Striving for different opinions or seeking verification: the storylines of collaborative decision-making in workplace meetings in long-term care Open Access

Many countries around the world are facing shortages of nursing professionals (OECD, 2020). Moreover, many of these professionals have reported an intention to leave their jobs due to their burdensome working conditions (Van Aerschot et al., 2022; ICN, 2021). This raises an urgent need to find solutions to promote the work-related well-being of social and healthcare professionals. Collaborative decision-making, also termed shared decision-making or shared governance, has the potential to increase nursing professionals' work engagement (Lal, 2023), which in turn can increase job satisfaction and retention (Kutney-Lee et al., 2016; Slåtten et al., 2022).

Research has shown that authoritative management styles and a lack of influence over how their work is planned reduce nursing professionals' work satisfaction (Ruotsalainen et al., 2020; Tsapnidou et al., 2025). Nursing professionals who have already left their jobs have reported that one reason for doing so is the lack of recognition and support from their supervisors (Ring et al., 2024). Psychological, group and structural empowerment are organizational models that are recognized as important in supporting nursing professionals' engagement (Friend and Sieloff, 2018). Structural empowerment is also a key component in the Magnet hospital model, an example of a modern leadership structure in healthcare (ANNC, 2025). Indeed, health and social care workplaces could benefit from more collaborative workplace decision-making practices.

Collaborative decision-making means that professionals at all levels of the organisation can be part of the decision-making practices and processes related to their work. Although many studies have focused on healthcare professionals' collaboration (e.g. Shaqura et al., 2022; Väisänen et al., 2024), less attention has been paid to how collaborative decision-making is practised at the interactional level in natural team interactions between nursing professionals and their supervisors. Hujala and Rissanen (2012) are among the very few who have studied interactions in team meetings in long-term care. They found that supervisors can foster staff participation and contribution by inviting them to take part in conversation through openings, turn taking, closings and supporting expressions (Hujala and Rissanen, 2012). However, their focus was on general management discourse. The current study contributes to this area of research by identifying different collaborative decision-making practices in team meetings in long-term care facilities.

The decision-making process can be differentiated from making the decision. This study focuses on the process of decision-making, understanding it as an incremental activity in which nursing professionals and their supervisors move on their agenda and construct a decision step by step (Huisman, 2001) during their team meetings. Meeting interaction differs from ordinary conversation in terms of topic progression and turn taking (Asmuß and Svennevig, 2009). The meeting participants have different interactional and discursive rights. The chair of a meeting has the formal authority to present new topics, move to a new topic, build consensus, make decisions and manage conflicts (Larsson, 2017). However, these interactional rights are not fixed; they are discursively constructed, contested and renegotiated.

The aims of this study were to identify and analyse the interactional practices of collaborative decision-making used in long-term care facilities' team meetings and to examine how nursing professionals and supervisors are positioned within the decision-making process.

The data, gathered in 2023, comprised video-recorded workplace team meetings (n = 10) in four long-term care facilities. The facilities provided housing and care services for older people and were located in southern Finland. They all provided 24-h long-term care, but some also provided residential care with only daytime services. Each facility had some 40–60 residents.

The meetings were formal workplace meetings in which the supervisor acted as chair. The supervisors were trained healthcare professionals, usually registered nurses, with varying levels of additional management training. The other participants in the meetings were long-term care staff, mostly practical nurses but also registered nurses and assistant staff. The number of staff members in the meetings (those who had given consent to participate in this study) ranged from 7 to 11. The exact number of participants in one meeting was not available, as only audio data were received.

The meetings were long-term care facilities' weekly or monthly staff meetings, the topics of which covered various work practices in the care unit, the care of specific residents and general employment-related issues. Most of the facilities had some kind of arrangement for the staff to propose topics for the meetings. For instance, they could write their suggestions on a list in the staff office.

The staff in the participating care facilities were trained to use the video cameras provided by the researchers and to record the meetings independently. No researcher was present when the recordings were made. This means that the participants could independently choose which meetings they wanted to record. The recordings lasted between 45 and 90 min and totalled about 11.5 h. All recordings were transcribed verbatim.

The study adhered to the ethical principles of the Finnish National Board on Research Integrity (TENK, 2019). The participants received written and oral information about the study and their rights as research participants before data collection began. It was emphasised that they had the right to withdraw from the study, that their participation was voluntary and that the researchers were committed to confidentiality. Informed written consent to take part in the study was obtained from each participant. If they did not give their consent, they could still take part in the meeting but were then instructed to position themselves so that they could not be seen in the video. Their talk was also omitted from all the data extracts.

This study utilised discourse analysis, which is an umbrella term for a variety of methodological theoretical approaches for examining the meanings and realities that individuals construct through their use of language (Potter and Wetherell, 1987; Willig, 2015). This study drew specifically from positioning theory and the concept of position (Langenhove and Harré, 1999). Position can be defined as a “cluster of short-term disputable rights, obligations, and duties” (Harré, 2012, 193). Positioning thus refers to the active process during which these rights and duties are assigned in unfolding social episodes (Harré, 2012).

Positions differ from static roles in that they are dynamic constructs and can thus be affirmed, resisted, rejected or changed even within a single turn of talk (Langenhove and Harré, 1999). According to Harré (2012), positions are determined by storylines, which are discursive practices that make sense of our lives and events. Harré gives an example storyline of “nurse and patient”, where one has the duty of care and the other has the right to receive care. Positioning theory suggests that positions are always relational, so positioning someone as, for instance, a care receiver means that the other is positioned as a caregiver (Harré, 2012). Positioning theory is a suitable methodological tool for studying small group interactions such as decision-making, as it can demonstrate the dynamic nature of negotiating identities and the tacit rules of co-operation in a group (Hirvonen, 2013).

The first step of the analysis was to become familiar with the data. The researcher watched all the video recordings to obtain an overall picture of the data. The second step was to locate the collaborative decision-making sequences within the data by carefully reading the transcripts. Collaborative decision-making was defined as a decision-making sequence in which more than one person took part verbally in the discussion.

In the next step, the researcher scrutinised the decision-making sequences to understand what kinds of storylines they constructed in terms of collaborative decision-making. Attention was paid to the practices that the participants used to open the decision-making process, who responded to these openings and how. Another researcher familiar with the data commented on these preliminary findings. Two decision-making storylines were identified: striving for different opinions and seeking verification (Table 1). The storylines were examined to see how the nursing professionals and supervisors discursively positioned themselves and each other within them.

The analyses were conducted in the original language of the data, using the transcriptions of the meetings, but were later refined using the video recordings. The excerpts chosen for this paper were translated into English. All names are pseudonyms. Many decision-making situations were borderline cases (a borderline case is one in which multiple storylines co-occur or shift dynamically within a single interactional situation). Excerpts selected for this paper represent three typical decision-making practices and one borderline case. Extended excerpts are available from the author upon request.

When someone (most often the supervisor) presented a new topic for discussion, they often structured their turn of talk as an open question. Thus, they enabled collaborative decision-making by inviting others in the meeting to voice their opinions on the topic. This kind of interaction constructed the storyline of striving for different opinions.

Within this storyline, the nursing professionals were positioned as care work experts and the supervisor as facilitator. The following excerpt is taken from a discussion on care meetings that the staff organised annually for long-term care residents and their family members. Anna, who was also a team leader, asks how they should conduct the meetings with residents who had no family members.

Anna explicitly asks Lisa, the supervisor, what she would like them to do when a resident has no family members, and consequently positions Lisa as an expert with the right to answer the question. However, Lisa does not answer Anna but asks what “you” think and how the care meetings have been arranged so far. She thus enables collaborative decision-making by inviting other participants in the meeting to voice their opinions. She gives them the opportunity to voice their opinions and thus positions them as experts with knowledge of how the care meetings should be organised. At the same time, Lisa positions herself as a facilitator, actively seeking the participation and opinions of the staff members. She portrays herself as committed to ascertaining and respecting the staff members' views on the topic.

The previous example contained quite a simple question-and-answer sequence in which the supervisor positioned the nursing professionals as care work experts. Next is an example of a more complex conversation from the same meeting. Lisa has previously introduced a new topic to be discussed in the team meeting by saying that there has been some disagreement on work task distribution among the staff members and that they will now review its practicalities. She asks the staff to share their experiences of work task distribution. Some of the staff members begin describing a recent disagreement between some workers. Lisa then asks:

In this extract, the supervisor enables collaborative decision-making and positions the nursing professionals as care work experts by allowing them to decide on the best practices (“how would you like to do it then? […] you can decide here and now how you want to do it”). Lisa’s turn implies that the nursing professionals have the knowledge and responsibility to come up with a solution. After this, the conversation continues with a long, multifaceted discussion on how to organise work task distribution (covering other side topics as well). Several nursing professionals participate in the conversation and actively offer their opinions. They do not contest the position of expert that their supervisor gave them. In the end, no clear decision is made on how to organise work task distribution, but the conversation continues with other topics.

Within this storyline, allowing the meeting participants to voice their opinions meant that it was sometimes difficult to come up with a decision (as in the previous data extract). These kinds of collaborative decision-making sequences often lacked a turn during which someone explicitly stated the final decision. Consequently, positioning nursing professionals as experts might sometimes risk side-tracking the decision-making process. This might be a pitfall in collaborative decision-making, especially if the goal is to reach a specific decision to which the meeting participants have contributed.

The seeking verification storyline was initiated when someone proposed a decision that preferred simple agreement, as opposed to constructing the topic as one requiring discussion. In this storyline, someone (most often the supervisor) presents a proposal and the others (most often one or more of the nursing professionals) showed minimal agreement. The supervisor thus enabled collaborative decision-making, although the contribution from the nursing professionals was minimal.

In the previous data extract, Suzy’s decision proposals are constructed as preferring simple agreement. She uses wordings such as “should we” several times in her turn. She also uses declarative propositions (“they could be placed here”). The preferred response to these kinds of propositions is acceptance, especially when the one making the proposition is higher in the workplace hierarchy. Hence, the nursing professionals were positioned as proposal acceptors, whereas the supervisor was positioned as a verifier who had an interest in reaching a certain shared decision and who prioritised the acceptance of their proposal. The position of verifier implies that the supervisor has the required information and knowledge to propose a decision (as opposed to the striving for different opinions storyline).

This storyline was an effective, quick way to reach a decision. However, it did not further a discussion in which staff members were expected to voice their opinions on the topic. The proposal acceptor position was rarely contested, probably due to the institutional roles of the supervisor and the subordinates. The supervisors always acted as the chair in the meetings. Intervening and proposing another decision or showing disagreement would be interactionally difficult for the nursing professionals.

The seeking verification storyline was categorised as part of collaborative decision-making because accepting a proposition can be viewed as taking part in the decision-making. The nursing professionals also had the option of rejecting the proposition, at least in theory. In fact, sometimes they were able to position themselves as experts despite having already been positioned as proposal acceptors, as shown in the next excerpt.

The excerpt is taken from a team meeting in which the supervisor has just stated that they have received feedback from the family members of the care home residents that more communication is needed between the facility and the family members. She suggests that she will respond to the family members.

Mathilda’s proposition turn (“If I put it … ”) constructs the seeking verification storyline that positions her as a verifier. Her turn of talk prefers simple agreement from the meeting participants, who can then take part in collaborative decision-making. However, Maria contests this storyline by making a counterproposal. Directly after Mathilda’s suggestion, Maria implies that family members should ask themselves if they need more information from the facility. In doing so, she positions herself as someone with the knowledge and the right to offer a new point of view.

The supervisors can either strengthen the nursing professionals' positions or dismiss and re-position them. In the previous example, the supervisor’s turns after the nursing professional’s proposal show minimal agreement with the professional’s suggestion (“Yes”, “Uhmm”). These kinds of minimal answers can, in some cases, be regarded as inadequate for making a decision and can even be used to avoid addressing the actual problem (Siitonen and Wahlberg, 2015).

In the data extract, the supervisor finally repeats her initial proposal. This may indicate that she did not present her first proposal as something that should be discussed but as something that the care workers should merely agree on (and positioned the nursing professionals as proposal acceptors). Repeating her proposal also indicates that she does not treat Maria’s turn as a suggestion that should be taken seriously.

Although Maria contests the position that Mathilda initially affords her, Mathilda’s final turn once again positions her as a proposal acceptor. When Mathilda repeats her proposal, the nursing professionals do not position her as a verifier. By not reacting to the suggestion this time, they are treating the supervisor’s turn as a decision and not a proposition. Consequently, this decision-making sequence was a borderline case of collaborative decision-making. Although the supervisor invited the nursing professionals to accept (or reject) her proposal, their failure to acknowledge Maria’s counterproposal supports the argument that, ultimately, the decision-making was not collaborative.

Collaborative decision-making is specifically important in social and health care because it increases nursing professionals' work engagement (Lal, 2023), which in turn increases job satisfaction and retention (Kutney-Lee et al., 2016; Slåtten et al., 2022). This study used discourse analysis (Potter and Wetherell, 1987) and positioning theory (Langenhove and Harré, 1999) to examine nursing professionals' and their supervisors' collaborative decision-making process. The aims of the study were to identify and analyse the interactional practices of collaborative decision-making and to examine how nursing professionals and supervisors are positioned within the decision-making process. Two collaborative decision-making storylines were identified: striving for different opinions and seeking verification.

Within the striving for different opinions storyline, the supervisors positioned the nursing professionals as experts with the right to take part in the decision-making and to communicate new insights. The supervisor stepped out of their formal role of director with the power to decide what to do and acted as more of a coach who encouraged and empowered staff members to take responsibility for the development of their work practices (also Lehto-Niskala et al., 2025). The findings of this study suggest a pitfall of collaborative decision-making: allowing the meeting participants to voice their opinions means that it can be difficult to come to a shared decision (also Stevanovic, 2023). It is imperative that nursing professionals' voices be heard, but the pitfall is that decision-making may be sidetracked. In the data, this meant that the decision-making process took a great deal of time in the meeting and that the final decision made was often difficult to discern.

The seeking verification storyline comprised relatively fast decision-making. The supervisors positioned the nursing professionals as proposal acceptors and themselves as verifiers. The findings of this study highlighted that this kind of decision-making may not further a discussion in which staff members are expected to voice their opinions on the topic, which can be detrimental to collaborative decision-making. That said, in the data, the nursing professionals could also reject their proposal acceptor position and present a counterproposal. The supervisors could either encourage or discourage the nursing professionals from taking part in the decision-making process, as they had the power to choose whether a topic would be considered for decision-making. Similarly, Hujala and Rissanen (2012) noticed that staff members' voices were inhibited by non-responses to conversation invitations. This is another pitfall of collaborative decision-making: by rejecting the care professionals' proposals, the supervisor bypasses their opinions.

Care professionals working with older people who report not receiving enough support from their supervisors are more likely to have intentions to leave their jobs than those who feel supported (Van Aerschot et al., 2022). Acknowledging staff members' proposals and strengthening their expert positions could help nursing professionals feel supported by their supervisors, at least regarding work-related decision-making. Not all supervisors in long-term care are trained in leading effective, inclusive or collaborative meetings. They could benefit from training programs in which they are invited to reflect on real-life examples of decision-making in staff meetings. Such training could help raise awareness of different decision-making styles and support the development of more inclusive and transparent collaborative practices. Moreover, the supervisors always acted as chair in the meetings, which meant that they possessed the interactional rights to present new topics, move to a new topic and make decisions (Asmuß and Svennevig, 2009; Larsson, 2017). Stemming from this, some social and healthcare units might benefit if staff members sometimes act as chair. This could potentially strengthen their interactional rights to propose decisions and make counterproposals if that is what is expected of them.

This study highlights that positioning theory can help elucidate nursing professionals' dynamic positions that are constructed and negotiated during workplace interactions. In a recent nationally representative survey, more than 50% of Finnish facility and unit managers in long-term care self-evaluated themselves as being “very good” at engaging their staff members in the unit’s decision-making (Olakivi and Lehto-Niskala, 2024). This study examined qualitative variations in how such engagement can take place in practice in four Finnish long-term care facilities, as well as the pitfalls and challenges such engagement may involve, whether noticeable to the managers themselves or not. This approach contributes to the research on leadership as a relational issue that is co-constructed in social interactions between leaders and followers (Fairhurst and Uhl-Bien, 2012). As the focus in healthcare organisations is moving towards shared, empowering leadership, these discussions are becoming more relevant.

The workplaces that participated in this study represented only a fraction of long-term care facilities or healthcare in general. It is likely that the situations or relationships between the nursing staff and the supervisors were not very problematic. As they had the autonomy to choose which meetings they recorded and shared with the researchers, it is likely that the recorded meetings did not represent the most difficult interactional situations. Therefore, the results are not representative of decision-making situations in long-term care in general. Nevertheless, the results showed that there can also be challenges in successful interactional situations. All meetings included similar decision-making sequences. Thus, similar decision-making practices may also occur in other healthcare workplaces, at least in long-term care.

Workplace meetings can be understood as “naturally occurring data” (Silverman, 2014). However, the participants were aware that they were being recorded, which might have affected their meeting topics, use of words or other social practices. Yet one participant explicitly mentioned during the recording that they had forgotten about the cameras.

Although the results are not generalisable due to the small sample and specific context, the specific strength of this study was that it was able to show the subtle, often unnoticed interactional practices and the qualitative variation of such practices that take place in decision-making situations. More research is needed to understand contextual factors influencing decision-making practices, such as organizational culture. In addition, research on decision-making practices from different contexts in the healthcare field is needed.

This study approached collaborative decision-making broadly as a decision-making process in which more than one person participates in the discussion. Using positioning theory, this study was able to show that nursing professionals' and supervisors' positions are not static during decision-making sequences and that they can be negotiated, strengthened or rejected. As collaborative leadership has become a growing expectation in healthcare and long-term care, it is essential to explore what this leadership truly entails, what types of interactional skills are expected of leaders and what kinds of support employees are hoping to receive from their supervisors. Supervisors should pay special attention to the subtle openings of their employees. Implementing democratic, collaborative decision-making practices in healthcare may enable nursing professionals to better express their concerns and perspectives and thus support their work satisfaction. Different interactional approaches in meetings between healthcare supervisors and nursing professionals may be needed for the success of collaborative decision-making.

I am grateful for all the staff members and their supervisors in the long-term care facilities who took their time and participated to this study. I would like to express my sincere thanks to Dr Antero Olakivi for their insightful comments to an earlier draft of this manuscript.