The positioning of nurses in health care in Vietnam: Interactions, organisations and space Hong Thuy Phuong Huynh RN, BScN, MAddNP, MAppScN Submitted in fulfillment of the requirement of the degree of Doctor of Philosophy School of Nursing, Faculty of Health Queensland University of Technology 2020 SUPERVISORY TEAM Associate Professor Carol Windsor Director of Post Graduate Research Faculty of Health School of Nursing Queensland University of Technology Victoria Park Road Kelvin Grove, 4059 Associate Professor Karen Theobald Director of Academic Programs Postgraduate Study Area Coordinator Health Professional Education Faculty of Health School of Nursing Queensland University of Technology Victoria Park Road Kelvin Grove, 4059 THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE i KEYWORDS Nursing practice Social positioning Negotiation Patient assessment Pragmatism Symbolic Interactionism Social Processes Social context Space THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE ii ABSTRACT The complexities of nursing practice are often obscured in the endeavour to construct a generic definition of nursing. The process of the construction of nursing practice and associated contextual factors, however, ensure considerable variation in nursing work within and across nations. Nursing practice is better understood as constructed by nurses as social actors who perform roles that are negotiated and mediated in context. The purpose of this research was to explore the nursing practices of Vietnamese Registered Nurses (RNs) in a clinical environment to gain insight into both the construction of nursing practice within that context and the broader implications for nursing in Vietnam. The research was grounded in the broad pragmatist tradition. The methods were informed by the works of Charmaz (2014). The purposeful sample constituted 29 RNs who worked across eight departments of a major hospital in Vietnam. Periods of observations and individual semi- structured interviews were the methods of data generation. Data analysis involved a systematic abstraction of theoretical concepts. Three key concepts, developed in the analytical process, reflected both agency and structure as important dimensions of nursing practice in Vietnam. Nurses as social actors were constantly engaged in a process of negotiation and renegotiation to sustain some sense of shared order in their practice. Yet, the shared order of practice was disrupted as medical doctors, family members and the managerial hierarchy posed varying demands as they moved in and out of the space of nurses. The concept of space was thus significant in depicting where and when nurses could practice autonomously. A broader structural interpretation of the space, both material and symbolic, in which the nurse participants worked, was framed within the historical, economic and political contexts of nursing work in Vietnam. THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE iii Table of Contents SUPERVISORY TEAM . III LIST OF FIGURES . VIII LIST OF TABLES . IX LIST OF ABBREVIATIONS .X STATEMENT OF ORIGINAL AUTHORSHIP . XV CHAPTER 1 INTRODUCTION .2 The Vietnamese context .1 The reform in the Vietnamese Higher Education and Healthcare System .2 The Vietnamese healthcare context after reform .3 The current Vietnamese healthcare context .3 Nursing in Vietnam .4 The research problem: A systematic process of reflexivity .5 Research purpose and aims.6 Roles of the researcher .7 Definition of terms .8 Overview of the thesis . 22 THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE iv CHAPTER 2 LITERATURE REVIEW .2 Nursing decision making around patient assessment .2 Patient assessment in nursing practice .4 Issues around nursing patient assessment . 32 CHAPTER 3 THEORETICAL TOOLS .2 The genesis of symbolic interactionism .3 Pragmatism and the early symbolic interactionism .1 Human actions as social performances .2 Human actions and structure .3 Data generation process .6 Strategies of ensuring quality of qualitative research . 85 CHAPTER 5 INTERNALISING NURSING PRACTICE .87 THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE v 5.2 The process of negotiation and mediation .1 Understanding nursing practice in the world of others .2 Mediating nursing practice .3 Intuition and nursing practice . 101 CHAPTER 6 INSTITUTIONALISING NURSING PRACTICE .2 Nursing practice - the negotiated order .1 Interactions and negotiations .2 Professional boundaries – the permeable product of negotiation .3 Negotiations at the structural level . 124 CHAPTER 7 SOCIAL SPACE OF NURSING PRACTICE .2 Nursing practice and the social space .1 Social space of nursing practice .2 Symbolic power, social space and nursing . 139 CHAPTER 8 DISCUSSIONS AND CONCLUSIONS .2 Key research findings .3 The social positioning of nurses - the paradoxes .1 The positioning of nurses in the political context of conflicting interests .2 The positioning of nurses in the historical and cultural context of Vietnam . 152 THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE vi REFERENCES.180 Appendix A Hospital Classifications (Vietnamese) . 180 Appendix B Nursing Competency Standards (Vietnamese) . 213 Appendix C Synthesised documents . 230 Appendix D The ethics approval of the University of Medicine and Pharmacy . 234 Appendix E Information sheet . 237 Appendix F The Research Poster . 242 Appendix G Bachelor of Science Nurse Curricula . 243 THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE vii List of figures Figure 1-1 The structure of health care system in Vietnam. Adapted from “A Health Financing Review of Vietnam with a Focus on Social Health Insurance”, by Tran Van Tien et al. 10 Figure 1-2 The administrative structure of health care in Vietnam. Adapted from “A Health Financing Review of Vietnam with a Focus on Social Health Insurance”, by Tran Van Tien et al. 11 Figure 4-1 Data generation process . 72 Figure 4-2 The theoretical lens . 79 THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE viii List of Tables Table 1.1 Healthcare professionals in Vietnam (MOH, 2014) .2 Simulated pay table for employees in government institutions in Vietnam pre October 2015 (2004) .3 Simulated pay for employees in government institutions in Vietnam post October 2015 (2018) .1 The process of purposeful sampling for participant approach and recruitment .2 Participant demographic data .3 Observation recording template .4 Categories of selected documents .5 Process of field notes taken .7 Levels of interpretation. Adapted from “Reflexive Methodology: new vistas for qualitative research”, by M. Skoldberg, 2009, London: SAGE, p.8 The memo-writing process . 83 THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE ix List of abbreviations ABBREVIATION DEFINITION Introduction CHS Commune Health Station DHC District Health Centers EWS Early Warning Scores HMU Hanoi Medical University ITPA Interactive Tailored Patient Assessment MOE Ministry of Education MOH Ministry of Health PHB Provincial Health Bureaus RN Registered Nurse RRS Rapid Response System SI Symbolic interactionism UMP University of Medicine and Pharmacy – Ho Chi Minh City US United States VNA Vietnam Nurse Association WHO World Health Organisation Literature review ANA American Nurses Association ACSQH Australian Commission on Safety and Quality in Healthcare EWS Early Warning Scores ICU Intensive Care Unit JSAPNC Jefferson Scale of Attitudes toward Physician-Nurse Collaboration MET Medical Emergency Team THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE x MP Medical Practitioner MOH Ministry of Health MSU Medical-Surgical Unit NCEPOD National Confidential Enquiry into Patient Outcome and Death NHS National Health Service NP Nurse Practitioner NSQHS National Safety and Quality Health Service RN Registered Nurse RRS Rapid Response System UK United Kingdom VNA Vietnam Nurse Association Theoretical tools MOH Ministry of Health MOHA Ministry of Home Affairs RN Registered Nurse SI Symbolic interactionism VNA Vietnam Nurse Association Method BSN Bachelor of Science Nurse HCMC Ho Chi Minh City MD Medical doctor MOH Ministry of Health MOHA Ministry of Home Affairs REIS Research Ethics Integrity and Safety RN Registered Nurse QUT Queensland University of Technology THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE xi SI Symbolic Interactionism UMP University of Medicine and Pharmacy – Ho Chi Minh City VNA Vietnam Nurse Association Internalising nursing practice MOH Ministry of Health RN Registered Nurse VNA Vietnam Nurse Association WHO World Health Organisation Institutionalising nursing practice AP Atlantic Philanthropy HPET Health Professionals Education and Trainings MOET Ministry of Education and Training MOH Ministry of Health UMP University of Medicine and Pharmacy – Ho Chi Minh City VNA Vietnam Nurse Association VNCS Vietnamese Nursing Competency Standards Social space of nursing practice MOH Ministry of Health VNA Vietnam Nurse Association Discussion and Conclusion ADB Asian Development Bank ANEP Advanced Nursing Education Program AP Atlantic Philanthropy ASEAN Association of Southeast Asian Nations CTU Can Tho University HMU Ha Noi Medical University THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE xii HPET Health Professionals Education and Training MOET Ministry of Education and Training MOH Ministry of Health MRANS Mutual Recognition Arrangement on Nursing Services NDU Nam Dinh University PNTU Pham Ngoc Thach University RN Registered Nurse SESDP Socio-Economic Strategic Development Plan SI Symbolic Interactionism UHC Universal health coverage UMP University of Medicine and Pharmacy Ho Chi Minh City UNESCO United Nations Education, Scientific and Cultural Organisation VHE Vietnamese Higher Education VHS Vietnamese Health System VNA Vietnam Nurse Association VNCS Vietnamese Nursing Competency Standards WHO World Health Organisation THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE xiii STATEMENT OF ORIGINAL AUTHORSHIP The work contained in this thesis has not been previously submitted to meet the requirements for an award at this or any other higher education institution. To the best of my knowledge and belief, the thesis contains no materials previously published or written by another person except where due reference is made QUT Verified Signature Signature Date: 23/03/2020 THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE xiv ACKNOWLEDGEMENTS I wish to acknowledge and thank the study participants for the voluntary participation they provided that I was able to achieve valuable information. I wish to express my very great appreciation and heartiest gratitude to my respected Assoc. Carol Windsor for her mentoring support and supervision which provided inspiration for me in research. I also wish to thank Assoc. Karen Theobald for her sincere supervision and support during my research journey. I would particularly like to thank the Cho Ray Hospital, the Queensland University of Technology, and the University of Medicine of Pharmacy HoChiMinh City for their support in making the research possible. My special thanks are extended to the Australian Government, and staff of the Australia Award Scholarship for giving me financial support to study in Australia. Advice given by my friends and colleagues has been a great help for me in conducting the research. Finally, I wish to thank my loving and supportive husband, Ngoc Toan, and my wonderful 4-year daughter, Mai Thi, and my family members for being by me without conditions throughout this beautiful journey. Everytime I look at you, I know that I am a lucky person THE POSITIONING OF NURSES IN HEALTHCARE IN VIETNAM: INTERACTIONS, ORGANISATIONS AND SPACE xv Chapter 1 Introduction 1.1 Background The work of nurses in health care workforces worldwide is considered critical in ensuring health security and in improving the quality of health services (WHO, 2019). Technological, demographic, medical and scientific developments within the healthcare industry have also underpinned an increasing demand for advanced nursing practice roles to meet the changing health needs of populations (Bryant-Lukosius et al. Indeed, there is a growing body of evidence on the effectiveness of advanced nursing practice in enhancing health service outcomes in terms of improved mortality and morbidity and reduction of healthcare utilisation and costs (Bryant-Lukosius et al., 2016; Donald et al. As part of this movement, there have been ongoing changes in nursing education to address the preparation of nurses for emergent practice roles. The initial impetus for this research was an observed apparent disconnect between nursing education and the practice of clinical nursing in Vietnam and particularly in the area of patient assessment by nurses. While nurses have always engaged in forms of patient assessment this practice has been more overtly associated with the role of the medical profession (Marsden, Dolan & Holt, 2003).
