had to do with making the patient independent by helping them live a life as normal as possible (an example of the nurse's task in this case was helping the patient with visits to the bank). Another participant described this role as encouraging patients in their everyday life and emphasised the importance of giving self‐care tips to make the patients’ daily life easier. In addition to the variety of tasks with a holistic perspective, it was important to work on proactive health promotion and prevention in all different types of care contexts, as emphasised by some participants in the Master's programme in Nursing. They stressed the importance of working with aspects of health as well as with illness and described the importance of identifying a patient's resources to achieve well‐being.

3.3. A practice based on multifaceted knowledge

The participants considered daily nursing work to be based on both theoretical and practical knowledge from the nursing discipline as well as knowledge from other disciplines, such as philosophy, psychology, medicine and sociology. Because of the broad knowledge base from different disciplines, this brought challenges regarding the focus in practice a nurse should have. The participants experienced that nursing theoretical perspectives helped them in their daily work by guiding them in practice. As one participant emphasised, ‘It is possible to read the theories and to use them as tools when working’, but as a newly graduated nurse, it ought to be okay to have ‘tunnel vision’ and just focus on tasks to be done during a work shift. However, this may come at the expense of being in close proximity to the patient. Participants expressed that nursing was difficult to describe, and that to attempt to find a single description of nursing; ‘…is very ambiguous. I always thought that. I thought that during [nursing] school time too, [and I asked] during lectures: What is it [nursing in practice]? What are you expecting [from us as nurses]?’. Another participant expressed: ‘It is a very important topic, but also challenging and difficult. Not quite easy to learn and acquire, but we must not give up’. Some participants used abstract theoretical concepts to describe nursing work in practice, for example; ‘to ease suffering’ and ‘to foster well‐being despite poor health’. Despite difficulties to find a unified description, the majority of the participants felt it was important to strengthen the profession. However, many had difficulties stating how this could be achieved.

3.4. A practice that mediates between traditional values and changing demands

Through changes in society, the possibility for nurses to be in close proximity to the patient was limited. The participants described how cuts in health care funding had led to less time to care for individual patients. This had led to participants working overtime and a feeling that the specific nursing tasks had become blurred in favour of the medical perspective, resulting in ‘physician assistant thinking’. Another cause of frustration was having to do a lot of paperwork. Thoughts shared by a participant ‘I also think that care has… if you look at a couple of decades, the care has become very …; as a nurse you have much administration nowadays, which takes a lot of focus from the nursing care, which I think that nursing [practice] has fallen a little by the side. It is the medical perspective that governs mostly’. Having the medical perspective at the forefront of care was seen to lead to difficulties in being near the patient; this resulted in a feeling of being everywhere but nowhere. In the context of nursing practice being blurred, thoughts such as ‘What happens after the surgery?’ and ‘How will the patient get home?’ were often missed in clinical care. It was emphasised that this leads to fragmented care where important aspects of a nursing perspective are neglected.

Participants described how theories supporting nurses’ work in practice needed to be updated to align with the developments going on in society. In addition, the participants expressed that nowadays, people have different requirements and expectations of health care compared with the past. Consequently, they say that nursing practice had to evolve accordingly to meet the needs of the population. However, it was difficult for the participants to identify the changes that were actually needed. Participants who worked in pre‐hospital care emphasised, for example, that society's view of an ambulance and ambulance services has changed because of the influence of the media and fast‐paced lifestyles. They were the only group of participants who explained this development further, for example by saying: ‘I have a general feeling that people do not have time to be ill in today's society. The media scares people with all sorts of diseases, while the ambulance dispatch centre rarely deny anyone requesting an ambulance; it just increases the number of emergencies calls we must respond to’. Sometimes patients had already packed their bags by the time the ambulance arrived, and expected to be driven directly to the hospital. A participant explained, ‘Today, an ambulance does not mean that the patient necessarily needs to go to hospital’ and that this sometimes made it difficult when the patient had a different view towards the pre‐hospital team. This makes nurses’ communication skills even more important; to find the ability to work in close proximity to the patient they needed to obtain an understanding of a patient's condition and experience of the situation. Another participant told that youngsters today expect to get an ambulance as a default instead of seeking health care for themselves. The participant explained that many people today do not trust themselves; besides, they said that the increasing Googling of symptoms contributes to a fear of being seriously ill. For this reason, many patients call for an ambulance. The participants described how the pre‐hospital team provides a lot of care when they reach a patient, which may be sufficient, and is an instance of working closely with the patient. This is another example where the nurse may experience tension between struggling to be in close proximity to the patient and dealing with the patient's wishes that are influenced by changes in society.

4. DISCUSSION

The participants in our study emphasised that nursing practice is about striving to be in close proximity to the patient, pointing towards a relational practice. The interviewed RNs recognised a comprehensive responsibility for specific tasks as well as for the overall situation of each patient, and they also reported feeling that others expected them to take responsibility. In addition, nursing practice was described as constantly being available to patients and their relatives as well as colleagues while also focusing on patients’ needs. Through these inexplicit responsibilities and boundaries, a nurse's work becomes a major challenge as it is unclear what a nurse should or should not do and as some tasks may prevent the RN from being in close proximity to the patient. The participants described that nurses tend not to say no to tasks, whereas other health care professions may do so. This has also been reported by Risjord (2010), who discusses the moral dimension of nursing practice, and by Kim (2015), who describe nurses as the major actors responsible for ensuring that patients receive the care they need, in order to manage their health. Our findings regarding the extensive tasks performed by nurses and the demands to always be available (compared with physicians, for example) are consistent with other studies in which nurses described ‘fuzzy’ boundaries (Bekker et al., 2015; Bruyneel et al., 2013). Earlier studies have already shown that ambiguities in nursing role could result in nurses performing others’ duties (Öhlén & Segesten, 1998; Rothberg et al., 2012). This skewed responsibility must be taken seriously, especially as nurses are given many additional responsibilities such as overall administration, as also highlighted by the participants. The findings highlight the importance of discussing and problematising the boundaries of and responsibilities in nursing practice. Discussions may help nurses to argue for the boundaries of their work when collaborating with other health care professionals. According to Kristoffersen and Friberg (2015), the nursing discipline can serve as a horizon of identity for nurses and provide a guide for what is important in practice. However, as participants in our study had problems to fully express their understanding of nursing, nurses may have problems using the discipline as a help to shape their professional identity in practice. Scully (2015) argues that skilful nursing managers could help structure nurses’ workload in practice and reduce ‘invisible’ responsibilities. However, our findings of how a nurse's role in practice remains inexplicit and of how there is a lack of clarity suggests that the issue is more complex and that finding suitable managers will not be enough. Furthermore, the participants emphasised that nursing practice is contextually dependent; as explained, for instance orthopaedic RNs in our study viewed fall risk assessments to be part of nursing. This can be linked to Kim’s (2015) definition of nursing practice being about how a nurse puts actions together in a context of a patient in need of care. Other studies give similar examples of the tasks a nurse performs being related to the workplace. For instance, nurses from municipal care may view nursing assessments and conversations with patients as part of nursing (Gransjon Craftman et al., 2016). However, our study shows that fundamental care (e.g. timely administrations of medication) was at the forefront of the nurse's role, whatever the context, which has also been reported in earlier studies (Ausserhofer et al., 2014).

Many participants had difficulties to explain nursing from a general point of view and, rather, used specific practical examples. This difficulty may be surprising because nursing has been the subject of much debate, with a large number of publications in the past 45–50 years. In our study, nursing was understood in different ways, with some participants defining it as an area that included knowledge from different disciplines, while others gave abstract definitions. The participants underlined the importance of strengthening the definition of nursing, but could generally not say how this might be achieved. As such, this was a paradox: the participants had difficulties to describe what nursing entails and how it should develop, while they were easily able to give many concrete, practical examples of their practice. It may be seen as challenging to strengthen a definition without a clear description, and at the same time, this highlights the contextual dimensions of nursing practice. Altogether, this implies that nursing practice always requires ongoing discussions and debates. Nursing practice is multifaceted and diverse, and takes place in different contexts. To gain an understanding of nursing practice, nurses should probably view it as the start of a life‐long learning journey where not all parts of practice may be evident at graduation. The RNs in our study who were studying for a doctorate said that nursing is often discussed at a superficial level; at the same time, one of them expressed that the PhD education had helped reduce the ambiguity about practice. This may indicate that it is easier to grasp nursing when not working clinically than when being ‘right in the middle of it’ as clinical nurses are. The RNs in higher education found it easier to integrate theory and practice compared with newly graduated nurses. However, the participants in our study generally demonstrated positivity towards theory formation, which was also described in the literature, for example by McCrae (2012), who reports that theory is considered to improve practice. To better understand nurses’ work in practice and to gain a better understanding of the importance of theorising practice, the participants in our study suggested that Master's students should conduct in‐depth degree projects linked to their workplace. Similar suggestions can be found in the literature, where preparing the students to meet the expectations placed on a nurse in practice is a responsibility shared by universities and the healthcare system (Millberg et al., 2014; Öhlén et al., 2012).

Our findings, that cuts in health care funding lead to reduced time for nursing practice, are consistent with the literature. Nursing is often perceived as time‐pressured and task‐oriented, which affects nurses’ decision‐making and communication (Chan et al., 2013). A study by Tønnessen et al. (2020) argues that the lack of visibility of priorities in relation to nursing practice in policy documents puts good patient care at risk. Another aspect related to the healthcare system that is highlighted in our study is the medical focus that was perceived as preventing nurses from being in close proximity to the patient. This was also addressed by Jones (2007), who reports nursing practice as blurred in favour of the medical perspective. In addition, Ghiyasvandian et al. (2014) found that teamwork between nurses and physicians is problematic, with uneven role distribution that triggers frustration among nurses. Scully (2015) notes that nurses and physicians have different opinions about patients’ care plans, which contributes to uncertainties around priorities and affects nursing outcomes. In today's society, where interprofessional working is considered desirable, it is essential to further explore the different roles within the health care team. It may be necessary to identify common competences, as well as competences for specific professions, to avoid clashes between profession, which could negatively affect care.

Related to societal changes, Rawaf (2018) argues that it is important to integrate public health into primary healthcare. Only a few participants in our study mentioned the importance of working with patients on proactive health promotion and prevention with patients, which may be explained by the fact that the majority of participants were working in hospitals. This explanation is supported by the literature, which suggests that a combination of individual, organisational and external environmental factors act as barriers to implementing health promotion in hospitals. Lack of knowledge about proactive health promotion and its importance reduces patients’ and public expectations of health promotion as a part of inpatient care (Afshari et al., 2018). Afshari et al. (2018) reported that, in their study, nurses highlighted the lack of interprofessional work as a major barrier to health promotion. Participants in our study discussed that nursing practice needs to evolve with society, taking into account societal changes, citizens’ expectations of health care, and media influence; however, they had difficulties in defining what should change, and how. Notably, nurses from pre‐hospital care were the only group that were able to deepen this discussion, which probably reflects how they care for people in the community and have insights into present changes. The other participants’ lack of reflection on nursing practice in relation to societal changes could be explained by Thorne (2014) who highlights the importance of a core focus within one's discipline. Today's health care is in the middle of a trend of people contacting, and receiving, care through health care services online, with a growing use of social media among patients and health care professionals (Antheunis et al., 2013). Unfortunately, this societal change was not addressed in our study, which may be due to no participants representing primary care where the majority of such technology shifts are seen.

5. METHODOLOGICAL CONSIDERATIONS

In interpretive descriptive studies, the number of participants usually range from five to 30, but may go up to 200. This study included 74 participants, which is a relatively large sample size. Thorne's argument (2016) that larger studies can defend their scope based on the relevant variation and complexity of the phenomenon and associated research questions is applicable to our study. A combination of different data collection methods is considered suitable to gain further depth and enhance the validity of a study (Thorne, 2016). The variety in pre‐understanding and experience in the research team contributed to the trustworthiness of the results of the study. The data used in this study were obtained using one method, but this cannot be considered a limitation. The participants in our study had several years of experiences working in different health care areas, which contributed to rich data. Our study did not have any data saturation limit, which is consistent with Thorne (2016), who highlighted the over‐reliance on the notion of saturation in qualitative studies.

This study used group interviews for data generation, which method has some limitations; for example, shy people who dislike talking to a group may not participate for that reason. During the group interviews, the participants were asked to give concrete examples of nursing situations, but not everyone took the opportunity to do this. Attempts were also made to include RNs from primary care, but without success, which should be considered a limitation. Similar to nurses from pre‐hospital care, RNs in primary care work closely with the public and have insight into people's everyday lives, which may influence their thoughts about how societal changes affect nursing practice and influence and the possibility to be in close proximity to the patient. Lastly, this study includes just a few participants from home care, which could be seen as another limitation. For future studies, it is important to deepen the knowledge around terms and conditions in primary and home care, especially during and after the reorganisation of healthcare systems.

6. CONCLUSION

This paper offers several insights into what RNs view as essential characteristics of current nursing practice. The RNs described striving to work in close proximity to the patient, but reported that several factors hinder this in reality. Their role in practice was described as broad and as including a comprehensive responsibility involving also moral responsibility. Ambiguous boundaries with the work of other actors in the health care team can contribute to the fact that nursing practice is not clearly understood and acknowledged by nurses and others, creating barriers. A holistic perspective (albeit not fully defined by the participants) recognising the patients’ unique needs was considered important and was generally seen to pervade nurses’ practical work although this varied depending on the context. Nursing practice was viewed as a multifaceted field and the participants struggled to define nursing but were able to easily describe it using concrete examples. Some participants emphasised that nursing practice should evolve as society is changing. Based on our findings, future studies should reflect an interprofessional practice of trying to better understand each health care professional's expertise. Studies from primary care and home care are also needed to broaden the understanding of nursing practice.

Lundin Gurné F, Lidén E, Jakobsson Ung E, Kirkevold M, Öhlén J, Jakobsson S. Striving to be in close proximity to the patient: An interpretive descriptive study of nursing practice from the perspectives of clinically experienced registered nurses. Nurs Inq. 2021;28:e12387. 10.1111/nin.12387