Skip to main content

Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice



Transitions in healthcare delivery, such as the rapidly growing numbers of older people and increasing social and healthcare needs, combined with nursing shortages has sparked renewed interest in differentiations in nursing staff and skill mix. Policy attempts to implement new competency frameworks and job profiles often fails for not serving existing nursing practices. This study is aimed to understand how licensed vocational nurses (VNs) and nurses with a Bachelor of Science degree (BNs) shape distinct nursing roles in daily practice.


A qualitative study was conducted in four wards (neurology, oncology, pneumatology and surgery) of a Dutch teaching hospital. Various ethnographic methods were used: shadowing nurses in daily practice (65h), observations and participation in relevant meetings (n=56), informal conversations (up to 15 h), 22 semi-structured interviews and member-checking with four focus groups (19 nurses in total). Data was analyzed using thematic analysis.


Hospital nurses developed new role distinctions in a series of small-change experiments, based on action and appraisal. Our findings show that: (1) this developmental approach incorporated the nurses’ invisible work; (2) nurses’ roles evolved through the accumulation of small changes that included embedding the new routines in organizational structures; (3) the experimental approach supported the professionalization of nurses, enabling them to translate national legislation into hospital policies and supporting the nurses’ (bottom-up) evolution of practices. The new roles required the special knowledge and skills of Bachelor-trained nurses to support healthcare quality improvement and connect the patients’ needs to organizational capacity.


Conducting small-change experiments, anchored by action and appraisal rather than by design, clarified the distinctions between vocational and Bachelor-trained nurses. The process stimulated personal leadership and boosted the responsibility nurses feel for their own development and the nursing profession in general. This study indicates that experimental nursing role development provides opportunities for nursing professionalization and gives nurses, managers and policymakers the opportunity of a ‘two-way-window’ in nursing role development, aligning policy initiatives with daily nursing practices.

Peer Review reports


The aging population and mounting social and healthcare needs are challenging both healthcare delivery and the financial sustainability of healthcare systems [1, 2]. Nurses play an important role in facing these contemporary challenges [3, 4]. However, nursing shortages increase the workload which, in turn, boosts resignation numbers of nurses [5, 6]. Research shows that nurses resign because they feel undervalued and have insufficient control over their professional practice and organization [7, 8]. This issue has sparked renewed interest in nursing role development [9,10,11]. A role can be defined by the activities assumed by one person, based on knowledge, modulated by professional norms, a legislative framework, the scope of practice and a social system [12, 9].

New nursing roles usually arise through task specialization [13, 14] and the development of advanced nursing roles [15, 16]. Increasing attention is drawn to role distinction within nursing teams by differentiating the staff and skill mix to meet the challenges of nursing shortages, quality of care and low job satisfaction [17, 18]. The staff and skill mix include the roles of enrolled nurses, registered nurses, and nurse assistants [19, 20]. Studies on differentiation in staff and skill mix reveal that several countries struggle with the composition of nursing teams [21,22,23].

Role distinctions between licensed vocational-trained nurses (VNs) and Bachelor of Science-trained nurses (BNs) has been heavily debated since the introduction of the higher nurse education in the early 1970s, not only in the Netherlands [24, 25] but also in Australia [26, 27], Singapore [20] and the United States of America [28, 29]. Current debates have focused on the difficulty of designing distinct nursing roles. For example, Gardner et al., revealed that registered nursing roles are not well defined and that job profiles focus on direct patient care [30]. Even when distinct nursing roles are described, there are no proper guidelines on how these roles should be differentiated and integrated into daily practice. Although the value of differentiating nursing roles has been recognized, it is still not clear how this should be done or how new nursing roles should be embedded in daily nursing practice. Furthermore, the consequences of these roles on nursing work has been insufficiently investigated [31].

This study reports on a study of nursing teams developing new roles in daily nursing hospital practice. In 2010, the Dutch Ministry of Health announced a law amendment (the Individual Health Care Professions Act) to formalize the distinction between VNs and BNs. The law amendment made a distinction in responsibilities regarding complexity of care, coordination of care, and quality improvement. Professional roles are usually developed top-down at policy level, through competency frameworks and job profiles that are subsequently implemented in nursing practice. In the Dutch case, a national expert committee made two distinct job profiles [32]. Instead of prescribing role implementation, however, healthcare organizations were granted the opportunity to develop these new nursing roles in practice, aiming for a more practice-based approach to reforming the nursing workforce. This study investigates a Dutch teaching hospital that used an experimental development process in which the nurses developed role distinctions by ‘doing and appraising’. This iterative process evolved in small changes [33,34,35,36], based on nurses’ thorough knowledge of professional practices [37] and leadership role [38,39,40].

According to Abbott, the constitution of a new role is a competitive action, as it always leads to negotiation of new openings for one profession and/or degradation of adjacent professions [41]. Additionally, role differentiation requires negotiation between different professionals, which always takes place in the background of historical professionalization processes and vested interests resulting in power-related issues [42,43,44]. Recent studies have described the differentiation of nursing roles to other professionals, such as nurse practitioners and nurse assistants, but have focused on evaluating shifts in nursing tasks and roles [31]. Limited research has been conducted on differentiating between the different roles of registered nurses and the involvement of nurses themselves in developing new nursing roles. An ethnographic study was conducted to shed light on the nurses’ work of seeking openings and negotiating roles and responsibilities and the consequences of role distinctions, against a background of historically shaped relationships and patterns.



The study aimed to understand the formulation of nursing role distinctions between different educational levels in a development process involving experimental action (doing) and appraisal.


We conducted an ethnographic case study. This design was commonly used in nursing studies in researching changing professional practices [45, 46]. The researchers gained detailed insights into the nurses’ actions and into the finetuning of their new roles in daily practice, including the meanings, beliefs and values nurses give to their roles [47, 48]. This study complied with the consolidated criteria for reporting qualitative research (COREQ) checklist.

Setting and participants

Our study took place in a purposefully selected Dutch teaching hospital (481 beds, 2,600 employees including 800 nurses). Historically, nurses in Dutch hospitals have vocational training. The introduction of higher nursing education in 1972 prompted debates about distinguishing between vocational-trained nurses (VNs) and bachelor-trained nurses (BNs). For a long time, VNs resisted a role distinction, arguing that their work experience rendered them equally capable to take care of patients and deal with complex needs. As a result, VNs and BNs carry out the same duties and bear equal responsibility. To experiment with role distinctions in daily practice, the hospital management and project team selected a convenience but representative sample of wards. Two general (neurology and surgery) and two specific care (oncology and pneumatology) wards were selected as they represent the different compositions of nursing educational levels (VN, BN and additional specialized training). The demographic profile for the nursing teams is shown in Table 1. The project team, comprising nursing policy staff, coaches and HR staff (N = 7), supported the four (nursing) teams of the wards in their experimental development process (131 nurses; 32 % BNs and 68 % VNs, including seven senior nurses with an organizational role). We also studied the interactions between nurses and team managers (N = 4), and the CEO (N = 1) in the meetings.

Table 1 Demographics of the study participantsa

Data collection

Data was collected between July 2017 and January 2019. A broad selection of respondents was made based on the different roles they performed. Respondents were personally approached by the first author, after close consultation with the team managers. Four qualitative research methods were used iteratively combining collection and analysis, as is common in ethnographic studies [45] (see Table 2).

  1. 1)

    Shadowing nurses (i.e. observations and questioning nurses about their work) on shift (65 h in total) was conducted to observe behavior in detail in the nurses’ organizational and social setting [49, 50], both in existing practices and in the messy fragmented process of developing distinct nursing roles. The notes taken during shadowing were worked up in thick descriptions [46].

  2. 2)

    Observation and participation in four types of meetings. The first and second authors attended: (1) kick-off meetings for the nursing teams (n = 2); (2) bi-monthly meetings (n = 10) between BNs and the project team to share experiences and reflect on the challenges, successes and failures; and (3) project group meetings at which the nursing role developmental processes was discussed (n = 20). Additionally, the first author observed nurses in ward meetings discussing the nursing role distinctions in daily practice (n = 15). Minutes and detailed notes also produced thick descriptions [51]. This fieldwork provided a clear understanding of the experimental development process and how the respondents made sense of the challenges/problems, the chosen solutions and the changes to their work routines and organizational structures. During the fieldwork, informal conversations took place with nurses, nursing managers, project group members and the CEO (app. 15 h), which enabled us to reflect on the daily experiences and thus gain in-depth insights into practices and their meanings. The notes taken during the conversations were also written up in the thick description reports, shortly after, to ensure data validity [52]. These were completed with organizational documents, such as policy documents, activity plans, communication bulletins, formal minutes and in-house presentations.

  3. 3)

    Semi-structured interviews lasting 60–90 min were held by the first author with 22 respondents: the CEO (n = 1), middle managers (n = 4), VNs (n = 6), BNs (n = 9, including four senior nurses), paramedics (n = 2) using a predefined topic list based on the shadowing, observations and informal conversations findings. In the interviews, questions were asked about task distinctions, different stakeholder roles (i.e., nurses, managers, project group), experimental approach, and added value of the different roles and how they influence other roles. General open questions were asked, including: “How do you distinguish between tasks in daily practice?”. As the conversation proceeded, the researcher asked more specific questions about what role differentiation meant to the respondent and their opinions and feelings. For example: “what does differentiation mean for you as a professional?”, and “what does it mean for you daily work?”, and “what does role distinction mean for collaboration in your team?” The interviews were tape-recorded (with permission), transcribed verbatim and anonymized.

  4. 4)

    The fieldwork period ended with four focus groups held by the first author on each of the four nursing wards (N = 19 nurses in total: nine BNs, eight VNs, and two senior nurses). The groups discussed the findings, such as (nurses’ perceptions on) the emergence of role distinctions, the consequences of these role distinctions for nursing, experimenting as a strategy, the elements of a supportive environment and leadership. Questions were discussed like: “which distinctions are made between VN and BN roles?”, and “what does it mean for VNs, BNs and senior nurses?”. During these meetings, statements were also used to provoke opinions and discussion, e.g., “The role of the manager in developing distinct nursing roles is…”. With permission, all focus groups were audio recorded and the recordings were transcribed verbatim. The focus groups also served for member-checking and enriched data collection, together with the reflection meetings, in which the researchers reflected with the leader and a member of the project group members on program, progress, roles of actors and project outcomes. Finally, the researchers shared a report of the findings with all participants to check the credibility of the analysis.

Table 2 Data collection methods for both cases, excluding document study

Data analysis

Data collection and inductive thematic analysis took place iteratively [45, 53]. The first author coded the data (i.e. observation reports, interview and focus group transcripts), basing the codes on the research question and theoretical notions on nursing role development and distinctions. In the next step, the research team discussed the codes until consensus was reached. Next, the first author did the thematic coding, based on actions and interactions in the nursing teams, the organizational consequences of their experimental development process, and relevant opinions that steered the development of nurse role distinctions (see Additional file). Iteratively, the research team developed preliminary findings, which were fed back to the respondents to validate our analysis and deepen our insights [54]. After the analysis of the additional data gained in these validating discussions, codes were organized and re-organized until we had a coherent view.


Ethnography acknowledges the influence of the researcher, whose own (expert) knowledge, beliefs and values form part of the research process [48]. The first author was involved in the teams and meetings as an observer-as-participant, to gain in-depth insight, but remained research-oriented [55]. The focus was on the study of nursing actions, routines and accounts, asking questions to obtain insights into underlying assumptions, which the whole research group discussed to prevent ‘going native’ [56, 57]. Rigor was further ensured by triangulating the various data resources (i.e. participants and research methods), purposefully gathered over time to secure consistency of findings and until saturation on a specific topic was reached [54]. The meetings in which the researchers shared the preliminary findings enabled nurses to make explicit their understanding of what works and why, how they perceived the nursing role distinctions and their views on experimental development processes.

Ethical considerations

All participants received verbal and written information, ensuring that they understood the study goals and role of the researcher [48]. Participants were informed about their voluntary participation and their right to end their contribution to the study. All gave informed consent. The study was performed in accordance with the Declaration of Helsinki and was approved by the Erasmus Medical Ethical Assessment Committee in Rotterdam (MEC-2019-0215), which also assessed the compliance with GDPR.


Our findings reveal how nurses gradually shaped new nursing role distinctions in an experimental process of action and appraisal and how the new BN nursing roles became embedded in new nursing routines, organizational routines and structures. Three empirical appeared from the systematic coding: (1) distinction based on complexity of care; (2) organizing hospital care; and (3) evidence-based practices (EBP) in quality improvement work.

Distinction based on complexity of care

Initially, nurses distinguished the VN and BN roles based on the complexity of patient care, as stated in national job profiles [32]. BNs were supposed to take care of clinically complex patients, rather than VNs, although both VNs and BNs had been equally taking care of every patient category. To distinguish between highly and less complex patient care, nurses developed a complexity measurement tool. This tool enabled classification of the predictability of care, patient’s degree of self-reliance, care intensity, technical nursing procedures and involvement of other disciplines. However, in practice, BNs questioned the validity of assessing a patient’s care complexity, because the assessments of different nurses often led to different outcomes. Furthermore, allocating complex patient care to BNs impacted negatively on the nurses’ job satisfaction, organizational routines and ultimately the quality of care. VNs experienced the shift of complex patient care to BNs as a diminution of their professional expertise. They continuously stressed their competencies and questioned the assigned levels of complexity, aiming to prevent losses to their professional tasks:

‘Now we’re only allowed to take care of COPD patients and people with pneumonia, so no more young boys with a pneumothorax drain. Suddenly we are not allowed to do that. (…) So, your [professional] world is getting smaller. We don’t like that at all. So, we said: We used to be competent, so why aren’t we anymore?’ (Interview VN1, in-service trained nurse).

In discussing complexity of care, both VNs and BNs (re)discovered the competencies VNs possess in providing complex daily care. BNs acknowledged the contestability of the distinction between VN and BN roles related to patient care complexity, as the next quote shows:

‘Complexity, they always make such a fuss about it. (…) At a given moment you’re an expert in just one certain area; try then to stand out on your ward. (…) When I go to GE [gastroenterology] I think how complex care is in here! (…) But it’s also the other way around, when I’m the expert and know what to expect after an angioplasty, or a bypass, or a laparoscopic cholecystectomy (…) When I’ve mastered it, then I no longer think it’s complex, because I know what to expect!’ (Interview BN1, 19-07-2017).

This quote illustrates how complexity was shaped through clinical experience. What complex care is, is influenced by the years of doing nursing work and hence is individual and remains invisible. It is not formally valued [58] because it is not included in the BN-VN competency model. This caused dissatisfaction and feelings of demotion among VNs. The distinction in complexities of care was also problematic for BNs. Following the complexity tool, recently graduated BNs were supposed to look after highly complex patients. However, they often felt insecure and needed the support of more experienced (VN) colleagues – which the VNs perceived as a recognition of their added value and evidence of the failure of the complexity tool to guide division of tasks. Also, mundane issues like holidays, sickness or pregnancy leave further complicated the use of the complexity tool as a way of allocating patients, as it decreased flexibility in taking over and swapping shifts, causing dissatisfaction with the work schedule and leading to problems in the continuity of care during evening, night and weekend shifts. Hence, the complexity tool disturbed the flexibility in organizing the ward and held possible consequences for the quality and safety of care (e.g. inexperienced BNs providing complex care), Ultimately, the complexity tool upset traditional teamwork, in which nurses more implicitly complemented each other’s competencies and ability to ‘get the work done’ [59]. As a result, role distinction based on ‘quantifiable’ complexity of care was abolished. Attention shifted to the development of an organizational and quality-enhancing role, seeking to highlight the added value of BNs – which we will elaborate on in the next section.

Organizing hospital care

Nurses increasingly fulfill a coordinating role in healthcare, making connections across occupational, departmental and organizational boundaries, and ‘mediating’ individual patient needs, which Allen describes as organizing work [49]. Attempting to make a valuable distinction between nursing roles, BNs adopted coordinating management tasks at the ward level, taking over this task from senior nurses and team managers. BNs sought to connect the coordinating management tasks with their clinical role and expertise. An example is bed management, which involves comparing a ward’s bed capacity with nursing staff capacity [1, 60]. At first, BNs accompanied middle managers to the hospital bed review meeting to discuss and assess patient transfers. On the wards where this coordination task used to be assigned to senior nurses, the process of transferring this task to BNs was complicated. Senior nurses were reluctant to hand over coordinating tasks as this might undermine their position in the near future. Initially, BNs were hesitant to take over this task, but found a strategy to overcome their uncertainty. This is reflected in the next excerpt from fieldnotes:

Senior nurse: ‘First we have to figure out if it will work, don’t we? I mean, all three of us [middle manager, senior nurse, BN] can’t just turn up at the bed review meeting, can we? The BN has to know what to do first, otherwise she won’t be able to coordinate properly. We can’t just do it.’ BN: ‘I think we should keep things small, just start doing it, step by step. (…) If we don’t try it out, we don’t know if it works.’ (Field notes, 24-05-2018).

This excerpt shows that nurses gradually developed new roles as a series of matching tasks. Trying out and evaluating each step of development in the process overcame the uncertainty and discomfort all parties held [61]. Moreover, carrying out the new tasks made the role distinctions become apparent. The coordinating role in bed management, for instance, became increasingly embedded in the new BN nursing role. Experimenting with coordination allowed BNs prove their added value [62] and contributed to overall hospital performance as it combined daily working routines with their ability to manage bed occupancy, patient flow, staffing issues and workload. This was not an easy task. The next quote shows the complexity of creating room for this organizing role:

The BNs decide to let the VNs help coordinate the daily care, as some VNs want to do this task. One BN explains: ‘It’s very hard to say, you’re not allowed.’ The middle manager looks surprised and says that daily coordination is a chance to draw a clear distinction and further shape the role of BNs. The project group leader replies: ‘Being a BN means that you dare to make a difference [in distinctive roles]. We’re all newbies in this field, but we can use our shared knowledge. You can derive support from this task for your new role.’ (Field notes, 09-01-2018).

This excerpt reveals the BNs’ thinking on crafting their organizational role, turning down the VNs wishes to bear equal responsibility for coordinating tasks. Taking up this role touched on nurse identity as BNs had to overcome the delicate issue of equity [63], which has long been a core element of the Dutch nursing profession. Taking over an organization role caused discomfort among BNs, but at the same time provided legitimation for a role distinction.

Legitimation for this task was also gained from external sources, as the law amendment and the expert committee’s job descriptions both mentioned coordinating tasks. However, taking over coordinating tasks and having an organizing role in hospital care was not done as an ‘implementation’; rather it required a process of actively crafting and carving out this new role. We observed BNs choosing not to disclose that they were experimenting with taking over the coordinating tasks as they anticipated a lack of support from VNs:

BN: ‘We shouldn’t tell the VNs everything. We just need this time to give shape to our new role. And we all know who [of the colleagues] won’t agree with it. In my opinion, we’d be better off hinting at it at lunchtime, for example, to figure out what colleagues think about it. And then go on as usual.’ (Field notes, 12-06-2018).

BNs stayed ‘under the radar’, not talking explicitly about their fragile new role to protect the small coordination tasks they had already gained. By deliberately keeping the evaluation of their new task to themselves, they protected the transition they had set into motion. Thus, nurses collected small changes in their daily routines, developing a new role distinction step by step. Changes to single tasks accumulated in a new role distinction between BNs, VNs and senior nurses, and gave BNs a more hybrid nursing management role.

Evidence-based practices in quality improvement work

Quality improvement appeared to be another key concern in the development of the new BN role. Quality improvement work used to be carried out by groups of senior nurses, middle managers and quality advisory staff. Not involved in daily routines, the working group focused on nursing procedures (e.g. changing infusion system and wound treatment protocols). In taking on this new role BNs tried different ways of incorporating EBP in their routines, an aspect that had long been neglected in the Netherlands. As a first step, BNs rearranged the routines of the working group. For example, a team of BNs conducted a quality improvement investigation of a patient’s formal’s complaint:

Twenty-two patients registered a pain score of seven or higher and were still discharged. The question for BNs was: how and why did this bad care happen? The BNs used electronic patient record to study data on the relations between pain, medication and treatment. Their investigation concluded: nurses do not always follow the protocols for high pain scores. Their improvement plan covered standard medication policy, clinical lessons on pain management and revisions to the patient information folder. One BN said: ‘I really loved investigating this improvement.’ (Field notes, 28-05-2018).

This fieldnote shows the joy quality improvement work can bring. During interviews, nurses said that it had given them a better grip on the outcome of nursing work. BNs felt the need to enhance their quality improvement tasks with their EBP skills, e.g. using clinical reasoning in bedside teaching, formulating and answering research questions in clinical lessons and in multi-disciplinary patient rounds to render nursing work more evidence based. The BNs blended EBP-related education into shift handovers and ward meetings, to show VNs the value of doing EBP [64]. In doing so, they integrated and fostered an EBP infrastructure of care provision, reflecting a new sense of professionalism and responsibility for quality of care.

However, learning how to blend EPB quality work in daily routines – ‘learning in practice’ –requires attention and steering. Although the BNs had a Bachelor’s degree, they had no experience of a quality-enhancing role in hospital practice [65]. In our case, the interplay between team members’ previous education and experienced shortcomings in knowledge and skills uncovered the need for further EBP training. This training established the BNs’ role as quality improvers in daily work and at the same time supported the further professionalization of both BNs and VNs. Although introducing the EBP approach was initially restricted to the BNs, it was soon realized that VNs should be involved as well, as nursing is a collaborative endeavor [1], as one team member (the trainer) put it:

‘I think that collaboration between BNs and VNs would add lots of value, because both add something different to quality work. I’d suggest that BNs could introduce the process-oriented, theoretical scope, while VNs could maybe focus on the patients’ interest.’ (Fieldnote, informal conversation, 11-06-2018).

During reflection sessions on the ward level and in the project team meetings BNs, informed by their previous experience with the complexity tool, revealed that they found it a struggle to do justice to everyone’s competencies. They wanted to use everyone’s expertise to improve the quality of patient care. They were for VNs being involved in the quality work, e.g. in preparing a clinical lesson, conducting small surveys, asking VNs to pose EBP questions and encourage VNs to write down their thoughts on flip over charts as means of engaging all team members.

These findings show that applying EPB in quality improvement is a relational practice driven by mutual recognition of one another’s competencies. This relational practice blended the BNs’ theoretical competence in EBP [66] with the VNs’ practical approach to the improvement work they did together. As a result, the blend enhanced the quality of daily nursing work and thus improved the quality of patient care and the further professionalization of the whole nursing team.


This study aimed to understand how an experimental approach enables differently educated nurses to develop new, distinct professional roles. Our findings show that roles cannot be distinguished by complexity of care; VNs and BNs are both able to provide care to patients with complex healthcare needs based on their knowledge and experience. However, role distinctions can be made on organizing care and quality improvement. BNs have an important role organizing care, for example arranging the patient flow on and across wards at bed management meetings, while VNs contribute more to organizing at the individual patient level. BNs play a key role in starting and steering quality improvement work, especially blending EBP in with daily nursing tasks, while VNs are involved but not in the lead. Working together on quality improvement boosts nursing professionalization and team development.

Our findings also show that the role development process is greatly supported by a series of small-change experiments, based on action and appraisal. This experimental approach supported role development in three ways. First, it incorporates both formal tasks and the invisible, unconscious elements of nursing work [49]. Usually, invisible work gets no formal recognition, for example in policy documents [55], whereas it is crucial in daily routines and organizational structures [49, 60]. Second, experimenting triggers an accumulation of small changes [33, 35] leading to the embeddedness of role distinctions in new nursing routines, allowing nurses to influence the organization of care. This finding confirms the observations of Reay et al. that nurses can create small changes in daily activities to craft a new nursing role, based on their thorough knowledge of their own practice and that of the other involved professional groups [37]. Although these changes are accompanied by tension and uncertainty, the process of developing roles generates a certain joy. Third, experimenting stimulated nursing professionalization, enabling the nurses to translate national legislation into hospital policy and supporting the nurses’ own (bottom-up) evolution of practices. Historically, nursing professionalization is strongly influenced by gender and education level [43] resulting in a subordinate position, power inequity and lack of autonomy [44]. Giving nurses the lead in developing distinct roles enables them to ‘engage in acts of power’ and obtain more control over their work. Fourth, experimenting contributes to role definition and clarification. In line with Poitras et al. [12] we showed that identifying and differentiating daily nursing tasks led to the development of two distinct and complementary roles. We have also shown that the knowledge base of roles and tasks includes both previous and additional education, as well as nursing experience.

Our study contributes to the literature on the development of distinct nursing roles [9,10,11] by showing that delineating new roles in formal job descriptions is not enough. Evidence shows that this formal distinction led particularly to the non-recognition, non-use and degradation [41] of VN competencies and discomforted recently graduated BNs. The workplace-based experimental approach in the hospital includes negotiation between professionals, the adoption process of distinct roles and the way nurses handle formal policy boundaries stipulated by legislation, national job profiles, and hospital documents, leading to clear role distinctions. In addition to Hughes [42] and Abbott [67] who showed that the delineation of formal work boundaries does not fit the blurred professional practices or individual differences in the profession, we show how the experimental approach leads to the clarification and shape of distinct professional practices.

Thus, an important implication of our study is that the professionals concerned should be given a key role in creating change [37, 39, 40]. Adding to Mannix et al. [38], our study showed that BNs fulfill a leadership role, which allows them to build on their professional role and identity. Through the experiments, BNs and VNs filled the gap between what they had learned in formal education, and what they do in daily practice [64, 65]. Experimenting integrates learning, appraising and doing much like going on ‘a journey with no fixed routes’ [34, 68] and no fixed job description, resulting in the enlargement of their roles.

Our study suggests that role development should involve professionalization at different educational levels, highlighting and valuing specific roles rather than distinguishing higher and lower level skills and competencies. Further research is needed to investigate what experimenting can yield for nurses trained at different educational levels in the context of changing healthcare practices, and which interventions (e.g., in process planning, leadership, or ownership) are needed to keep the development of nursing roles moving ahead. Furthermore, more attention should be paid to how role distinction and role differentiation influence nurse capacity, quality of care (e.g., patient-centered care and patient satisfaction), and nurses’ job satisfaction.


Our study was conducted on four wards of one teaching hospital in the Netherlands. This might limit the potential of generalizing our findings to other contexts. However, the ethnographic nature of our study gave us unique understanding and in-depth knowledge of nurses’ role development and distinctions, both of which have broader relevance. As always in ethnographic studies, the chances of ‘going native’ were apparent, and we tried to prevent this with ongoing reflection in the research team. Also, the interpretation of research findings within the Dutch context of nurse professionalization contributed to a more in-depth understanding of how nursing roles develop, as well as the importance of involving nurses themselves in the development of these roles to foster and support professional development.

We focused on role distinctions between VNs and BNs and paid less attention to (the collaboration with) other professionals or management. Further research is needed to investigate how nursing role development takes place in a broader professional and managerial constellation and what the consequences are on role development and healthcare delivery.


This paper described how nurses crafted and shaped new roles with an experimental process. It revealed the implications of developing a distinct VN role and the possibility to enhance the BN role in coordination tasks and in steering and supporting EBP quality improvement work. Embedding the new roles in daily practice occurred through an accumulation of small changes. Anchored by action and appraisal rather than by design, the changes fostered by experiments have led to a distinction between BNs and VNs in the Netherlands. Furthermore, experimenting with nursing role development has also fostered the professionalization of nurses, encouraging nurses to translate knowledge into practice, educating the team and stimulating collaborative quality improvement activities.

This paper addressed the enduring challenge of developing distinct nursing roles at both the vocational and Bachelor’s educational level. It shows the importance of experimental nursing role development as it provides opportunities for the professionalization of nurses at different educational levels, valuing specific roles and tasks rather than distinguishing between higher and lower levels of skills and competencies. Besides, nurses, managers and policymakers can embrace the opportunity of a ‘two-way window’ in (nursing) role development, whereby distinct roles are outlined in general at policy levels, and finetuned in daily practice in a process of small experiments to determine the best way to collaborate in diverse contexts.

Availability of data and materials

The data generated and analyzed during the current study is not publicly available to ensure data confidentiality but is available from the corresponding author on reasonable request and with the consent of the research participants.



Bachelor-trained nurse


Vocational-trained nurse


Evidence-based Practices


  1. Allen D. Nursing and the future of ‘care’ in health care systems. J Health Serv Res Policy. 2015;20(3):129–30.

    Article  PubMed  Google Scholar 

  2. NHS England. Leading change, adding value. A framework for nursing, midwifery and care staff. 2016. Accessed 11 Nov 2020.

  3. Institute of Medicine (IOM). The future of nursing; Leading change, advancing Health. Washington (DC): National Academies Press; 2011.

    Google Scholar 

  4. World Health Organization (WHO). Gloabal strategic directions for strengthening nursing and midwifery 2016–2020. Geneva: WHO Press; 2016.

    Google Scholar 

  5. Dawson AJ, Stasa H, Roche MA, et al. Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies. BMC Nurs. 2014;13:11.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Hayes LJ, O’Brien-Pallas L, Duffield C, et al. Nurse turnover: a literature review–an update. Intern J Nurs Stud. 2012;49(7):887–905.

    Article  Google Scholar 

  7. Persson U, Carlson E. Conceptions of professional work in contemporary health care—Perspectives from registered nurses in somatic care: A phenomenographic study. J Clin Nurs. 2019;28(1–2):201–8.

    Article  PubMed  Google Scholar 

  8. Senek M, Robertson S, Ryan T, et al. Determinants of nurse job dissatisfaction-findings from a cross-sectional survey analysis in the UK. BMC Nurs. 2020;19(1):1–10.

    Article  Google Scholar 

  9. Jacob ER, McKenna L, D’Amore A. The changing skill mix in nursing: considerations for and against different levels of nurse. J Nurs Manag. 2015;23(4):421–6.

    Article  PubMed  Google Scholar 

  10. Sermeus W, Aiken LH, Van den Heede K, et al. Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology. BMC Nurs. 2011;10:6.

    Article  PubMed  PubMed Central  Google Scholar 

  11. de Bont A, van Exel Job, Coretti S, Ökem ZG, Janssen M, Hope KL, Ludwicki T, Zander B, Zvonickova M, Bond C, Wallenburg I. Reconfiguring health workforce: a case-based comparative study explaining the increasingly diverse professional roles in Europe. BMC Health Serv Res. 2016;16(1).

  12. Poitras ME, Chouinard MC, Fortin M, et al. How to report professional practice in nursing? A scoping review. BMC Nurs. 2016;15(1):31.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Jones ML. Role development and effective practice in specialist and advanced practice roles in acute hospital settings: systematic review and meta-synthesis. J Adv Nurs. 2005;49(2):191–209.

    Article  PubMed  Google Scholar 

  14. Ranchal A, Jolley MJ, Keogh J, et al. The challenge of the standardization of nursing specializations in Europe. Int Nurs Rev. 2015;62(4):445–52.

    CAS  Article  PubMed  Google Scholar 

  15. Lowe G, Plummer V, O’Brien AP, et al. Time to clarify–the value of advanced practice nursing roles in health care. J Adv Nurs. 2012;68(3):677–85.

    Article  PubMed  Google Scholar 

  16. Fealy GM, Casey M, O’Leary DF, et al. Developing and sustaining specialist and advanced practice roles in nursing and midwifery: A discourse on enablers and barriers. J Clin Nurs. 2018;27(19–20):3797–809.

    Article  PubMed  Google Scholar 

  17. Aiken LH, Sermeus W, Van den Heede K, et al. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. 2012;344;e1717.

  18. Lu H, Zhao Y, While A. Job satisfaction among hospital nurses: A literature review. Intern J Nurs Stud. 2019;94:21–31.

    Article  Google Scholar 

  19. Duffield C, Roche M, Twigg D, et al. Adding unregulated nursing support workers to ward staffing: Exploration of a natural experiment. J Clin Nurs. 2018;27(19–20):3768–79.

    Article  PubMed  Google Scholar 

  20. Chua WL, Legido-Quigley H, Ng PY, et al. Seeing the whole picture in enrolled and registered nurses’ experiences in recognizing clinical deterioration in general ward patients: A qualitative study. Intern J Nurs Stud. 2019;95:56–64.

    Article  Google Scholar 

  21. van Oostveen CJ, Mathijssen E, Vermeulen H. Nurse staffing issues are just the tip of the iceberg: a qualitative study about nurses’ perceptions of nurse staffing. Intern J Nurs Stud. 2015;52(8):1300–9.

    Article  Google Scholar 

  22. Saville CE, Griffiths P, Ball JE, et al. How many nurses do we need? A review and discussion of operational research techniques applied to nurse staffing. Intern J Nurs Stud. 2019;97:7–13.

    Article  Google Scholar 

  23. Vatnøy TK, Sundlisæter Skinner M, Karlsen T, et al. Nursing competence in municipal in-patient acute care in Norway: a cross-sectional study. BMC Nurs. 2020;9:70.

  24. De Jong JHJ, Kerstens JAM, Sesink EM, et al. Deskundigheidsbevordering en professionalisering. In: Handboek verpleegkunde. Houten: Bohn Stafleu van Loghum; 2003. p. 396–421.

  25. Lalleman P, Stalpers D, Goossens L, et al. RN2Blend: meerjarig onderzoek naar gedifferentieerde inzet van verpleegkundigen. Verpleegkunde. 2020;1:4–6.

    Google Scholar 

  26. Endacott R, O’Connor M, Williams A, et al. Roles and functions of enrolled nurses in Australia: Perspectives of enrolled nurses and registered nurses. J Clin Nurs. 2018;27(5–6):e913–20.

  27. Jacob E, Sellick K, McKenna L. Australian registered and enrolled nurses: Is there a difference? Intern J Nurs Pract. 2012;18(3):303–7.

    Article  Google Scholar 

  28. Matthias AD. Educational pathways for differentiated nursing practice: a continuing dilemma. In: Lewenson SB, McAllister A, Smith KM, editors. Nursing History for Contemporary Role Development. New York: Springer Publishing Company; 2017. p. 121–40.

    Google Scholar 

  29. Boston-Fleischhauer C. Another Look at Differentiating Nursing Practice. J Nurs Adm. 2019;49(6):291–3.

    Article  PubMed  Google Scholar 

  30. Gardner G, Duffield C, Doubrovsky A, et al. Identifying advanced practice: a national survey of a nursing workforce. Intern J Nurs Stud. 2016;55:60–70.

    Article  Google Scholar 

  31. Duffield C, Twigg D, Roche M, et al. Uncovering the disconnect between nursing workforce policy intentions, implementation, and outcomes: Lessons learned from the addition of a nursing assistant role. Policy Polit Nurs Pract. 2019;20(4):228–238.

  32. Terpstra D, Van den Berg A, Van Mierlo C, et al. Toekomstbestendige beroepen in de verpleging en verzorging: rapport stuurgroep over de beroepsprofielen en de overgangsregeling. 2015.

  33. Bohmer RM. The hard work of health care transformation. N Engl J Med 2016;375(8):709–11. doi:

    Article  PubMed  Google Scholar 

  34. Ellström PE. Integrating learning and work: Problems and prospects. Hum Res Dev Q. 2001;12(4):421–35.

    Article  Google Scholar 

  35. Lyman B, Hammond E, Cox J. Organizational learning in hospitals: A concept analysis. J Nurs Manag. 2019;27:633–46.

    Article  PubMed  Google Scholar 

  36. van Schothorst J, van Roekel AM,  Weggelaar-Jansen JWM, de Bont A, Wallenburg I. The balancing act of organizing professionals and managers: An ethnographic account of nursing role development and unfolding nurse-manager relationships. J Professions an Orga. 2020;7(3):283–99.

  37. Reay T, Golden-Biddle K, Germann K. Legitimizing a New Role: Small Wins and Microprocesses of Change. Acad Manag J. 2006;49(5):977–98.

    Article  Google Scholar 

  38. Mannix J, Wilkes L, Jackson D. Marking out the clinical expert/clinical leader/clinical scholar: perspectives from nurses in the clinical arena. BMC Nurs. 2013:12;12.

  39. Nelson-Brantley HV, Ford DJ. Leading change: a concept analysis. J Adv Nurs. 2017;73(4):834–46.

    Article  PubMed  Google Scholar 

  40. Boamah SA. Emergence of informal clinical leadership as a catalyst for improving patient care quality and job satisfaction. J Adv Nurs. 2019;75(5):1000–9.

    Article  PubMed  Google Scholar 

  41. Abbott A. Linked ecologies: States and universities as environments for professions. Sociol Theory. 2005;23(3):245–74.

    Article  Google Scholar 

  42. Hughes D. Nursing and the division of labour: sociological perspectives. In: Allen D, Hughes D, editors. Nursing and the Division of Labour in Healthcare. Hampshire and New York: Palgrave Macmillan; 2017. p. 1–21.

    Google Scholar 

  43. Ayala RA. Towards a Sociology of Nursing. Palgrave Macmillan; 2020.

  44. Chua WF, Clegg S. Professional closure. Theory Soc. 1990;19(2):135–72.

    Article  Google Scholar 

  45. Roper JM, Shapira J. Ethnography in nursing research. Thousand Oaks: Sage Publications; 2000.

    Book  Google Scholar 

  46. Polit DF, Beck CT. Nursing research: Generating and assessing evidence for nursing practice, 8th Edition. Philadelphia: Wolters Kluwer Health/ Lippincott Williams & Wilkins; 2008.

  47. Atkinson P, Hammersley M. Ethnography: Principles in practice. New York: Routledge; 2007.

    Book  Google Scholar 

  48. Draper J. Ethnography: Principles, practice and potential. Nurs Stand. 2015;29(36):36–41.

    Article  PubMed  Google Scholar 

  49. Allen D. The invisible work of nurses: Hospitals, organisation and healthcare. The Invisible Work of Nurses: Hospitals, Organisation and Healthcare. Oxfordshire and New York: Routledge; 2014.

    Book  Google Scholar 

  50. Lalleman P, Bouma J, Smid G, et al. Peer-to-peer shadowing as a technique for the development of nurse middle managers clinical leadership: An explorative study. Leader Health Serv. 2017;30(4):475–90.

    Article  Google Scholar 

  51. Atkins S, Lewin S, Smith H, et al. Conducting a meta-ethnography of qualitative literature: lessons learned. BMC Med Res Methodol. 2008;8:21.

  52. Houghton C, Casey D, Shaw D, et al. Rigour in qualitative case-study researh. Nurse Res. 2013;20(4):12–7.

    Article  PubMed  Google Scholar 

  53. Denzin NK, Lincoln YS, editors. The Sage handbook of Qualitative research. Thousands Oak: Sage; 2011.

  54. Creswell JW, Miller DL. Determining validity in qualitative inquiry. Theory Pract. 2000;39(3):124–30.

    Article  Google Scholar 

  55. Baker L, Observation. A complex research method. Library Trends. 2006;55(1):171–89.

    Article  Google Scholar 

  56. Kanuha VK. “Being” native versus “going native”: Conducting social work research as an insider. Social Work. 2000;45(5):439–47.

    CAS  Article  PubMed  Google Scholar 

  57. Dwyer SC, Buckle JL. The space between: On being an insider-outsider in qualitative research. Intern J Qual Methods. 2009;8(1):54–63.

    Article  Google Scholar 

  58. Star SL, Strauss A. Layers of silence, arenas of voice: The ecology of visible and invisible work. Comp Support Coop Work. 1999;8(1–2):9–30.

    Article  Google Scholar 

  59. Allen DA, Lyne PA. Nurses’ flexible working practices: some ethnographic insights into clinical effectiveness. Clin Effective Nurs. 1997;1(3):131–8.

    Article  Google Scholar 

  60. Allen D. Translational mobilisation theory: a new paradigm for understanding the organisational elements of nursing work. Intern J Nurs Stud. 2018;79:36–42.

    Article  Google Scholar 

  61. Arrowsmith V, Lau-Walker M, Norman I, et al. Nurses’ perceptions and experiences of work role transitions: a mixed methods systematic review of the literature. J Adv Nurs. 2016;72(8):1735–50.

    Article  PubMed  Google Scholar 

  62. Apker J, Propp KM, Ford WSZ, et al. Collaboration, credibility, compassion, and coordination: professional nurse communication skill sets in health care team interactions. J Prof Nurs. 2006;22(3):180–9.

    Article  PubMed  Google Scholar 

  63. Currie G, Koteyko N, Nerlich B. The dynamics of professions and development of new roles in public services organizations. The case of modern matrons in the English NHS. Public Adm. 2009;87(2):295–311.

    Article  Google Scholar 

  64. Skela-Savič B, Hvalič-Touzery S, Pesjak K. Professional values and competencies as explanatory factors for the use of evidence-based practice in nursing. J Adv Nurs. 2017;73(8):1910–23.

    Article  PubMed  Google Scholar 

  65. FURÅKER C. Registered Nurses’ views on their professional role. J Nurs Manag. 2008;16(8):933–41.

    Article  PubMed  Google Scholar 

  66. Stokke K, Olsen NR, Espehaug B, et al. Evidence based practice beliefs and implementation among nurses: a cross-sectional study. BMC Nurs. 2014;13(1):8.

    Article  Google Scholar 

  67. Abbott A. The system of professions: an essay on the expert division of labor. Chicago: The University of Chicago Press; 1988.

    Book  Google Scholar 

  68. Clegg SR, Kornberger M, Rhodes C. Learning/becoming/organizing. Organization. 2005;12(2):147–67.

    Article  Google Scholar 

Download references


The authors would like to thank all participants for their contribution to this study.


The Reinier de Graaf hospital in Delft, who was central to this study provided financial support for this research.

Author information

Authors and Affiliations



A.W. and I.W. developed the study design. J.S. and A.W. were responsible for data collection, enhanced by I.W. for data analysis and drafting the manuscript. C.H. and A.B. critically revised the paper. All authors have read and approved the manuscript.

Corresponding author

Correspondence to Jannine van Schothorst–van Roekel.

Ethics declarations

Ethics approval and consent to participate

All methods were carried out in accordance with relevant guidelines and regulations. The research was approved by the Erasmus Medical Ethical Assessment Committee in Rotterdam (MEC-2019-0215) and all participants gave their informed consent.

Consent for publication

Not applicable.

Competing interests

No competing interests has been declared by the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

van Schothorst–van Roekel, J., Weggelaar-Jansen, A.M.J., Hilders, C.C. et al. Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice. BMC Nurs 20, 97 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • Evidence-based practice
  • nursing practice
  • Policy
  • Registered nurses
  • Vocational-trained nurses
  • Role development
  • Role distinctions
  • Skill mix
  • Qualitative study