Promoting the application of policy documents by nursing and midwifery staff at the point of care: a mixed-methods study.

Introduction: Policy application is essential for normative integration, as the point of care represents the practical meeting point of healthcare priorities common to organisations, professional groups and individuals. Nursing and midwifery staff are the largest component of the healthcare workforce internationally and occupy the point of care. This presents a unique position from which to inform and influence policy development and application to balance organisational and professional priorities with the needs of patients and carers. The aim of this research was to understand current practices and barriers impacting policy application by nursing and midwifery staff at the point of care, and identify strategies which mitigate those barriers.

Methods: The research was conducted in Liverpool Hospital and Campbelltown Hospital in Sydney, Australia. An explanatory, sequential mixed-methods design was employed. Fifty completed responses of an online survey were received and analysed to determine current practices and barriers impacting policy application. Two focus group discussions were conducted to explain the survey data collected and identify potential strategies to mitigate the barriers identified. Each group comprised seven participants, representing frontline nursing and midwifery staff and healthcare professionals involved in policy development.

Results: While 72% of survey respondents believe policy documents should always be applied, 53% have knowingly deviated from policy requirements. Organisational barriers significantly impact both the relevance and accessibility of policy documents for frontline staff, leading to deviation from requirements. Insufficient mechanisms are in place to enable frontline staff to engage in policy development and review.

Discussion: Frontline discretion of policy application reaffirms the role of nursing and midwifery staff in policy implementation. Focus group participants agreed that causal factors impacting policy application were largely organisational rather than behavioural. Organisational barriers negatively impact normative integration by impeding standardised practice and fostering a culture of discretion. Insufficient frontline consultation during policy development creates a distance between values and impedes the development and maintenance of a common frame of reference in integrated care.

Conclusions: Nursing and midwifery staff discretion at the point of care negatively impacts normative integration by creating a distance between professional values and impeding the maintenance of a common frame of reference. Nursing and midwifery staff are willing to apply policy documents when accessible and relevant to their professional duties, but current policy development processes are not meeting frontline needs. Current behavioural factors impacting policy application are reactive to causal organisational barriers. Implementation of strategies to ensure policy documents are accessible and relevant to frontline care would align values, standardise clinical practice and facilitate normative integration.

Lessons learned: Policy documents neither include sufficient consideration of frontline challenges nor represent current, evidence-based practice. Improved mechanisms are needed for frontline staff to engage in policy development to maintain relevance, promote policy application and enable normative integration.

Limitations: This study was limited to nursing and midwifery staff of Liverpool and Campbelltown Hospitals who either occupy the point of care or develop policy documents.

Suggestions for future research: Future research may investigate how organisational barriers impact normative integration in a wider study to determine generalisability.