title: Dual agency in critical care nursing: Balancing responsibilities towards colleagues and patients.
abstract: OBJECTIVE
  To explore critical care nurses' decisions to seek help from doctors.
  
  
  BACKGROUND
  Despite their well-documented role in improving critically ill patients' outcomes, research indicates that nurses rarely take decisions about patients' treatment modalities on their own and constantly need to seek advice or authorization for their clinical decisions, even for protocol-guided actions. However, research around the factors related to, and the actual process of, such referrals is limited.
  
  
  METHODS
  A grounded theory study, underpinned by a symbolic interactionist perspective.
  
  
  METHODS
  Data collection took place in a general intensive care unit between 2010 - 2012 and involved: 20 hours of non-participant and 50 hours of participant observation; ten informal and ten formal interviews; and two focus groups with ten nurses, selected by purposive and theoretical sampling. Data analysis was guided by the dimensional analysis approach to generating grounded theory.
  
  
  RESULTS
  Nurses' decisions to seek help from doctors involve weighing up several occasionally conflicting motivators. A central consideration is that of balancing their moral obligation to safeguard patients' interests with their duty to respect doctors' authority. Subsequently, nurses end up in a position of dual agency as they need to concurrently act as an agent to medical practitioners and patients.
  
  
  CONCLUSIONS
  Nurses' dual agency relationship with patients and doctors may deter their moral obligation of keeping patients' interest as their utmost concern. Nurse leaders and educators should, therefore, enhance nurses' assertiveness, courage and skills to place patients' interest at the forefront of all their actions and interactions.
authors.affiliation: Department of Nursing, University of Malta, L-Imsida, Malta.
authors.forename: Josef
authors.initials: J
authors.lastname: Trapani
authors.affiliation: School of Health Science, University of Brighton, UK.
authors.forename: Julie
authors.initials: J
authors.lastname: Scholes
authors.affiliation: Department of Nursing, University of Malta, L-Imsida, Malta.
authors.forename: Maria
authors.initials: M
authors.lastname: Cassar
mesh_terms: D003422:Critical Care; D064648:Critical Care Nursing; D003657:Decision Making; D006801:Humans; D007362:Intensive Care Units; D009741:Nursing Staff, Hospital
keywords: critical care; decision-making; dimensional analysis; dual agency; grounded theory; nurses; principal-agent theory; referral; seeking help