Enhancing Role Clarity for the Practical Nurse: A Leadership Imperative

Resilience for working in Ontario home and community care: registered practical nurses need the support of themselves, family and clients, and employers

BACKGROUND

The context of practice is often not explicit in the discourse around the personal and professional resilience of nurses. The unique factors related to providing nursing care in home and community care may provide novel insight into the resilience of this health workforce. Therefore, this research addressed how nurses build and maintain resilience working in the home and community care sector.

METHOD

A qualitative study was conducted between November 2022 to August 2023 using 36 in-depth interviews (29 registered practical nurses [RPNs], five supervisors of RPNs, two family/care partners (FCPs) of clients receiving home and community care services). Analysis was consistent with a grounded theory approach including coding and comparative methods.

RESULTS

The factors of personal and professional resilience were not distinct but rather mixed together in the experience of nurses having resilience working in the home and community care sector. The process of building and maintaining resilience as home and community care nurses was informed by three categories: (1) The conditions of working in HCC; (2) The rapport RPNs held with FCPs; and (3) The nurses' ability for supporting the 'self'. Multiple components to inform these categories were identified and illustrated by the words of the nurse participants.

CONCLUSION

The process of building and maintaining resilience by RPNs working in the home and community care sector was guided by the day-to-day experiences of providing care for clients and the conditions of being a mobile health care provider. However, nurses may sense when they need to support their 'self' and must be empowered to request and receive support to do so.

Development of the nursing associate professional identity: A longitudinal qualitative study

AIM

The aim of this study was to understand the factors that contribute to the development of the nursing associate professional identity.

DESIGN

A 3-year longitudinal qualitative study of trainee nursing associates.

METHODS

Trainee nursing associates in England were interviewed remotely annually in February 2020, March 2021 and March 2022. They also provided diary entries. Data were anonymised, transcribed and analysed thematically.

RESULTS

Nursing associate professional identity was developed through: increased knowledge, skills and responsibility; and self-perceptions of identity alongside responses to the role by colleagues. Tensions arose when the scope of practice expected by organisations differed from that expected by the nursing associates. Frustrations occurred when nursing associates were perceived as substitutes for Registered Nurses in the context of nursing workforce shortages.

CONCLUSION

Nursing associates in this study clearly valued their new knowledge, skills and responsibility, enabling them to provide enhanced patient care. Increased clarity of role boundaries is necessary in enhancing the professional identity of nursing associates and reducing inter-professional tensions arising from role ambiguity within health and social care organisations.

IMPLICATIONS FOR THE PROFESSION

National guidance and employers should provide clarity on the boundaries of the nursing associate role which will strengthen their professional identity and mitigate role ambiguity within health and social care organisations.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research has been used to guide reporting.

PATIENT OF PUBLIC CONTRIBUTION

A patient and public involvement group was consulted during the initial study design stage.

IMPACT

This study aimed to understand the factors which contribute to the development of a nursing associate professional identity. Nursing associate professional identity is developed through increased knowledge, skills and responsibility, and the perceptions of identity by participants themselves and their colleagues. The findings should inform the implementation of initiatives to clarify nursing associate role boundaries and the development of similar roles internationally.

Trainee nursing associates in England: A multisite qualitative study of higher education institution perspectives

AIM

To explore the experiences of university employees on the development and implementation of the nursing associate programme.

BACKGROUND

As part of wider policy initiatives to address workforce shortages, provide progression for healthcare assistants and offer alternative routes into nursing, England recently introduced the nursing associate level of practice. Little research has yet considered university perspectives on this new programme.

METHODS

An exploratory qualitative study reported following COREQ criteria. Twenty-seven university staff working with trainee nursing associates in five universities across England were recruited. Data, collected via semi-structured interviews from June to September 2021, were analysed through a combined framework and thematic analysis.

RESULTS

Three themes developed: 'Centrality of partnerships' considered partnerships between employers and universities and changing power dynamics. 'Adapting for support' included responding to new requirements and changing pedagogical approaches. 'Negotiating identity' highlighted the university's role in advocacy and helping trainees develop a student identity.

CONCLUSIONS

Nursing associate training in England has changed the dynamics between universities and healthcare employers, shifting learners' identity more to 'employee' rather than 'student'. Universities have adapted to support trainees in meeting academic and professional standards whilst also meeting employer expectations. While challenges remain, the ability of nurse educators to make adjustments, alongside their commitment to quality educational delivery, is helping establish this new training programme and thereby meet government policy initiatives.

IMPLICATIONS FOR NURSING POLICY

The international movement of apprenticeship models in universities has the potential to change the status of the learner in nursing educational contexts. National policies that encourage this model should ensure that the implications and challenges this change of status brings to learners, employers and education institutions are fully considered prior to their implementation.

The relationship between role ambiguity, emotional exhaustion and work alienation among chinese nurses two years after COVID-19 pandemic: a cross-sectional study

BACKGROUND

work alienation is receiving increasing attention as a psychological risk at work, and little is known about the mechanisms of role ambiguity and work alienation in nurses in the context of the COVID-19 pandemic. This article aims to examine how role ambiguity affects work alienation among Chinese nurses during the two years after COVID-19 pandemic and verify emotional exhaustion as mediators.

METHODS

A cross-sectional study design was used to recruit 281 Chinese nurses. Nurses completed online questionnaires containing demographic characteristics, role ambiguity, emotional exhaustion, and work alienation, and SPSS 26.0 and AMOS 24.0 were used for data analysis and structural equation modelling.

RESULTS

work alienation scores were (34.64 ± 10.09), work alienation was correlated with role ambiguity and emotional exhaustion (r1 = 0.521, r2 = 0.755; p < .01), and role ambiguity was positively correlated with emotional exhaustion (r = 0.512; p < .01). A mediating effect of emotional exhaustion between role ambiguity and work alienation held (mediating effect of 0.288, 95% CI: 0.221-0.369, accounting for 74.8% of the total effect).

CONCLUSION

Role ambiguity has a significant direct effect on nurses' feelings of alienation and exacerbates alienation through emotional exhaustion. Clarifying roles at work and being less emotionally drained are effective ways to reduce nurses' feelings of alienation.

Role Clarity and Interprofessional Colleagues in Psychological Safety: A Faculty Reflection

SUMMARY STATEMENT

Psychological safety in high-fidelity simulation-based experiences ensures that learners feel safe with new experiences in the service of learning. This article is a faculty reflection on breaches in the psychological safety among nursing students in 2 independent, high-fidelity simulation-based experience studies that were conducted in 2019. Demonstrated breaches in psychological safety included fear and anxiety in the sole provider role in multiple-patient simulations and incivility directed toward nursing students in a primary nurse role in interprofessional simulations. This article adds to the growing literature on psychological safety by sharing important lessons learned regarding role clarity and interprofessional colleagues, proposing recommendations, and providing suggestions for future research on psychological safety.

Investigating the Effects of Intraprofessional Learning in Nursing Education: Protocol for a Longitudinal Study

Interprofessional learning (IPL), where nursing students learn how to work with multiple health professionals in their future practice to deliver the highest quality of care, has become an essential feature of undergraduate nursing programs. Intraprofessional learning (IaPL) is where individuals of two or more disciplines within the same profession collaborate; however, there is a dearth of literature investigating its effects in nursing education. The aim of this study is to investigate the impact of IaPL on the development of nursing students' knowledge, skills, and attitudes for collaborative practice. The study will utilize a mixed methods approach with surveys conducted at six time points across two years of two nursing programs and focus groups at the end of the program. Participants will be recruited from the Diploma and Bachelor of Nursing programs at an Australian Training and Further Education institute. Four specific IaPL educational experiences incorporating simulation will be developed on aged care, mental health, complex care and acute care. The study will provide nursing students with multiple opportunities to develop the necessary capabilities for collaborative practice. It will longitudinally evaluate nursing students' attitudes towards IaPL and examine whether IaPL motivates Diploma of Nursing students to pathway into a Bachelor of Nursing degree. The study will also investigate awareness amongst nursing students of the scope of practice, roles and responsibilities of the nursing team.

The Comparison of Role Conflict Among Registered Nurses and Registered Practical Nurses Working in Acute Care Hospitals in Ontario Canada

OBJECTIVES

The study aimed to describe and compare nurses' perceptions of role conflict by professional designation [registered nurse (RN) vs registered practical nurse (RPN)] in three primary areas of practice (emergency department, medical unit, and surgical unit).

METHODS

This analysis used data (n = 1,981) from a large cross-sectional survey of a random sample of RNs and RPNs working as staff nurses in acute care hospitals in Ontario, Canada. Role conflict was measured by the Role Conflict Scale.

RESULTS

A total of 1,981 participants (RN = 1,427, RPN = 554) met this study's eligibility criteria and provided complete data. In general, RN and RPN mean total scale scores on role conflict hovered around the scale's mid-point (2.72 to 3.22); however, RNs reported a higher mean score than RPNs in the emergency department (3.22 vs. 2.81), medical unit (2.95 vs 2.81) and surgical unit (2.90 vs 2.72). Where statistically significant differences were found, the effect sizes were negligible to medium in magnitude with the largest differences noted between RNs and RPNs working in the emergency department.

CONCLUSIONS

The results suggest the need to implement strategies that diminish role conflict for both RNs and RPNs.

Social support and job satisfaction in nursing staff: Understanding the link through role ambiguity

AIM

This study aimed to analyze the mediator effect of role ambiguity between social support from supervisor and colleagues and job satisfaction in Portuguese nursing staff.

BACKGROUND

Few studies have analyzed the processes through which social support increases job satisfaction in the nursing context.

DESIGN

A cross-sectional design using questionnaires.

METHOD

A total of 124 registered nurses and 130 certified nursing assistants participated in the study. Mediation analysis was performed by calculating Percentile confidence intervals (10,000 resamples).

RESULTS

Mediation analysis revealed a partial mediation between social support and job satisfaction through role ambiguity. The direct effect was greater in the case of supervisor support.

CONCLUSIONS

Social support is a crucial resource in the nursing work context with a beneficial effect on well-being (e.g. reducing role stress) and job satisfaction. Implications for Nursing Management Managers of hospitals and health units can establish the organizational bases to facilitate this process, considering the importance of the role of the supervisors and colleagues in the provision of high levels of instrumental and socio-emotional support.

The Daily Basic Psychological Need Satisfaction and Work Engagement of Nurses: A ‘Shortitudinal’ Diary Study

Nurses’ satisfaction and work engagement have been linked to patient outcomes. Nightshift nurses provide healthcare to the population and experience unique challenges in performing their healthcare tasks. Therefore, the current study aimed to investigate the daily basic needs satisfaction and work engagement of nightshift nurses in accordance with the satisfaction of three basic psychological needs as indicated by the Self-Determination Theory. A quantitative, ‘shortitudinal’ design (diary study; over a few days) with a multi-level research approach using a daily diary survey method was completed by a convenience sample of nurses working the nightshift in a public hospital (n = 33). The results revealed that the daily need for autonomy and need for relatedness did not significantly predict variance in daily work engagement. However, need for competence did significantly predict variance in daily work engagement, and general emotional load explained significant variability in daily need satisfaction of competence. Lastly, general role clarity had a negative impact on the daily variability in work engagement. This study provides healthcare organisations with explanations for variance in nursing performance and suggests possible interventions to address nursing outcomes in accordance with the three basic needs of nightshift nurses in daily activity.

To whom health care aides report: Effect on nursing home resident outcomes

INTRODUCTION

Health care aides (personal support workers and nursing assistants) provide ~80%-90% of direct care to residents in nursing homes; it is therefore important to understand whether supervision of health care aides affects quality of care. We sought to determine whether health care aide reporting practices are associated with resident outcomes in nursing homes.

DESIGN AND METHODS

We conducted a cross-sectional secondary analysis of survey data of 3991 health care aides from 322 units in 89 nursing homes in Western Canada. We then linked resident data from the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 database to care aide surveys at the unit level. We used hierarchical mixed models to determine if the proportion of health care aides reporting to a respective nursing leader role was associated with 13 practice sensitive quality indicators of resident care.

RESULTS

Most health care aides reported to a registered nurse (RN, 44.5%) or licenced practical nurse (LPN, 53.3%). Only 2.2% of health care aides reported to a care manager and were excluded from the analysis. Resident outcomes for only declining behavioural symptoms were more favourable when a higher proportion of health care aides (on a unit) reported to RNs, β = -0.004 (95% CI -0.006, -0.001, p = .004). The remaining indicators were not affected by care aide reporting practices.

DISCUSSION AND IMPLICATIONS

Resident outcomes as evaluated by the indicators appear largely unaffected by care aide reporting practices. LPNs' increasing scope of practice and changing work roles and responsibilities in nursing homes across Western Canada may explain the findings.

Collaboration among nurses when transitioning older adults between hospital and community settings: a scoping review

BACKGROUND

The transitioning of older patients between healthcare sectors requires the provision of high-quality nursing care. Collaboration among nurses is identified as an essential element of transitional care, yet nurse-nurse collaboration has received little attention.

AIM

The aim of this study was to examine the extent, range and nature of nurse-nurse collaboration when transitioning older patients between hospital and community settings, and to identify gaps in the literature.

METHODS

Arksey and O'Malley's (International Journal of Social Research Methodology, 8, 2005 and 19) framework was used to undertake a scoping review to answer the research questions: how do nurses collaborate together when transitioning older patients from hospital to community settings and what are the facilitators, barriers and outcomes of nurse-nurse collaboration when transitioning older patients between sectors? The Nurse-Nurse Collaboration Scale (NNCS) subdomains informed the identification of selected studies.

RESULTS

Twelve papers were included with most coming from Scandinavian countries and the majority using qualitative methodologies. Communication, coordination and professionalism were found to be both facilitators and barriers of nurse-nurse collaboration. Gaps in the literature included conflict management, and the outcomes of collaboration which was only reported in one study.

CONCLUSIONS

The findings indicate there is limited study of collaboration among nurses when transitioning older patients between hospital and community settings. Future research should address the impact of conflict on nurses working in collaborative practice as well as conducting intervention studies to examine the outcomes of nurse-nurse collaboration.

Healthcare professionals' perspectives on enrolled nurses, practical nurses and other second-level nursing roles: A systematic review and thematic synthesis

BACKGROUND

Significant workforce shortages and economic pressures have led to the expanded scope and reintroduction of new roles for second-level nurses in many Organization for Economic Co-operation and Development countries. Given this, there is a need to understand the emic and etic perspectives of second-level nurses, to ensure collaborative teamwork and safe patient care.

OBJECTIVE

This review aimed to systematically identify, appraise, and synthesize qualitative research evidence on healthcare professionals' perspectives on second-level nursing roles in the healthcare workforce. These findings inform recommendations that would influence the development and implementation of these roles in healthcare organisations.

DESIGN

A systematic review and thematic synthesis of qualitative research was conducted. Six databases were systematically searched and forward and backwards searching completed. Included studies focused on healthcare professionals' perspectives (including views of second-level nurses themselves) on second-level nursing roles. All included articles were from Organization for Economic Co-operation and Development countries. The Critical Appraisal Skills Programme checklist for qualitative research was used to assess the evidence quality. The results section of each included article was coded and descriptive themes were developed. An interpretative and iterative process led to the final analytic themes.

FINDINGS

Twenty-six qualitative studies were identified from five countries over 26 years. Four analytic themes were identified: undifferentiated role; efficient but limited; subordinated task-doers; and broadening scope and strengthened identity. The synthesis demonstrated dichotomies wherein some second-level nursing roles were devalued, and others had increasing scope and responsibility. Role and boundary confusion was evident and had not decreased over time. Hierarchies in nursing practice underlined the split between critical thinking and hands-on approaches to care which, in some cases, debased the second-level nursing role because of its association with practical hands-on care.

CONCLUSIONS

The analytic themes in this synthesis suggest that second-level nurses have faced the same issues over decades with little change. Perceptions of second-level nursing roles are primarily influenced by meso (organisational level) factors and micro (individual, behavioural) factors. The synthesis concludes that a cultural shift in valuing the hands-on care provided by second-level nursing is necessary, along with systems-level shift that clarifies the role of second-level nursing within healthcare teams to enhance collaborative practice. Further research should attend to macro-level influences on perceptions of second-level nurses, the work they do, and how this is valued or institutionally embedded. Tweetable abstract: Healthcare professionals' perspectives on second-level nursing roles: a systematic review and thematic synthesis.

Exploring the link between structural empowerment and job satisfaction through the mediating effect of role stress: A cross-sectional questionnaire study

BACKGROUND

Role stress (ambiguity and conflict) is a major psychosocial risk at work negatively associated with job satisfaction in the nursing context. According to Kanter's empowerment theory, high levels of structural empowerment reduce role stress, so role ambiguity and conflict could be potential mediators of the relationship between empowerment and job satisfaction.

OBJECTIVE

The aim of this study was to analyze the relationships between structural empowerment, role stress (ambiguity and conflict), and job satisfaction, assuming the mediating role of role stress on the relationship between structural empowerment and job satisfaction.

DESIGN

A cross-sectional design was utilized, using questionnaires for data collection and convenience sampling.

SETTING(S)

Private health care organizations in southern Portugal.

PARTICIPANTS

One hundred and twenty-four registered nurses (sample 1) and one hundred and thirty certified nursing assistants (sample 2) completed self-report measures of structural empowerment, role stress, and job satisfaction.

METHODS

Mediation analysis was performed using linear regression models and the bootstrapping method. Bias-Corrected confidence intervals (95%) were calculated for the study of direct and indirect effects.

RESULTS

In both samples, structural empowerment, role ambiguity, and role conflict were significant predictors of job satisfaction. Both ambiguity and role conflict partially mediated the effect of structural empowerment on job satisfaction. The effect mediated by ambiguity was greater than the effect mediated by role conflict in both registered nurses and certified nursing assistants.

CONCLUSIONS

Two processes could explain the effect of structural empowerment on job satisfaction in the nursing context: a direct effect generating experiences and perceptions of power in professionals; and an indirect effect reducing role stress levels in the workplace. The creation of empowering workplaces which clarify work roles and functions of nursing staff should be a priority issue for health managers and nurse executives.

Collaboration among Registered Nurses and Licensed Practical Nurses: A Scoping Review of Practice Guidelines

Professional associations, nurse scholars, and practicing nurses suggest that intraprofessional collaboration between nurses is essential for the provision of quality patient care. However, there is a paucity of evidence describing collaboration among nurses, including the outcomes of collaboration to support these claims. The aim of this scoping review was to examine nursing practice guidelines that inform the registered nurse (RN) and registered/licensed practical nurse (R/LPN) collaborative practice in acute care, summarize and disseminate the findings, and identify gaps in the literature. Ten practice guidelines, all published in Canada, were included in the final scoping review. The findings indicate that many of the guidelines were not evidence informed, which was a major gap. Although the guidelines discussed the structures needed to support intraprofessional collaboration, and most of the guidelines mention that quality patient care is the desired outcome of intraprofessional collaboration, outcome indicators for measuring successful collaborative practice were missing in many of the guidelines. Conflict resolution is an important process component of collaborative practice; yet, it was only mentioned in a few of the guidelines. Future guidelines should be evidence informed and provide outcome indicators in order to measure if the collaborative practice is occurring in the practice setting.

The Similarities and Differences in Transition to Practice Experiences for New-Graduate RNs and Practical Nurses in Long-term Care

OBJECTIVE

The aim of this study was to describe the transition-to-practice experience of new-graduate nurses (NGNs) in long-term-care (LTC) settings.

BACKGROUND

Transitioning to professional practice is a challenging time for an NGN. This experience is scarcely described for RNs outside of acute care settings and not described for the LPN.

METHODS

A qualitative case study was used to explore the described transition-to-practice experience of new-graduate RNs and LPNs in LTC.

RESULTS

This study revealed that the transition-to-practice experience of new-graduate LPNs was similar to the experience described by RNs. Differences in experience were related to leadership roles in the setting.

CONCLUSIONS

Findings contribute to new understanding of the experience of the NGN in LTC settings. This study reinforces the need for greater support for nursing graduates in this setting.

Emergency nurses' perceptions of their roles and practices during epidemics: a qualitative study

BACKGROUND

although emergency nurses have a pivotal role in the public health response to epidemics, little is known about their responsibilities and practice in terms of epidemic management.

AIMS

this study aimed to explore how emergency nurses understand and perform their professional roles and practice during epidemics.

METHODS

a qualitative descriptive study design was used. Data were collected from 24 participants through semistructured interviews and subjected to thematic analysis.

FINDINGS

the analysis yielded two overarching themes: expansion in the practice of emergency care; and the altered role of emergency nurses.

CONCLUSION

emergency nurses perceive their practice during the management of an epidemic expanded in that they shouldered a greater responsibility in the control of infectious diseases. This expansion led to role ambiguity among them.

Collaboration among registered nurses and practical nurses in acute care hospitals: A scoping review

AIM

This study examined the extent, range, and nature of registered nurse (RN) and practical nurse (PN) collaboration in acute care hospitals and identified research gaps in the existing literature.

BACKGROUND

Optimal patient care requires collaboration between RNs and PNs. A lack of unity and unresolved tension among different types of nurses influences collaboration and has significant implications on practice and the organizations where nurses work.

METHODS

Using Arksey and O'Malley's (2005) framework, a scoping review was undertaken to answer the research question: what is known from the existing literature about the structures, processes, and outcomes of RN-PN collaboration in hospitals?

RESULTS

Twenty-nine studies were included with the majority coming from North America. Donabedian's model assisted with the identification of three themes: scope of practice, interpersonal skills, and nurse and patient-related outcomes.

CONCLUSION

The findings demonstrate there is a paucity of research specific to RN-PN collaboration. Nurse administrators/managers play an important role in addressing the interpersonal skills of nurses and providing an ongoing education on collaboration in the practice setting. Additional studies should focus on the development of nursing collaborative practice models of patient care, the examination of interventions to improve RN-PN collaborative practice, and the assessment of outcomes relating to collaboration among nurses.

Nursing care providers' perceptions on their role contributions in patient care: An integrative review

AIMS AND OBJECTIVES

To explore registered nurses', licensed practical nurses' and healthcare aides' perceptions of their own and each other's role contributions.

BACKGROUND

In response to contemporary economic and political pressures, healthcare institutions across the world have endeavoured to download job duties to less educated healthcare providers. As a result, nursing care is usually delivered by a team of nursing staff that have different roles. This means that there are fewer registered nurses and more licensed practical nurses and healthcare aides on nursing teams, despite evidence that increased numbers of registered nurses improve patient safety and care outcomes.

DESIGN

This study was an integrative review using Whittemore and Knafl's stages for ensuring rigour. These stages include problem identification, literature searching, data evaluation, data analysis and presentation.

METHODS

Four electronic databases were searched according to previously designed search strategies. The 14 retrieved articles were appraised using MMATs for quality. Data were extracted and analysed thematically.

RESULTS

The findings of the integrative review revealed that registered nurses, licensed practical nurses and healthcare aides had little understanding about the roles of their fellow nursing team members and had difficulties describing their own roles. However, no studies concurrently examined registered nurses', licensed practical nurses' and healthcare aides' perceptions on their own or each other's roles and little were written about licensed practical nurses.

CONCLUSION

More research is needed to examine the entire nursing team's perceptions about the various nursing roles.