Recruitment and informants

Informants were nurses employed at four nursing homes in southeast Norway. In Norwegian facility-based care, three types of nursing personnel are present: RNs, health care workers, and health care assistants. RNs hold a bachelor’s degree in nursing, which provides licensure, and the skills needed to lead care for all patients, including those with complex conditions [32]. Health care workers, considered non-RNs here, have completed upper secondary education plus apprenticeship and licensure [33]. Health care assistants, lacks formal health education, and make up about 25% of the nursing workforce [34].

The informants had previously consented to take part in a larger two-part research project. The first part involved structured observations [35], while the current study used a qualitative descriptive design with focused interviews. From 58 eligible nurses (24 RNs and 34 non-RNs), 21 RNs and 10 non-RNs were purposefully selected and invited to participate [36]. Reasons for non-participation included time constraints, language barriers, and one withdrawal due to personal reasons. From the recruited nurses, eight RNs and eight non-RNs were selected to form eight dyads. The selection was based on having worked together in the same unit and on the same shift during the structured observations in the first part of the project [36].

Data collection

Data were collected through 16 individual, focused interviews, representing non-dyadic qualitative data [30]. Conducting individual interviews helped to mitigate potential challenges such as dominance by one participant, which can occur in dyadic settings due to differences in social status, confidence, or assertiveness [37]. Interviews were conducted at a mutually agreed time and place, audio-recorded, and demographic/background information was also collected. The interviews centred around two open-ended questions:

1. “Can you describe your nursing practice in general and in relation to FoC?”
2. “Can you describe your individual and shared scope of nursing practice?”

Probing questions such as “Can you give me an example?”, “Can you explain in more detail?”, and “How did you think, feel, or reflect?” were used to encourage elaboration. All interviews were transcribed verbatim using GDPR-compliant transcription software [38] and secure data storage [39]. Data collection took place between March and June 2024. The average length of the 16 interviews was 52 minutes.

Data analysis

The non-dyadic qualitative interview transcripts were analysed using a dyadic approach informed by the Framework Method. Conducting separate individual interviews (i.e., non-dyadic data) allowed us to perform analysis at both the individual and dyadic levels—an approach not possible with interviews conducted at the same time with both informants (i.e., dyadic qualitative data) [30]. This strategy enabled us to examine contrasts and overlaps between each individual dyad’s perspectives, exploring both the explicit content (text) and implicit meanings (subtext) at descriptive and interpretive levels [40].

The analysis followed eight iterative stages. Stage 1 involved transcription of the interviews, followed by familiarisation with the data (Stage 2). In Stage 3, content relevant to the interview foci was extracted and entered into a structured dyadic coding template. To assess interrater reliability, one dyad was randomly selected. Each author independently extracted quotations in response to interview questions 1 and 2 from the first three pages of the nurses’ interviews. This process yielded a 93.3% agreement rate. In Stage 4, codes were organised into a chart, which informed the analytical process in Stage 5. This stage laid the foundation for developing an analytical framework in Stage 6. The framework was refined iteratively in Stage 7 and then used to guide the interpretation of the data in Stage 8, drawing on insights gathered throughout all preceding stages (Table 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Overview of the process for the framework analysis.

https://doi.org/10.1371/journal.pone.0334124.t001

Stages 1–4 were conducted separately for each professional group. From Stage 5 onwards, codes were compared across professions to identify patterns of similarity and difference both within and between groups. Thematic development and refinement continued iteratively as our familiarity with the data deepened. The authors collaborated closely at each stage, ensuring rigorous and consistent progression through the analytic process.

Ethical considerations

The study received ethical approval from relevant authorities in both Norway and Sweden:

• Regional Committees for Medical and Health Research Ethics, Norway (ID: 691021/2024)
• Norwegian Agency for Shared Services in Education and Research (ID: 524471/2024)
• Research Ethics Committee, Karlstad University, Sweden (ID: C2024/55)
• Swedish Ethical Review Authority (ID: 2024-000586-01)

Informants were recruited between 28 February and 4 June 2024. All informants provided written informed consent after receiving both verbal and written information about the study.

Rigour and reflexivity

All authors are RNs. Four hold academic positions and have extensive experience in clinical and research settings. The first author is a PhD student with no prior detailed experience in the nursing home context; the same applies to two other team members. The remaining two authors possess extensive experience in facility-based care and geriatric nursing. This diverse composition contributed to critical reflection throughout the research process. Regular discussions and reflexive practices ensured that interpretation remained grounded in the informant’s narratives, minimising the impact of preconceptions.

Theme 1: The context of practice

The first mutual theme, “The context of practice,” reflected variations in nurses’ experiences of their general SoP, while also revealing underlying systemic challenges. This theme comprised three key characteristics: duties versus chores, dwindling resources, and environmental challenges. Each of these were interpreted as modulating the nurses’ SoP.

The distinction between duties vs chores highlighted how the nurses experienced their responsibilities differently. RNs reported feeling trapped in a complex organisational system dominated by mandatory administrative obligations. These included tasks related to the nursing home’s internal quality systems, as well as broader municipal and governmental care indicators. They described their responsibilities as representing a “fork in the road”: on one side was their professional duty to ensure high-quality care for residents; on the other, the demands of the system consumed valuable time, creating a sense of frustration and detachment from direct patient care. These obligations were experienced as bureaucratic and exasperating. In contrast, non-RNs referred to their responsibilities as daily “chores.” Although their accounts echoed concerns about time being diverted from care, they focused more on routine operational duties such as maintaining cleanliness, supporting mealtimes, ensuring a well-functioning ward environment, and completing required documentation. This included updating quality indicators and conducting mandatory functional assessments. Despite differing roles and language, the nurses conveyed a shared perception that systemic demands significantly limited their ability to spend meaningful time with residents (S2:1).

The nurses reported that dwindling resources—particularly related to staffing levels and skill mix—negatively affected their SoP. RNs primarily expressed concern about the shortage of RNs and the challenges of working in understaffed units. One RN described the situation starkly: “If everyone breathes at the end of the shift, you are satisfied” (Dyad 1), highlighting the high-pressure environment and reduced capacity to provide comprehensive care. Non-RNs also addressed issues related to staffing, but their concerns encompassed a broader range of factors. In addition to echoing the RNs’ concerns about inadequate staffing and the impact on care quality, non-RNs described the implications of limited budgets, noting how financial constraints restricted staffing flexibility and compromised the overall safety and well-being of residents. Their accounts illustrated a wider perspective on systemic limitations and resource allocation (S2:2).

The theme “context of practice” also highlighted environmental challenges faced by the nurses. While the concerns were similar, non-RNs expressed a broader range of issues. RNs primarily described their SoP as hectic and stressful, marked by time pressure and a constant need to move between tasks. In contrast, non-RNs not only shared these concerns but also reported feeling the additional burden of an overwhelming workload. Their experiences reflected a sense of exhaustion, with many describing the feeling of carrying the entire workload on their own, which contributed to a heightened sense of pressure and fatigue (S2:3).

Theme 2: The Nurses’ professional stance

The theme “the nurses’ professional stance” reflected a mutual understanding in how nurses experienced their general SoP but also highlighted incongruencies in two main characteristics: Professional conduct and professional values vs. working morale, which were interpreted as constituting the theme.

The RNs described their SoP in a way that reflected professional conduct characterized by taking shortcuts, even though they knew how to perform tasks properly and were aware of the expected practices. The reasons they provided for this behaviour included a desire to avoid burnout, lack of time to do things properly, or feeling that they lacked the capacity to do so. One RN from Dyad 1 stated:

“So, you overlook that thing because another thing is more important, in a way. And because you can’t be bothered to fight all the battles all the time. And that you’re a bit lazy. I don’t know.”

In contrast, the Non-RNs expressed a SoP where their professional conduct was in clear incongruence with the RNs’ conduct. The non-RNs emphasized the importance of teamwork, collaborative efforts, and the need to cooperate more, regardless of professional titles. They also highlighted the importance of individual conduct, which included being ethically considerate, empathetic, contributing to a positive working environment, and taking responsibility. Furthermore, they saw it as part of their general SoP to support RNs by easing tasks such as medication management, staying professional in challenging situations, and displaying pride in their work (S2:4).

The theme ‘nurses’ professional stance’ also encompassed experiences related to the nurses’ professional values vs. their working morale. This characteristic was experienced by the nurses in ways that were mutual yet reflected some variation. RNs described a sense of never feeling that their work was good enough, often not feeling like a competent nurse, experiencing guilt, and striving to do their best to get everything done. Non-RNs described experiences similar to RNs, differing mainly in their view of responsibilities. They highlighted concerns about compromised professional values and a care culture they saw as ethically questionable (S2:5).

Theme 3: SoP in relation to Residents’ general care

The mutual theme, ‘SoP in relation to residents’ general care’, highlighted an incongruency across two main characteristics: The whys and the what’s.

The first characteristic, the whys, primarily reflected the RNs’ descriptions of their professional responsibilities, particularly their role. RNs expressed that they were tasked with solving problems on a daily basis, managing the overall daily operation, and ensuring that residents’ needs were met in an adequate manner. Their experience also included responsibilities for prioritizing activities and tasks, as well as transferring accountability—such as delegating tasks to others. RNs noted that they often had to forward unfinished tasks to the next shift. Non-RNs, by contrast, described assisting RNs with minor tasks and spending more direct time with residents—offering emotional support, sitting with them, and holding hands (S2:6).“

The second characteristic, the what’s, predominantly reflected the activities and tasks, or their function, as described by the nurses. These were seen as part of their general SoP within the nursing home context. They described their primary engagement in clinical observations and assessments. Additionally, the non-RNs emphasized their involvement in delivering daily care, such as addressing residents’ physical needs and supporting the maintenance of their functional abilities. They also described activities such as forwarding information to the RNs and updating documentation in residents’ journals as part of their SoP (S2:7).

Theme 4: SoP in relation to the Residents’ FoC

The fourth theme, ‘SoP in relation to the residents’ FoC’, reflected a sense of mutuality between the nurses, yet also revealed substantial variation and some concerns within the single characteristic that constituted this theme: The what’s.

The nurses described their activities and tasks—their what’s, or functional roles—in ways that predominantly focused on residents’ physical needs. For the RNs, their SoP in relation to FoC was described as having a strong somatic focus, with medication management consistently prioritized. In contrast, the non-RNs’ descriptions varied more substantially and demonstrated a broader engagement with the psychosocial and relational dimensions of care. While their activities in the physical domain included assisting with hygiene, dressing, nutrition, and monitoring medication, they also emphasized contributions within the psychosocial and relational domains. These included ensuring residents’ well-being, offering emotional support—such as holding hands, showing compassion, providing comfort and building trust—and involving relatives in the care process (S2:8).

RNs and non-RNs shared a mutual concern regarding the what’s—the activities and tasks—that reflected a significant shift in the nursing home population, with residents now being older and frailer than in previous years. This shift was particularly notable when considered alongside their earlier accounts in the theme ‘The context of practice’, where they described challenges such as inadequate staffing and a lack of appropriate skill mix. These systemic limitations were seen as increasingly problematic in light of the growing number of residents requiring care across all dimensions of the FoC—namely, physical, psychosocial, and relational needs.

Among all identified themes, ‘SoP in relation to the residents’ FoC revealed the largest incongruency between the nurses what’s, i.e., the specific activities and tasks they reported engaging in. (See pattern chart inspired by Waigwa et al., 2018 [41]–Table 3-based on the FoC framework [8,9].

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Pattern chart of interview codes for SoP in relation to the FoC framework [8,9].

https://doi.org/10.1371/journal.pone.0334124.t003

The pattern chart helped visualize that RNs predominantly described their SoP as aligned with the physical dimension of the FoC framework, with medication management being the most frequently reported activity. In contrast, non-RNs described a more varied SoP, encompassing activities and tasks across all three dimensions of the FoC framework—physical, psychosocial, and relational. This variation points to a divergence in care priorities and engagement between the two nursing roles within the same care context.

Theme 5: Notions about each other’s SoP

The theme ‘Notions about each other’s SoP reflected varied and incongruent descriptions, as well as concerns regarding how the nurses experienced and described each other’s SoP. Three overarching characteristics constituted the theme: The ‘other’s’ whys, the ‘other’s’ what’s, and absence vs. presence.

The RNs’ descriptions of the other’s whys—that is, the non-RNs’ responsibilities in relation to their own—reflected concerns related to their own vague and unclear role. They described a struggle to articulate their role, using expressions such as: “it is too difficult to explain,” “the role is unclear,” “there’s a lack of boundary,” or “there is not much difference between us —only medication.” Their experiences also highlighted how limited resources and economic constraints led to task shifting, which further complicated their role. When RNs did describe their responsibilities, it was mainly in terms of having more responsibility overall, such as medication management, maintaining an overview, performing administrative tasks, planning and ordinating care, and conducting more complex or specialised procedures. In contrast, the non-RNs’ descriptions of the other’s whys also reflected difficulty in articulating the RNs’ role, with some suggesting the RNs depended on the non-RNs in practice, while others expressed that non-RNs themselves relied on RNs’ clinical knowledge. There were also descriptions indicating that non-RNs sometimes had to take responsibility for activities outside of their expected role, even though the RNs were still involved in point-of-care activities (S2:9).

Descriptions of the other’s what’s—that is, the activities and tasks performed—also reflected inconsistencies. The RNs predominantly focused on their own SoP, especially the preparatory work surrounding physician visits. They described activities such as preparing cases, managing medication, taking bloodwork, informing about residents’ status, and executing delegated tasks. Some RNs expressed frustration over being assigned to what they perceived as less relevant tasks, and a concern that non-RNs assumed they were only “sitting in front of the computer” rather than actively preparing for physician visits or revising care plans.

The non-RNs’ descriptions of the RNs’ activities mostly aligned with those of the RNs, including involvement in medication management and physician-related preparations. Non-RNs acknowledged that RNs had a greater workload but also noted that RNs were less visible in daily care. When non-RNs described their own activities in relation to the RNs, they emphasised monitoring, documenting, and relaying information to the RNs, as they were more consistently present with the residents (S2:10).

The final characteristic of this theme, absence vs. presence, reflected experiences of physical presence in the ward and closeness to care. RNs described frequently working alone, being less physically present on the units, and having responsibility for many residents—sometimes for an entire unit, or even the whole nursing home during weekends. This limited presence made it difficult for them to engage directly in care. The non-RNs shared similar experiences, describing the RNs as less present during shifts, and more distanced from daily resident interaction.

They also described that RNs often entered the unit only when called and were otherwise mostly absent, reinforcing the view that non-RNs were the ones consistently closest to the residents (S2:11).

Theme 6: Challenges related to the ‘Others’

The final theme, ‘Challenges related to the others’, was identified as a unique theme, emerging solely from the RNs’ experiences. Although this theme was not reflected in the non-RNs’ accounts, it was considered too significant to omit, given its implications for collaborative practice and care quality. The theme centred around one key characteristic: not stronger than our weakest link.

This characteristic described the RNs’ experiences of dependence on non-RNs when accountability was transferred, such as when delegating clinical activities or care responsibilities. RNs described being acutely aware of the varying skills and competencies among non-RNs, which could affect their ability to assess situations and make informed decisions. They also emphasised the importance of trust—trusting non-RNs to monitor residents accurately, to communicate changes clearly, and to complete delegated tasks properly. The RNs highlighted that, in many cases, they were required to rely on non-RNs for key aspects of resident care—particularly given persistent RN shortages—and that this created a vulnerability in the system. One RN expressed this dependence, and the challenges associated with trust in the following way:

“A healthcare worker who has taken a course so that they are allowed to administer medication, you can’t go and check them afterwards, you have to trust that it is done.” (Dyad 2, RN)

The theme also encompassed RNs’ descriptions of how delegation often occurred as a response to understaffing. Activities described as “minor”—such as wound care, basic clinical observations, medication management, and addressing psychosocial and relational needs, were commonly delegated. Some RNs found delegation difficult, noting that certain non-RNs resisted accepting tasks that they perceived as outside their role. These challenges were particularly evident in relation to the organisational context, and sometimes caused frustration for the RNs:

“That’s the problem because... It is also a challenge in terms of management. Because there aren’t many healthcare workers who accept tasks from us... They say that it is not their job. Many say that. ‘Those are nursing tasks. It is not so positive, when we delegate tasks to them, it is challenging…” (Dyad 5, RN)

This theme underscored a critical concern among RNs: although they held ultimate responsibility for resident care, their ability to fulfil this role depended heavily on the skills, cooperation, and willingness of the non-RNs to whom tasks were delegated. This reliance exposed a vulnerability in their scope of practice, as they were “not stronger than the weakest link.”

Methodological considerations

This study followed several methodological strategies to ensure trustworthiness, transferability, dependability, and confirmability [66]. Our recruitment process targeted informants with varied experiences and characteristics across four distinct nursing home settings, leading to a diverse and contextually rich dataset, as intended in a qualitative descriptive design [28]. Although our sample can be considered relatively homogeneous in terms of years of work experience, it is worth noting that three of the RNs and three of the non-RNs had completed additional shorter educational courses. One of the eight RNs had undertaken specialist education, i.e., MSc. However, our analysis did not indicate that these informants differed from the others in terms of the codes or themes identified. The use of focused individual interviews [29] enabled informants to express their views in a more open and flexible manner compared to structured formats. Our decision to collect non-dyadic data – individual focused interviews [29] – additionally reduced the influence of hierarchical power dynamics between the two professions, thereby allowing them to speak more freely and independently about their experiences and perspectives. We analysed the material using the framework method for non-dyadic qualitative data [30,67], which, in opposition to dyadic qualitative data where the interviews are conducted together, allowed us to conduct systematic comparison on both an individual level as well as within and across dyads. Notably, five of the six identified themes reflected distinct yet complementary perspectives from each professional group, emerging consistently across all dyads and sites. This thematic recurrence supports the trustworthiness and theoretical sufficiency of our analysis [68]. With a sample size of 16 interviews (8 dyads), our study exceeds the commonly cited threshold, around twelve interviews at which saturation is likely achieved [69]. Indeed, no new codes or themes were identified in our data matrices following the analysis of the fifth dyad (i.e., 10 interviews). However, the transferability of our findings should be considered within the specific context of Norwegian nursing homes operating under the Nordic welfare model. Caution is therefore warranted when applying these results to healthcare systems outside the Nordic countries and maybe especially systems operating with limited resources. Nonetheless, it is important to note that securing large sample sizes is not a primary objective in qualitative research. Instead, the focus is on ensuring that informants offer a diversity of experiences relevant to the phenomenon under investigation [70].