Nurse leader agency: Creating an environment conducive to support for graduate nurses

Aim: The aim of the study was to gain insight on how nurse leaders manage a culture of safety for graduate nurses. Background: Current theoretical approaches to safety culture tend towards a checklist approach that focusses on institutional characteristics, failing to examine the quality of interpersonal relationships. These interpersonal interactions are often seen as separate from the institutional realities of resource allocation, nurse-patient ratios, patient acuity or throughput. A theoretical approach is required to illuminate the dialectic between the structure of an organisation and the agency created by nurse leaders to promote patient safety. Design: Qualitative exploratory descriptive study. Methods: Semi-structured interviews were undertaken with 24 nurse leaders from hospital and aged care settings. Thematic analysis and Giddens structuration theory was used to describe the findings. Results: Nurse leaders identified a range of reciprocal communicative and cultural norms and values, decision-making processes, personal nursing philosophies, strategies and operational procedures to foster patient safety and mentor graduate nurses. The mentoring of graduate nurses included fostering critical thinking, building and affirming formal structural practices such as handover, teamwork, medication protocols, and care plans. Conclusions: The study provides insight into how nurse leaders foster a culture of safety. Emphasis is placed on how agency in nurse leaders creates an environment conducive to learning and support for graduate nurses. Implications for Nursing Management: Nurse leadership functions and decision-making capacity hinges on multiple factors including practicing agency and aspects of the social structure such as the rules for safe communication, and the various institutional protocols. Nurse leaders enforce these forms of engagement and practice through their legitimation as leaders. They have both allocative and authoritative resources; they can command resources, direct staff to attend to patients and/or clinical tasks, mentor, guide, assign, correct, and encourage with the authority vested in them by the formal structure of the organisation. In doing so, they sustain the structure and reinforce it.