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

Abstract 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 focuses 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.

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.
agency, graduate nurses, nurse leaders, patient safety, structuration theory, structure 1 | INTRODUCTION This paper explores the way in which nurse leaders (NLs) actively pursue patient safety through strategic interactions with graduate nurses (GNs). In particular, NL mentorship at the ward level is important in fostering good work ethics, maintaining staff motivation and overall supportive and collegial workplace habits. In this paper, we present an overview of how the culture in nursing impacts patient safety. We introduce Giddens (1984) theory of structuration as a way of understanding how NLs at the ward level consciously practice creating a culture of safety with GNs. Additionally, we demonstrate how NLs exercise their agency through mentoring GNs and foster a culture of support conducive to patient safety.
2 | LITERATURE REVIEW 2.1 | Nurse role in patient safety management Nurses are viewed as the 'safety nets', overseeing various practices of patient care and related safety practices. They engage in prolonged periods of direct patient care and are considered pivotal to preventing errors (Rosén et al., 2017). Nonetheless, it is widely acknowledged that safe nursing practice can be challenged by inappropriate staffing levels (Twigg et al., 2015), increased patient load, complexity of care and constrained timeframes (Duffield et al., 2011). According to Johnstone et al. (2008), the multi-faceted nursing role predisposes nurses to making preventable errors, thereby threatening quality of care and overall patient safety (Johnstone et al., 2008). In particular, GNs are at higher risk and vulnerable to errors due to their lack of experience in managing competing priorities and the complex workload. Documented evidence of the challenges faced by GNs includes the ability to handle an intense work environment (Regan et al., 2017), utilization of advanced medical technology (Orbaek et al., 2015) and management of high patient acuity (Duclos-Miller, 2011).
Of concern, GNs have been found to be largely uncomfortable in approaching senior nurse colleagues for support (Sahay & Willis, 2021). GNs have identified their need for support through effective mentorship (Laschinger et al., 2010) and rely on more experienced nursing colleagues for guidance (Sahay et al., 2015). Nevertheless, some studies indicate that GNs do not seek support from other nurses if the colleague's behaviour is not conducive to learning (Laschinger et al., 2010;Sahay & Willis, 2021). This is where the NL role becomes paramount in fostering a culture of support and collaboration.

| Influence of unit-level nurse leadership on patient safety
Leaders proficient in effectively implementing a culture of safety are known to create a context where safety concerns are constantly discussed. Leader commitment and engagement in safety actions reinforces nurses' adherence to safety protocols while heightening an overall sense of safety for patients, colleagues and self. There is also evidence that NL commitment towards safety initiatives increases reporting of errors and incidents by nurses, thereby, increasing opportunities to learn and develop 'error wisdom', which refers to knowledge gained from errors (Reason, 2004, p. ii32). This aligns with the clinical governance framework, which suggests that NLs who foster an environment of support and a 'just culture', enable the delivery of safe clinical care. To gain an understanding of the underpinning principles behind a NL's actions, we have adopted Giddens's (1984) structuration theory as it allows exploration between the individual NL's decision making, the culture created and the structure of the organisation.

| Structure within the structuration theory
The evaluation of the many organisational changes in hospitals and health services attest to the gap between functionalist notions of structure and the ethnomethodological realities of everyday interactions. A social system exists within these structures as it is reproduced over time through the practices of its agents/individuals and groups (Mustafa & Mische, 1998). Giddens describes the 'social system as having three dimensions: signification, domination and legitimation, that in turn reflect three forms of interaction: communication, exercise of power and sanction' (Whittington, 2015, p. 148). Signification denotes the rules governing communication, and legitimation, the formal and informal rules and legal requirements of interaction. Domination depends on both allocative and authoritative resources.
Allocative resource capacity refers to objects and materials, while authoritative denotes command over individuals. Both allocative and authoritative resources are reproduced through agency: the first in practical ways through material production and the second within the social space where humans come together in actions of production, and service. It is within the authoritative realm that humans form groups and associations, and also where their position influences their life chances (Giddens, 1984). These forms of interactions and dimensions are not mutually exclusive; for example, the legitimation of the position of nurse manager speaks to their power and to the forms of communication they engage in, including the significance of their discourse (Whittington, 2015).
In Giddens's framework, structure is the various practices, behaviours, rules and norms that individuals operate under. It does include institutions such as the family, the legal or education system, but Giddens focuses more on the rules and patterns of everyday life (virtual) that create social structures, than the institutions themselves that provide the framework for behaviour (Braithwaite, 2006). Giddens proposes that structure and agency are co-dependent; that in effect the practices of the agent create the structure. One does not exist without the other. It is the agency of the various individuals that creates structure as they act upon the world. The structure of a society and its agents are in interaction with each other; they only exist because of the other, although they also exist independently. Individuals can think, reflect and act independently of a social structure, but what they think and do is a reflection in one way or another of the mutual dependence on the structure.

| Agency and structuration theory
The important starting point for understanding agency is in its reflexive capacity. Giddens refers to the intentional and purposeful direction of human behaviour as constituting agency. He distinguishes this act of agency from unintentional acts, arguing that agency is practiced when the actor is fully conscious, has a sense of what the outcome will be and that it is not a spontaneous or habitual action (Eteläpelto et al., 2013).
In order to elaborate on this purposeful action of the agent, Giddens makes a distinction between the concepts of discursive consciousness; practical consciousness; and unconscious motives/ cognition (Giddens, 1984;Mustafa & Mische, 1998 understanding of why they are done, but clearly motivated by aspects of our social world and socialization. This is outlined in Figure 1. Reflexivity operates mainly at the level of discursive and practical consciousness and is often articulated in hindsight (Braithwaite, 2006) or based on experience or practical evaluation of past situations. It is the deliberate decision making about the appropriate course of action, even when the individual knows the evidence to be flimsy (Mustafa & Mische, 1998), or within the framework of trust based on ontological security (Giddens, 1990).
Giddens identifies that agency operates at the level of practical consciousness, as it is a cognitive exercise that leads us to reflect on why we do what we do, to think it through. These discursive and practical conscious acts are bound by the structures within which we operate. Our reflections follow the cultural and social rules of our particular time and place, which can be loosely defined as culture. The structure is bound by a particular time and space, given it is constituted by agents acting reflexivity. As Giddens notes, 'All human action is carried on by knowledgeable agents who both construct the social world through their action, but yet whose action is also conditioned and constrained by the very world of their creation' (Giddens, 1981, p. 54). In arguing for intentional action, Giddens is clear that the individual must have the power both in terms of authority and resources to bring about the action; intention or knowledge of typification or schema is not agency. It requires action and an awareness that this is what we are doing, even when done under duress (Eteläpelto et al., 2013).

| Culture, structure and agency
We can further understand the duality of agency and structure by reflecting on the place of culture within the framework. The practices performed by the agents-individuals constitute the given culture of an organisation. The patterned form of interactions is of cultural practice.
It includes the way we talk, act, or what is espoused. Braithwaite notes organisational culture is 'the way things are done around here' (page 97). In order for society to operate and function, there is a shared understanding of many of the practices, beliefs and norms. It is not simply a duality between one individual acting upon the social that creates the structure, but many individuals with a shared understanding of the norms, values and practices that create the structural component of Giddens's agency structure including the culture.

| Agency and identity
The interpretation the individual agent assigns to these cultural norms, values, symbols, beliefs and practices and how they respond to them builds up and reflects their identity. Without it there would be no redemption, personal change or self-improvement. It is our selfconcept or identity that shapes our intentional actions, but they in turn are influenced in concert with social change. How individual NLs support their team and mentor GNs speaks to their agency, the culture they create on the ward and their own sense of identity as a leader.

| METHODS
Data presented here is from a larger study. The aim of the study was to gain insight on how NLs managed a culture of safety for GNs.
Ethics approval was sought from a large hospital and health service and an academic institution. Data were gathered by the first author through a series of interviews with 24 NLs in Australia. The NLs were purposively selected and interviewed in a venue of their choice between May 2016 and June 2017. They were invited to engage in the study through responding to advertisements posted across several hospitals in Victoria (Australia) and in local libraries, and/or snowball approach. The interview schedule asked NLs to reflect on how they supported GNs to provide safe and quality patient care. The interviews were collected till data saturation, with member checking occurring with the NLs through a process of identifying themes. Table 1 provides the demographic details of the NLs.

| Analysis
The methods used in this paper are limited to an analysis of what these NLs said they did, rather than to what their practice was. In taking this approach, we have examined the interviews and used Braun and Clarke's (2012) six step guide to thematically draw on the concept of agency and its duality with structure. This has allowed us to take note of the words used, the norms espoused and the practices sanctioned. The interviews were examined to answer three questions about the NL's agency. These were as follows: The process of analysis involved reading the interviews with the three questions in mind for relevant responses and surrounding textual material. This was done in two stages with the first author organising the interview quotes into generalized themes, and the second author linked them to the research questions noted above. This approach mirrors template analysis where the researcher reads the data with a specific theoretical framework in mind and searches the text for confirmation (Waring & Wainwright, 2008). The pathway does not exhaust the data, or necessarily capture all there is to say about the context. Rather it identifies one of the salient features within the data and illustrates the theoretical links (King, 2004 Feedback can be given in various ways, and be viewed as positive, constructive and/or negative. However, the way feedback is perceived or interpreted could also play a role in how it is processed. The data indicate the quality of feedback impacts on GN confidence, competence and patient safety outcomes. 4.3 | Theme two: Enhancing structure through sanctioning official practices As Giddens (1984) argues the decisions or agency of the individual finds expression in practice. The decisions made by NLs must be made concrete at the ward level in how handover or the medication rounds are conducted, and what pathways and protocols are followed. The discussion below reflects on how NLs created teams and how they used the structure of handover to make concrete the norms and values they wished to enforce in the interest of patient safety. Therefore, answering the question: How were these actions linked to structure and culture?

| Working as a team to improve patient care
NLs explained that interactions improve when nurses accepted each other as equals and there is clarity about team member roles: [Teamwork is] about engaging with each other and seeing each other as equals and understanding that we all have a role to play … If we lack that cohesiveness and collaboration, then it impacts on patient outcomes (NL 12).
However, NLs recognized that working as a team can sometimes present challenges, due to the multiple personalities that make-up a team. They noted that some nurses work well together, while others struggle to collaborate and interact with one another: When nurses are unable to settle their differences, then it makes people work in isolation, and you cannot do that.
Nurses do not discuss and clarify things with one another, and that's when mistakes happen. You need to work as a team and stay professional even if you reserve less favorable thoughts for your team members (NL 1).
Another NL emphasized the importance of appropriately matching and/or pairing team members to increase collegiality and team efficiency.
If I put three disinterested people in a pod, the care level would be 50%; the documentation would not be up to scratch … the interactions will be poor. Pairing them with a stronger team member I find will get them to step-up a level … You tend to find that's when a team comes together. It's being able to identify where to place someone in the unit so that it is a cohesive group (NL 18).
NLs also referred to constant interruptions during verbal handovers as another factor that affects the quality of nurse-to-nurse interactions. This subsequently impacts on the quality and type of information transferred, thereby resulting in omission of vital patient information. The data revealed that interruptions during handover were caused by two factors: environmental factors (e.g., patient discharges, phone calls, family concerns and new patient admissions,); and incoming nurse receiving the handover.
NLs reported that interruptions influenced by the ward environment were detrimental to the complete transfer of patient care information. This consequently resulted in the omission of information, such as planning to undertake blood tests and administration of antibiotics and other medications: When the handover time is interrupted from the environ- A careful reading of the NL comments also provides an analysis of the culture of safety required on any ward where there are GNs.
These NLs, exhibit discursive consciousness in what they say they do, and how they build up the culture of the ward or unit, in how they mentor GNs, encourage teamwork, or guard against routine habituated practice (Mustafa & Mische, 1998). In many ways much of this will have become practical consciousness. They may not be able to identify why they do it at the time, but spontaneously act in the interest of the structure of the organisation.

| Limitation
The study was designed to be descriptive. The participants were largely from within one state which makes the study geographically limited. However, participants were from different specialty areas, which enabled the collection of data from a diverse range of nursing settings. Furthermore, as the study aim was examined from the perspective of NLs only, it is not representative of all nurse groups (i.e., nurses at various levels of work experience) or nursing roles. It is possible that perceptions of the impact of nurse-to-nurse interactions on patient safety outcomes may differ among other nurse groups.
Despite these limitations, the study has relevance, and important implications for practice and future research initiatives.

| CONCLUSION
In this article we have outlined the agency of NLs as they manage mentoring of GNs in order to ensure they develop the necessary critical skills, clinical expertise and time management. These skills are required to ensure patient safety. We demonstrated the way in which these NLs consciously instigate lines of communication with GNs as part of their mentoring. We also demonstrated the way they use their legitimate authority to ensure the various structural practices, such as handover, are adhered too. The very process of interviewing these NLs allowed them to bring to the surface (discursive consciousness) an awareness of how they create and re-create a culture of safety within the ward, while simultaneously mentoring GNs. We also highlighted their awareness of practical consciousness acts which are routine and lie somewhere between consciousness and the habitual.
We have suggested that unconscious actions, while not always accorded agency, do arise from the individual's orientation or socialization and for that reason have currency. Importantly, the paper points to the fact that patient safety goes beyond the number of staff allocated to a shift, or the material resources available. It extends to the very culture of a ward or hospital, and to the interactions between nurses, doctors and other health staff. How these interactions play out, how they contribute to the expertise of junior staff are all matters of patient safety.

| 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. NLs 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.