Exploring the complex realities of nursing work in Kenya and how this shapes role enactment and practice—A qualitative study

Abstract Aim We explore how nurses navigate competing work demands in resource‐constrained settings and how this shapes the enactment of nursing roles. Design An exploratory‐descriptive qualitative study. Methods Using individual in‐depth interviews and small group interviews, we interviewed 47 purposively selected nurses and nurse managers. We also conducted 57 hours of non‐participant structured observations of nursing work in three public hospitals. Results Three major themes arose: (i) Rationalization of prioritization decisions, where nurses described prioritizing technical nursing tasks over routine bedside care, coming up with their own ‘working standards’ of care and nurses informally delegating tasks to cope with work demands. (ii) Bundling of tasks describes how nurses were sometimes engaged in tasks seen to be out of their scope of work or sometimes being used to fill for other professional shortages. (iii) Pursuit of professional ideals describes how the reality of how nursing was practised was seen to be in contrast with nurses' quest for professionalism.


| INTRODUC TI ON
There is a growing attention towards nursing roles in the contemporary healthcare setting, with debates about nursing roles and why nurses struggle to meet their professional standards (Harvey et al., 2020;Mantovan et al., 2020). The dilemmas and struggles nurses face in meeting individual patient care needs and consequent failure to meet their professional expectations of care are well documented Mbuthia et al., 2021). Nursing in resource-constrained settings is typified by daunting working conditions characterized by high workloads to inadequate resources, high nurse-to-patient ratios, poor physical infrastructure and inadequate supplies Strong, 2017). This, coupled with lack of role clarity and minimal emotional support means that nurses face even more dilemmas and challenges in operationalizing professional ideals of optimal patient care (Harvey et al., 2020;Kruk et al., 2018).
Further, nurses often find themselves burdened with nonnursing duties including administrative tasks, transporting patients and housekeeping duties which take them away from specific nursing duties (Grosso et al., 2019;Mantovan et al., 2020;Netshisaulu et al., 2019). Cumulatively, these have been shown to contribute to 'missed care' where fundamental aspects of nursing work are delayed or neglected as nurses grapple with competing work demands and this may result to a compromise in the quality and safety of patients (Ball et al., 2018;See et al., 2020). Relatedly, intensification of nursing work is also related to a phenomenon described as 'busyness'involving nursing tasks being performed in a hectic manner with the aim of task completion, leading to a task-based nursing approach to care over knowledge-based care (Govasli & Solvoll, 2020;Safazadeh et al., 2018) and this has been shown to limiting the provision of holistic patient care (Cho et al., 2020;Harvey et al., 2020;Nzinga et al., 2019). Despite these evidence on the practical limitations of performing nursing, the training and socialization of nurses into the profession continue to be characterized by incongruence between how nursing is taught and how it is actually applied in practice (Kerthu & Nuuyoma, 2019) and studies have shown that this theorypractice gap is problematic, not just for students but also qualified nurses (Greenway et al., 2019;Salifu et al., 2019).

| Nursing context in Kenya
Nursing training in Kenya is offered in three entry levels; certificate, diploma and degree, as well as specializations offered in higher diploma, masters and PhD levels. To improve the status of nursing as a profession, the Nursing Council of Kenya (NCK) has been making efforts to advance nurses training in Kenya, with fewer certificate programmes being offered in favour of diploma and degree in nursing. Kenya has also been scaling up training of nurses; the NCK which regulates nursing training reports there are 121 accredited nursing/midwifery training institutions in Kenya (Nursing Council of Kenya, 2022). Paradoxically, this has also coexisted with nursing staffing shortages, especially in public hospitals, with nursing densities varying from 9.7 per 10,000 population in Nairobi to as low as 0.1 per 10,000 population in Mandera county (Ministry of Health, 2015). Under a devolved system of government in Kenya, health was devolved to be managed at the county level. The national government allocates block grants to the county governments, who decide how these finances are appropriated . Therefore, huge disparities exist on the available human resources for health across the counties. Despite NCK efforts to come up with a nursing scope of practice and efforts to mainstream the nursing process, reduced hospital autonomy in financial management, hospital administration, procurement and human resource management functions post-devolution, remain a challenge in implementation (Barasa et al., 2017;Wagoro & Rakuom, 2015).
The country has made several advancements aimed at transforming and professionalizing nursing, with increased investments in both expanding nursing training and developing a professional scope of practice for nurses (Nursing Council of Kenya, 2020).
Additionally, to bridge theory-practice gap and to offer a scientific and systematic approach to deliver high-quality patient-centred care, the Kenya-Nursing process was operationalized in public hospitals and incorporated in the training curricula for nurses, the framework for nursing care and the nurses' scheme of service (Mangare et al., 2016;Wagoro & Rakuom, 2015). While nurses have embraced the implementation of the nursing process, failures in implementation have been associated with negative attitudes and lack of support for the nursing process by senior nurse managers, chronic staffing shortages as well as financial restrictions (Lotfi et al., 2020;Mwangi et al., 2019;Rakuom et al., 2016;Wagoro & Rakuom, 2015).
Nonetheless, Kenyan nurses still struggle to provide the appropriate care and practise to the full extent of their training and education due to staffing shortages and huge workloads Gathara et al., 2020). Further, the practice of nursing care to full capacity depends on conducive work environments where nurses have the liberty to make fundamental decisions and autonomous clinical actions (Rakuom et al., 2016). Our study therefore sought to explore how nurses navigate competing work demands in resource-constrained settings and how this shapes the enactment of nursing roles.

| Study design
This was an exploratory-descriptive qualitative research study. This design was appropriately selected as it allowed the researchers to explore and contextualize how nurses enacted their roles within resource-constrained county referral hospitals but also provided a picture of what happens in inpatient care settings.

| Study setting and study participants
The Kenyan Health system is organized as illustrated in Figure 1.
The study was conducted in three purposively selected county referral hospitals offering inpatient, outpatient care and referral care according to the Kenya Essential Health Package guidelines illustrated in Figure 1. The hospitals were purposively sampled to capture variation in terms of size and bed capacity, health workforce size, universal health coverage (UHC) implementation status and geographical locations (serving different urban/peri-urban and rural areas, Table 1).
Participants were purposively selected based on their work experience (ranging 1-over 20 years' experience), different areas of specialization, gender, varying ages and professional designation based on grades, that is, nurse managers (ward in-charges) and frontline nurses (junior nurses) and national level nurse managers to ensure diversity (see Table 2 for more details). National level nurse managers were purposively selected to offer expert advice on experience in nursing workforce planning and management, and experience in developing and implementing nursing policies in the country.
A total of 47 participants participated in in-depth interviews [IDIs] and three small group interviews of three frontline nurses each.
Small group interviews were adopted to enable more detailed exchange regarding the topic, allowing multiple insights and addressing any emerging disagreements. To complement data from the IDIs and small group interviews, we conducted 57 h of non-participant structured observationinvolving observing participants without actively participatingacross the three counties, but exclusively in County C as we felt we had reached point of data saturation from IDIs and group discussions from the first two hospitals. Given that data collection and analysis were undertaken iteratively, theoretical saturation was achieved before entry to hospital C. However, to capture the contextual variation, we exclusively conducted structured observations in Hospital C mainly to provide a more detailed view of emerging findings using an observation guide similar to the interview guides adopted in Hospital A & B and complemented by informal conversations with the nurses. We observed the nurses and the managers in their natural setting as they conducted various nursing tasks ranging from routine provision of care, ward rounds, handovers, ward meetings and during social interactions, for example, tea breaks.
The events observed were recorded as field notes and the informal conversations were used to reflect on ongoing analysis.

| Data analysis
DM & JN developed interview summaries after each interview to familiarize themselves with the emerging data. The audio data were then transcribed verbatim and together with the field notes imported into NVIVO 12 qualitative software for data management.
The data were then inductively coded adopting aspects of grounded theory approach which encompassed concurrent data collection and analysis (Corbin & Strauss, 1990). Open codes from the initial coding were compared and then grouped into themes in an iterative process involving data collection and analysis. The emergent themes were used to revise data collection tools for subsequent data collection, and in making comparison between the emergent themes and the new data as described by Corbin & Strauss (1990). These comparisons informed the second level of coding which involved developing more interpretive higher-level themes by grouping together smaller themes into bigger themes and comparing the relationship between the themes in a process of selective coding in order to explain and make sense of the phenomenon under study. For instance, minor themes like prioritizing tasks, missed care, triaging patients and delegating tasks were all grouped under rationalization of prioritization decisions.

| Trustworthiness
Several techniques were used to ensure trustworthiness by implementing a criterion of measures for ensuring credibility, dependability, confirmability and transferability (Connelly, 2016).
Credibility was achieved by using more than one method of data collection. Additionally, two researchers debriefed after the interviews and developed interview summaries. Two researchers TA B L E 1 Below describes the selection criteria for each of the study sites.

Study site Selection criteria
County A referral hospital Pilot site for universal health coverage (UHC) and thus with advanced coverage of the UHC benefit package among its population (Muinde & Prince, 2022) Serves urban population Also, logistically convenient as near Nairobi where national level stakeholders are based and also the operational base of the researchers thus allowing collection of observational data.

Staffing: 199 nurses
Bed capacity: 430 beds independently coded the initial interview data and agreed on a coding framework, from which emergent themes and categories were developed. Subthemes, themes and categories were reviewed and discussed during research team meetings and disagreements discussed until consensus reached Confirmability was achieved by ensuring that the results are supported by direct quotes from participants. By outlining a step-by-step procedure for data collection and analysis, the researchers were able to establish dependability and make their work replicable. Transferability was ensured by sampling participants with diverse characteristics.

| Study participants
A total of 47 nurses participated in this study. The table below shows the distribution of the study participants.
We present the results of this study under in three thematic areas ('Rationalization of prioritization decisions', 'Bundling of tasks' and 'Pursuit of professional ideals') as depicted in Table 3.  (3), Senior managers at Nursing Council of Kenya charged with regulatory oversight of nursing education and practice in the county (2) Nurse managers at National Nurses Association of Kenya which represents the professional and social well-being of all nurses (2)] As nurses strive to achieve completion of 'core' and 'indispensable' tasks, minimal time is allocated to caring works and communicating with patients thus impacting on nurse-patient relationship.

| Rationalization of prioritization decisions
Nurses described working in a hurry and using strategies to mini- These improvisations were so deeply internalized that it impacted on how students are mentored and socialized into the profession. We observed how common it was for nurses to use students to cover the wider staffing deficits. In one of the hospitals (County C), senior students were paired to work with, and train the less experienced students, without supervision and mentorship of qualified nurses.
By now some students are already in the acute room with the medicine trolley and they have begun giving treatment. I notice that they are working alone, unsupervised, as they dilute and give injections… The in charge would occasionally look over from afar to observe as the students continued working. At some point during the ward round, the in charge left and went over to supervise a student who putting a patient through an IV treatment before returning back to the ward round. The other students continue going round giving treatment while unsupervised.

[Observation Notes, County C]
This raised concern among senior nurse managers about training and mentorship of students unconsciously perpetuating negative socialization into the profession of new nurses.
"Even the ones we are training may not reach that standard… they're used to seeing short cuts and many other things that are done wrongly… If a student think feeding a patient through an NG (Nasogastric) tube is a relative's procedure, then that's what they'll do and practise. So, in many years to come we will not have a nurse, we will just have quacks.

| Pursuit of profession ideals
In response to the challenges of practising nursing work, participants spoke on how ongoing tremendous changes in nursing practice in Kenya were helpful in seeking to establish nursing as an independent profession away from the long-held view of nursing as doctors' handmaiden.
"People are going back to school, they are investing much in their education, and also the patient has developed that trust with a nurse, and also it has become its own profession rather being a doctor's assistant." [Frontline Nurse_014,County B] At the core of this were advancements in nursing education and entry standards contributing to nursing 'professionalizing' and acquiring status as an independent profession with its body of knowledge.
These changes were associated with a calling for proficient application of knowledge in nursing practice in order to influence patient outcomes. Participants also described this as the shortcoming of the nursing profession-that nursing remains task oriented, failing to exert its body of knowledge in practice, describing this as the weakest link, especially when care is not planned and evaluated.
"…that is the weakest point in nursing, most of them just work on impulse, they don't plan for care, they In sum, we describe the advancements in nursing profession in Kenya, highlighting a move towards 'professionalization' in nursing. We also highlight the tensions between the forward-looking direction that nursing aspires to in practising their ideals versus how nursing is practised in reality.  (Nzinga et al., 2019;Richards & Borglin, 2019). As such, nurses in our study adopted strategies such as deterring services by blocking interruptions or requests from patients, which allowed them to manage competing work demands and priorities and thus giving them a sense of control over their work. Elsewhere, nurses have also been shown to adopt strategies such as reducing the quality of planned nursing care so as to manage their time and stick to their routine (Mantovan et al., 2020) and this may ultimately contribute to depersonalization and role incongruity (Harvey et al., 2020).

| DISCUSS ION
Managing competing work demands forced nurses in our study to engage in inappropriate task shifting. Nurses used relatives or nursing students as sources of support and sometimes assigned them nursing and caring tasks such as giving medication and doing observations, which in turn allowed them time to concentrate on other patients or more technical tasks (Fitzgerald et al., 2020;McKnight et al., 2020;Nzinga et al., 2019). This however raised concerns about patient safety, the image and confidence of the profession and reinforced normalization of these practical norms which negatively impacted on the mentorship and socialization of students.
These pragmatic micro-choices of organizing care within demanding workloads consequently become the new norm of how care is delivered, sometimes in contravention of official care guidelines (Mbuthia et al., 2021;Olivier de Sardan et al., 2017).
Further, strategies adopted to cope with work demands included intensification of work, with priorities often being set towards task completion. This undermined nurses' capacity to plan and evaluate nursing care plans as idealized and further limited time dedicated to train and mentor students (Foolchand & Maritz, 2020). While delegating tasks to students and patients' relatives ensured productivity, in the long term, this may undermine application of nursing expertise in care, as care follows a particular routine and thus becomes taskbased, with care taking priority over student education. Studies have shown that routine-based approach to care limits students' application of theoretical knowledge in practice as they tend to emulate how experienced nurses practise, contributing to theory-practice gap (Safazadeh et al., 2018).
While the nursing process provides for a systematic and rational method for nurses to plan and provide individualized care, in practice, nurses were unable to fully execute the nursing process. Our work revealed that the implementation of task-oriented nursing activities took precedence, thus undermining other critical steps (assessment, diagnosis, planning and evaluation) in the care process where the knowledge and expertise of nurses are needed even more. Without proper guidelines, decisions to prioritize and ration care remain largely at the nurses' intuition and discretion rather than through analytic or logic processes (Mantovan et al., 2020;McKnight et al., 2020). This is potentially dangerous and discriminatory to patients as well as morally burdensome to nurses (Scott et al., 2019). Our findings illustrate how failure to meet these professional standards resulted in nurses creating their own implicit 'working standards'. These standards consequently shaped both the identity of the nursing care profession and how nursing care is practically delivered. Furthermore, unregulated task shifting as a coping mechanism for health worker shortages often took nurses away from their 'core' nursing tasks ( With nursing in Kenya undergoing professionalization and seeking to establish itself as an independent vocation, the challenges in transferring knowledge as taught in nursing education and the bridging practice gap remains (Rakuom et al., 2016). To address some of these challenges, advancements like the mainstreaming of the Kenya nursing process and revision of the nursing scope of practice remain constrained by limited financing, lack of support from senior nurse management and poor work environment (Nursing Council of Kenya, 2020; Rakuom et al., 2016;Wagoro & Rakuom, 2015).
Consequently, nursing practice remains routine based (Nzinga et al., 2019) and this undermines nurses' application of their expertise and evidence-based practice into everyday nursing practice and limits the transfer of this expertise to nursing students.
To bridge the knowledge-practice gap, there is need for change in culture where the nursing process is not only taught in the classroom settings, but also in the clinical areas, and should serve as the benchmark for evaluating nursing practice (Rakuom et al., 2016). We recommend the development of explicit nursing standards and care guidelines that are context specific to guide nursing practice and to serve as the basis for audits and quality evaluation. Such standards should not only serve to improve professionalism, but also serve as the basis for informing decisions on staffing levels. Further, at the policy level, urgent action is needed to address nursing staffing deficits and the implications on care rationing, patient safety, quality of care and theory-practice gap, hence urgent need for increased investment in nursing staffing. At the micro level, especially in settings faced with severe shortage of nursing staff, there is need for supporting guidelines and explicit principles to aid nurses with care rationing decisions rather than care rationing being left to nurses' intuitions, decision making skills, personal feelings, or beliefs. Nurse managers also play a critical role in implementing necessary reforms geared towards quality improvements and thus have a duty to inculcate a culture of holistic care provision and caring attitude as well as training nurses on the nursing process.

| Limitations
Our study was conducted in only three county hospitals in Kenya; therefore, the results of this study may not be generalizable to the rest of the population. Additionally, since the study was conducted in county referral hospitals, the experiences of nurses working in these contexts may be more extreme than those working in wellresourced national hospitals or even lower-level county hospitals.

| CON CLUS ION
Our findings highlight how nurses construct their roles in constrained work contexts by focusing on the must do technical tasks over bedside caring roles, rationing care and coming up with their own 'working standards' of care in a bid to ensure continuity of care.
We argue that without improving the working conditions of nurses and ensuring adequate staffing, nurses struggle to bring in their wealth of knowledge into practice, hence nursing work remains constructed around routines and ensuring task completion thus creating tensions with the forward-looking direction that the profession is pursing. To implement their professional expertise, there is urgent need to cultivate organization cultures where evidence-based nursing is supported, professional identities respected and collaborative multi-disciplinary working facilitated. All the authors contributed equally to this editorial.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors declare that they have no conflicts of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author through KEMRI Data Governance Committee. The data are not publicly available due to privacy or ethical restrictions.

E TH I C S S TATEM ENT
This study was approved by Kenya Medical Research Institute ethics review committee (Approval NO: KEMRI/RES/7/3/1) and written informed consent was obtained from all participants.