Expert nurses and the division of labour in hospitals

This article analyses nursing expertise with a particular focus at the level of clinical and organizational practice. Through an examination of a specialist team of hospital nurses, and drawing on the concept of a community of practice, the article provides a critique of discussions of nursing expertise which can be overly normative, individualistic or divorced from practice. The theoretical background to our analysis is the division of labour in health care; the case study on which this analysis is based is a particular health policy: the introduction of critical care outreach services. The empirical portions of the article are based on a qualitative study of eight such services in England. In the first part of the analysis we elaborate on three ways in which 'expertise' can be deployed in practice: teaching and training; consultancy and advice; and practical clinical action. Each of these is shown to be related to the development of a community of practice. In the second part of the analysis we examine in more detail the impact of outreach nurses on the division of labour in health care and on traditional occupational hierarchies. A general implication of our findings is that expertise has fundamentally social characteristics which need to be acknowledged in academic and policy discourse.