Curbing the urge to care: A Bourdieusian analysis of the effect of the caring disposition on nurse middle managers' clinical leadership in patient safety practices.

Background: Nurse managers play an important role in implementing patient safety practices in hospitals. However, the influence of their professional background on their clinical leadership behaviour remains unclear. Research has demonstrated that concepts of Bourdieu (dispositions of habitus, capital and field) help to describe this influence. It revealed various configurations of dispositions of the habitus in which a caring disposition plays a crucial role.

Objectives: We explore how the caring disposition of nurse middle managers' habitus influences their clinical leadership behaviour in patient safety practices.

Design: Our paper reports the findings of a Bourdieusian, multi-site, ethnographic case study.

Settings: Two Dutch and two American acute care, mid-sized, non-profit hospitals.

Participants: A total of 16 nurse middle managers of adult care units.

Methods: Observations were made over 560h of shadowing nurse middle managers, semi-structured interviews and member check meetings with the participants.

Results: We observed three distinct configurations of dispositions of the habitus which influenced the clinical leadership of nurse middle managers in patient safety practices; they all include a caring disposition: (1) a configuration with a dominant caring disposition that was helpful (via solving urgent matters) and hindering (via ad hoc and reactive actions, leading to quick fixes and 'compensatory modes'); (2) a configuration with an interaction of caring and collegial dispositions that led to an absence of clinical involvement and discouraged patient safety practices; and (3) a configuration with a dominant scientific disposition showing an investigative, non-judging, analytic stance, a focus on evidence-based practice that curbs the ad hoc repertoire of the caring disposition.

Conclusions: The dispositions of the nurse middle managers' habitus influenced their clinical leadership in patient safety practices. A dominance of the caring disposition, which meant 'always' answering calls for help and reactive and ad hoc reactions, did not support the clinical leadership role of nurse middle managers. By perceiving the team of staff nurses as pseudo-patients, patient safety practice was jeopardized because of erosion of the clinical disposition. The nurse middle managers' clinical leadership was enhanced by leadership behaviour based on the clinical and scientific dispositions that was manifested through an investigative, non-judging, analytic stance, a focus on evidence-based practice and a curbed caring disposition.