2.1 Study design and data collection

The study was conducted in NICUs of 2 perinatology centres in tertiary health care in Lithuania. The research employed the focus group method, which allows the questions of interest to be discussed in a short time. For this research we had three focus groups with nurses working in neonatal intensive care units. The length of each discussion ranged from 1 hour and 5 minutes to 1 hour and 20 minutes. To ensure comprehensive and effective research of the issue and a sufficient number of participants, each focus group involved 5 nurses in a discussion.

The sample consisted of 15 mid-age intensive care nurses. Most are married, live in the city, and had no university education. They had an average of over 22 years of work experience in neonatal intensive care units. The characteristics of the research participants are presented in Table 1.

Every participating person signed an informed consent agreement. The nurses who agreed to participate were provided a convenient time and place for the group discussion. Analysis of the group discussion material was presented in the form of quotes from unrelated stories. Prior to the study, each person was informed of her rights regarding personal data handling, including the right to know what personal data was being used and the right to correct, delete, or stop personal data handling should she desire to withdraw from the study. Furthermore, it was made clear that if a nurse decided to withdraw or otherwise decline to participate, such a decision would not influence her professional career.

Two researchers participated in each of the focus groups. One of them, the author of this article, was moderating the discussion, and the other was observing the process. The main criteria for selecting the observer of the discussion were her ability to be objective and her level of experience in moderating and participating in focus groups.

The discussions were arranged in a circle format for both participants and researchers. This allowed everyone to observe each other, maintain eye contact, and encourage engagement in the discussion. Discussions were led according to the framework of the conversation, which was developed in advance. The following leading questions were used to open or direct the discussion:

• - What kind of preparation do nurses need to be able to work in a neonatal intensive care unit?

• - How would you describe your interaction with a team of doctors and parents of newborns?

At the beginning of the discussion, participants introduced themselves, answered questions about work, how they felt after a day of work (e.g., “Did you get very tired at work today?”). This made it possible to get acquainted with the participants of the focus group, to establish contact with them. Gradually, the discussion was led to the research questions. Questions were formed freely, stimulating the discussion process (e.g., “So, what are the tasks that rightfully belong to doctors, but, from your perspective, are often performed by you?”; “What do you often talk about, what information do you provide to the parents of newborns? Are there any forbidden topics or things you shouldn’t do or say to parents in cases when a baby dies?”).

2.2 Data analysis

The results of the study were analysed using the thematic analysis described in Braun and Clarke (2006) [8]. This method was used to highlight the structure of data identification, analysis, and presentation of results. Following the recommendations of the methodologists, the data analysis process involved 6 steps [8, 9].

In the first phase, when transcribing the discussion material, we got acquainted with the collected data. At this stage, we repeatedly listened to the recordings of the discussions and re-read the notes, highlighting thoughts and insights that arose while listening and reading.

In the second phase, the text was broken down to find units of meanings, generating the initial code analysis checklist for the analysis of the research material.

The third phase can be called the “topic-search” phase. In this stage, the research material was re-read, suitability of the selected codes was re-evaluated, codes were grouped into subtopics, and then into potential topics.

In the fourth stage, the topics were reviewed. It was done on two levels. At first, we reviewed the topics and checked the topic titles. While reading the material, we evaluated whether the code structure was coherent, consistent, and relevant to all of the material. On the second level, re-grouping of codes took place, and the “topic map” was created.

The fifth stage can be described as the stage of identifying and defining the main themes. At this stage, material analysis was continued, and titles were created and clarified.

The sixth phase can be called the completion phase of the analysis. In describing the topic, the aim was to select vivid, logical examples that would properly illustrate and reveal the topic. The obtained results were related to scientific literature [8,9].

Ethics of the study: The study was approved by the Kaunas regional committee for bioethical research (permission No. BE-2-15).

3.1 Limits are defined formally and clear

The participants of the study talked about the fact that in Lithuania nursing competencies are clearly written out and their functions are formally defined: “They [competencies] are defined and very clearly written out. <...> What we can do as a nurse, everything is [thoughtfully] defined” (Inesa).

Particularly rigorous limits for nurses have been identified regarding communication with the parents of newborns. They are forbidden to talk about their treatment: “We cannot tell all of the things to parents, anything to do with treatment” (Giedrė). It is not permitted to talk about the procedures performed on newborns: “You cannot talk about resuscitation, about antibiotics” (Regina).

3.2 Limits often are exceeded

When speaking about competencies, nurses often emphasized that they have had to go beyond what they are permitted. According to the thoughts the nurses shared in the research, we distinguished the following reasons for exceeding competency limits:

3.3 Nurse takes greater responsibility by her own choice

It is demanded by the nature of the job, which promotes greater personal responsibility: “... this work is special because the nurse has a lot of responsibility while performing her tasks. She sometimes takes a lot of responsibility” (Julija). Nurses working in neonatal intensive care units feel personally responsible for a newborn baby: “... I am responsible for the child, and he got all blue, his hands trembling” (Edita). Therefore, the limit of competences is exceeded and sometimes a nurse does more than defined in the regulations: “... he [the doctor] is also busy somewhere and will not be able to catch up. Yes, then you will cross the limit, do a lot more, and think: ‘Let it be’ [gets silent]” (Inesa); “Sometimes you will cross the limit and do more than you have to, but I can’t imagine how to do [that] otherwise” (Ilona).

When working in intensive care, there are situations when one faces a dilemma: follow competency limits or simply be human? “... but do we really work like that and [or] do we really only do this? Because if you only follow what is written, you will deviate from humanity” (Inesa).

Also, nurses themselves sometimes feel that they can carry out more than mere nursing functions for newborns, more complex procedures requiring special skills: “<...> the nurse does not only, sorry, do cleaning of the butt or feeding the newborn, but many procedures [are performed], which are complex, which require knowledge, skills ...”(Julija).

3.4 Life-threatening situations

Another reason why nurses go beyond their competencies is to save the life of the newborn in life-threatening situations. In such situations, every minute is precious, and delay can cost the newborn’s life. “When a child is worsening, you are doing your job, and there is no doctor besides, and until he comes, he [the newborn] may die” (Inesa). “She [a nurse] very often just does more than just her job, because sometimes we do not have time to invite a doctor. For example, if a newborn dies, we will begin to solve the problem and someone will invite <...> (Julia).

3.5 Doctors delegate larger functions

Another reason why nurses go beyond their competencies is that doctors delegate them certain tasks. The participants in the study talked about the fact that they often carry out procedures that should be performed by doctors: “It happens [that] that we carry out doctors’ procedures for doctors” (Sandra). However, it was also noted that doctors only entrusted such procedures to experienced nurses: “It’s just those [nurses] who have worked here twenty years or more. Doctors are used that they know everything, and part of their work they put on that nurse” (Regina). The nurse named a lot of complicated procedures, which sometimes do not involve doctors: “Well, putting in the central catheter must be done in the presence of a doctor, drainage of the trachea, and we do a lot more” (Regina).

3.6 Conflicting feelings

Emergency situations in intensive care require prompt and immediate solutions. In such situations, it is very difficult to do everything the way it is written up and one needs to decide what is most important task at that moment: “Competence and responsibility, and knowing we sometimes stand at a decision which if you cross and something fails, you will get it for that thing [nervous laugh, pause], you will just get into trouble” (Julia).

During the conversation, nurses mentioned the fears that they experience when they need to go beyond their competencies. Feelings of insecurity are particularly common in recent times when parents are reluctant to actively participate and react to everything that is happening to their infant: “... it’s more because of my insecurity, I try to stay within that limit, because of all these accusations. Thinking now is terrible and going too far <...>” (Edita). Nevertheless, it was also stated that the greater responsibility delegated to them by doctors also brings feelings of satisfaction and pride: “... we really began to enjoy the appreciation and extra work that we are given” (Julia). Conflicting feelings are also caused by the fact that the nurse must adhere to the limits of the competence regulations and cannot say to parents more than is currently allowed: “She [the nurse] does not say the results, but they can say whether that procedure is done. But this is forbidden to us” (Julia).