title: Gaps in governance: protective mechanisms used by nurse leaders when policy and practice are misaligned.
abstract: BACKGROUND
  Due to large geographical distances, the telephone is central to enabling rural Australian communities to access care from their local health service. While there is a history of rural nurses providing care via the telephone, it has been a highly controversial practice that is not routinely documented and little is known about how the practice is governed. The lack of knowledge regarding governance extends to the role of Directors of Nursing as clinical leaders charged with the responsibility of ensuring practice safety, quality, regulation and risk management. The purpose of this study was to identify clinical governance processes related to managing telephone presentations, and to explore Directors of Nursing perceptions of processes and clinical practices related to the management of telephone presentations to health services in rural Victoria, Australia.
  
  
  METHODS
  Qualitative documentary analysis and semi structured interviews were used in the study to examine the content of health service policies and explore the perceptions of Directors of Nursing in eight rural health services regarding policy content and enactment when people telephone rural health services for care. Participants were purposively selected for their knowledge and leadership role in governance processes and clinical practice. Data from the interviews were analysed using framework analysis. The process of analysis resulted in the identification of five themes.
  
  
  RESULTS
  The majority of policies reviewed provided little guidance for managing telephone presentations. The Directors of Nursing perceived policy content and enactment to be largely inadequate. When organisational structures failed to provide appropriate governance for the context, the Directors of Nursing engaged in protective mechanisms to support rural nurses who manage telephone presentations.
  
  
  CONCLUSIONS
  Rural Directors of Nursing employed intuitive behaviours to protect rural nurses practicing within a clinical governance context that is inadequate for the complexities of the environment. Protective mechanisms provided indicators of clinical leadership and governance effectiveness, which may assist rural nurse leaders to strengthen quality and safe care by unlocking the potential of intuitive behaviours. Kanter's theory of structural power provides a way of conceptualising these protective mechanisms, illustrating how rural nurse leaders enact power.
authors.affiliation: La Trobe Rural Health School, Bendigo, VIC, Australia. k.knight@latrobe.edu.au.
authors.forename: Kaye M
authors.initials: KM
authors.lastname: Knight
authors.affiliation: La Trobe Rural Health School, Bendigo, VIC, Australia. a.kenny@latrobe.edu.au.
authors.forename: Amanda
authors.initials: A
authors.lastname: Kenny
authors.affiliation: Centre for Health and Social Care Innovation, Faculty of Health and Human Sciences, University of Plymouth, Drake Circus, Plymouth UK & Monash University, Melbourne, Australia. ruth.endacott@plymouth.ac.uk.
authors.forename: Ruth
authors.initials: R
authors.lastname: Endacott
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006291:Health Policy; D006801:Humans; D007857:Leadership; D008297:Male; D008875:Middle Aged; D009718:Nurse Administrators / Q000523:psychology* / Q000592:standards*; D024382:Professional Role; D012112:Residential Facilities / Q000592:standards*; D019035:Rural Health Services / Q000592:standards*; D017216:Telemedicine / Q000592:standards*; D014739:Victoria