Boundary matters: clinical leadership and the distinctive disciplinary contribution of nursing to multidisciplinary care

Nursing Leaders as Visionaries and Enablers of Action

OBJECTIVES

The engagement of nursing leaders is critical for the future of the cancer nursing profession, quality cancer care, and the overall health care system. The field of cancer care is facing enormous challenges, requiring strong nursing leadership. Cancer nursing leadership is needed to overcome the challenges caused by workforce shortages, restricted resources, historic and ongoing under-recognition of nursing, unsafe working conditions, and unequal access to education. The aim of this article is to contribute to the discussion about how cancer nursing leaders can act as visionaries and support transformation of cancer nursing for the future.

DATA SOURCES

Author experience, journal articles and organizational position papers were used.

CONCLUSION

To improve the state of cancer nursing and the working conditions of the cancer nursing workforce, nursing leadership practices need to be embraced on all governance levels in clinical practice and academia. When effective and high-quality nursing leadership is enacted, positive outcomes for people affected by cancer, nursing, and health care systems can be achieved. Cancer nursing leadership needs to be supported through nursing scholarship, influencing national and global policies and strategies and by active involvement in national and international health care management.

IMPLICATIONS FOR NURSING PRACTICE

Nursing leadership and governance is critical to strengthening the cancer nursing workforce. Strong nursing leadership is required to realize the vision for transforming the health care systems and cancer care. Therefore, collaboration among multidisciplinary leadership, health care organizations, academic institutions, professional organizations, and policy-making structures is warranted.

Exploring clinical leadership in long-term care: An integrative literature review

AIM

The aim of this study is to understand the concept of clinical leadership and clinical leadership development for nurses working with older adults in long-term care health care facilities.

BACKGROUND

In Canada, clinical care within long-term care is undertaken by registered nurses and licenced practical nurses working with health care aides. Effective clinical leadership is essential for providing quality nursing care.

EVALUATION

An integrative literature review using the framework of Whittemore and Knafl (2005). All selected articles were quality appraised using the Critical Appraisal Skills Program and the accuracy, authority, coverage, objectivity, date and significance checklist.

KEY ISSUES

The analysis resulted in four themes: ambiguous definitions, practice-based and value-driven care, the impact of clinical leadership and clinical leadership development for Canadian nurses.

CONCLUSION

The findings suggest that ambiguity surrounds the concept of clinical leadership, with the term denoting both 'management' as a formal administrative role and 'leadership' in general. More recently, the clinical leadership focus has been on informal leadership by nurses at the bedside, where personal and professional values align with clinical action.

IMPLICATIONS FOR NURSING MANAGEMENT

Effective clinical leadership can have a positive impact on quality care and employee job satisfaction.

A Proposed Shared Vision for Leadership Development for all Medical Students: A Call from a Coalition of Diverse Medical Schools

Issue: Despite clear relevance, need, descriptive literature, and student interest, few schools offer required curriculum to develop leadership skills. This paper outlines a proposed shared vision for leadership development drawn from a coalition of diverse medical schools. We advocate that leadership development is about self (looking inward), teams (not hierarchy), and change (looking outward). We propose that leadership development is for all medical students, not for a subset, and we believe that leadership curricula and programs must be experiential and applied. Evidence: This paper also draws on the current literature and the experience of medical schools participating in the American Medical Association's (AMA) Accelerating Change in Medical Education Consortium, confronts the common arguments against leadership training in medical education, and provides three cross-cutting principles that we believe must each be incorporated in all medical student-centered leadership development programs as they emerge and evolve at medical schools. Implications: By confronting common arguments against leadership training and providing a framework for such training, we give medical educators important tools and insights into developing leadership training for all students at their institutions.

Clinical leadership and rural and remote practice: A qualitative study

AIM

To explore how clinical leadership is perceived by nurses in rural and remote areas of New South Wales, Australia.

BACKGROUND

There are few empirical studies aimed at understanding clinical leadership from a rural and remote perspective.

METHODS

A qualitative approach, based on interpretive phenomenology, used thematic analysis of recorded and transcribed interviews. Ethical approval was secured, 56 interviews were undertaken, across 14 different rural and remote health facilities, with nurses across the spectrum of practice.

RESULTS

Thematic analysis led to five themes and findings that support an understanding of clinical leadership from a rural and remote context. Clinical leaders were seen to considerably impact on the initiation of change and quality of care. They also faced barriers if the health facility was poorly staffed, lacked support and if the community were strongly co-dependent.

CONCLUSION

In rural and remote areas, clinical leadership is evident to support change, innovation and care quality.

IMPLICATIONS FOR NURSING MANAGEMENT

Managers should be aware that staff shortages and challenges to staff retention or the initiation of change are affected by poor clinical leadership. This paper suggests that managers who facilitate clinical leadership are better able to support professional education and greater efficiencies in the delivery of quality health care.

Critical reflection on the role of theater nurses in a multidisciplinary team for perioperative care in China

Objective

The aim of this article is to reflect on the role of theater nurses in a multidisciplinary team, understand the factors that have influenced theater nurses’ practice, and improve the authors’ clinical practice ultimately.

Methods

The author used Smyth’s model to guide the process of reflection on the practice issue. Critical reflection, critical emancipatory theory, reflexivity, and critical social theory were used to help the author analyze the factors that have affected theater nurses’ practice in the organization.

Results

There are gaps between the espoused and enacted theories. A theater nurse’s practice is determined by multiple factors, such as political, structural, social, historical, cultural issues, and so on. The hierarchy of the health context could hinder possible changes in theater nurses’ practice. To better understand our practice and implement transformation, we should shape a supportive environment, bear in mind the practice motto of “patient-centered” care, and improve our knowledge and reflection skills.

Conclusions

Reflection plays a significant role in the advancing of practice among theater nurses and needs to be combined with clinical practice. To provide the best service of care to perioperative patients, a theater nurse should have an insightful understanding of the factors that have influenced her/his behaviors historically, socially, and culturally. By improving their critical reflection skills, practitioners could gain knowledge from experience.

Encouraging interprofessional collaboration: The effects of clinical protocols

AIMS AND OBJECTIVES

To consider the characteristics of protocol documents themselves as a factor influencing the nature of care delivery and their potential to facilitate greater interprofessional collaboration.

BACKGROUND

Healthcare guidelines and clinical protocols provide important guidance and direction to health professionals in their delivery of care. By detailing requirements and actions to be taken in specified circumstances or contexts, these documents may facilitate a broadening of the pool of people able to deliver care.

DESIGN

Critical reading of four clinical protocols representing the range of protocol types in use was carried out to consider the extent to which the documentation of guidelines and protocols and the documents themselves might be considered as vehicles for increased collaboration in health care.

METHODS

A "close reading" rubric was developed directing the researcher to look for evidence in each protocol of the following: authorship, person or group responsible for the protocol's development; stated document purpose; target readers, either stated or implied; the particular subjects, the document names and the objects created by them such as care pathways; the use of specific terminology and imagery, the documents' form and structure; and evidence of intertextuality referring to other documents, for example legislation or policy statements. Tabulation of the coding analysis is presented.

RESULTS

Nurses were the only professional group named in the documents as assignees or subjects. "Patients" and "care" are the objects created, and the scientific-biomedical discourse with its associated procedural language was dominant.

CONCLUSIONS

Many protocols have been developed to standardise practice and increase the effectiveness of teamwork. They may, however, constrain collaboration in healthcare settings because they diminish a nursing "voice" and create the expectation that nurses alone work across the spectrum of protocols.

RELEVANCE TO CLINICAL PRACTICE

An unintended consequence of the global use of clinical protocols and guidelines to support safe and efficient healthcare delivery may be to reduce interprofessional collaboration.

The Role of the Registered Nurse Working in Substance Use Disorder Treatment: A Hermeneutic Study

Substance Use Disorders (SUDs) are a national public health crisis. However, there is minimal existing research literature on the role of the nurse working in SUD treatment. The purpose of this study was to describe the meaning of the professional role of the registered nurse working in the SUD setting. The study utilized a Heideggerian Phenomenological approach with a modified Colaizzi method for analysis and interpretation. The nine study participants, two males and seven females, aged 27-60 had worked in SUD treatment for 1-37 years. Three major themes, with sub-themes, emerged: Defining the Role for Self; Learning the Role; and Navigating with Ease in an Unchangeable Culture. Findings demonstrated that nurses in SUD treatment value their role and the care of patients with SUDs. Patient recovery or relapse influenced job satisfaction. Significantly, the findings highlighted an outdated role with rigid boundaries and no real contemporary identity. Findings can be used to address the need for a contemporary SUD nursing identity and to support ongoing involvement of nurses in health policy related to SUDs.

Discursive constructions of professional identity in policy and regulatory discourse

AIM

To examine and describe disciplinary discourses conducted through professional policy and regulatory documents in nursing and midwifery in Ireland.

BACKGROUND

A key tenet of discourse theory is that group identities are constructed in public discourses and these discursively constructed identities become social realities. Professional identities can be extracted from both the explicit and latent content of discourse. Studies of nursing's disciplinary discourse have drawn attention to a dominant discourse that confers nursing with particular identities, which privilege the relational and affective aspects of nursing and, in the process, marginalize scientific knowledge and the technical and body work of nursing.

DESIGN

We used critical discourse analysis to analyse a purposive sample of nursing and midwifery regulatory and policy documents.

METHOD

We applied a four-part, sequential approach to analyse the selected texts. This involved identifying key words, phrases and statements that indicated dominant discourses that, in turn, revealed latent beliefs and assumptions. The focus of our analysis was on how the discourses construct professional identities.

FINDINGS

Our analysis indicated recurring narratives that appeared to confer nurses and midwives with three dominant identities: "the knowledgeable practitioner," the "interpersonal practitioner" and the "accountable practitioner." The discourse also carried assumptions about the form and content of disciplinary knowledge.

CONCLUSIONS

Academic study of identity construction in discourse is important to disciplinary development by raising nurses' and midwives' consciousness, alerting them to the ways that their own discourse can shape their identities, influence public and political opinion and, in the process, shape public policy on their professions.

Conceptualizations of clinical leadership: a review of the literature

Introduction

Poor patient outcomes in South African maternal health settings have been associated with inadequately performing health care providers and poor clinical leadership at the point of care. While skill deficiencies among health care providers have been largely addressed, the provision of clinical leadership has been neglected. In order to develop and implement initiatives to ensure clinical leadership among frontline health care providers, a need was identified to understand the ways in which clinical leadership is conceptualized in the literature.

Design

Using the systematic quantitative literature review, papers published between 2004 and 2016 were obtained from search engines (Google Scholar and EBSCOhost). Electronic databases (CINHAL, PubMed, Medline, Academic Search Complete, Health Source: Consumer, Health Source: Nursing/Academic, ScienceDirect and Ovid^®) and electronic journals (Contemporary Nurse, Journal of Research in Nursing, Australian Journal of Nursing and Midwifery, International Journal of Clinical Leadership) were also searched.

Results

Using preselected inclusion criteria, 7256 citations were identified. After screening 230 potentially relevant full-text papers for eligibility, 222 papers were excluded because they explored health care leadership or clinical leadership among health care providers other than frontline health care providers. Eight papers met the inclusion criteria for the review. Most studies were conducted in high-income settings. Conceptualizations of clinical leadership share similarities with the conceptualizations of service leadership but differ in focus, with the intent of improving direct patient care. Clinical leadership can be a shared responsibility, performed by every competent frontline health care provider, regardless of the position in the health care system.

Conclusion

Conceptualizations of clinical leadership among frontline health care providers arise mainly from high-income settings. Understanding the influence of context on conceptualizations of clinical leadership in middle- and low-income settings may be required.

Studying the old masters of nursing: A critical student experience for developing nursing identity

In the past professional identity in nursing was inculcated in students alongside institutional pride. A strong sense of professional identity is key to staff retention and recruitment and key to the delivery of quality nursing care. With the wholesale transfer of pre-registration nursing education to the third level sector, however, the reality is that students now divide their affiliations between university and healthcare institutions and professional identity development may be stymied. For this reason, there is need to explore alternative means of developing professional identity. Exposure to nursing history may counteract this tendency. Based on adult nursing students' reflections of a visit to the Florence Nightingale Museum, we discuss the potential of this activity in aiding development of critical professional identity.

Shifting the balance of care? A qualitative study of policy implementation in community nursing

AIM

This qualitative study examined the interaction between policy implementation and service organisation and delivery for community nursing services.

BACKGROUND

Leadership in nursing is at the fore front of the policy agenda for shifting the balance of care from hospitals to the community setting and for improving the quality of healthcare services. Yet, little is known about the implementation of policy within the community setting.

METHOD

A qualitative, interpretive analysis including semi-structured interviews with nurse leaders (n = 12) and community nurses (n = 27) and three focus groups (n = 13) with community nurses (Total N = 39) in three Health Boards in Scotland.

RESULTS

Policy implementation is not adequately integrated between primary and secondary care service at the point of care delivery. The 'top down approach' to policy implementation for shifting the balance of care is currently at odds with the grass roots service organisation and delivery in the community setting.

CONCLUSIONS

The aspirations of integrated, collaborative health and social care require more clinicians working at the frontline in both primary and secondary care to value more the work of colleagues in the different sectors.

IMPLICATION FOR NURSING MANAGEMENT

The current 'top down approach' to policy implementation encourages resistance in the frontline community nurses rather than commitment. A more 'bottom up' integrated approach to policy implementation is therefore required.