Clinical nurse specialist: walking the wire

The experience of being an advanced practice nurse in Australian acute care settings: A systematic review of qualitative evidence

BACKGROUND

There is a vast amount of international literature which, although agreeing on the need for advanced practice nurse roles, simultaneously debates and discusses the difficulties with nomenclature, definition and subsequent implementation of such roles. Due to this ambiguity it is difficult to equally compare evidence in this field across different countries. A context-specific systematic review on the qualitative evidence of the experience of being an advanced practice nurse in Australia has not been undertaken previously, however it is imperative for nursing managers and leaders to understand the complexities of advanced nursing roles in order to effectively utilise and retain these experienced and valuable nurses. With the creation of a national nursing regulating authority in 2010, it is timely to explore in-depth the experience of being an advanced practice nurse from a national perspective.

OBJECTIVE

To identify the experience of being an advanced practice nurse working in Australian acute care settings.

INCLUSION CRITERIA

Registered nurses working in advanced practice roles in acute care settings throughout Australia.The experience of being an advanced practice registered nurse working in an Australian acute care setting, as reported by the nurses themselves.Interpretive qualitative studies including designs such as phenomenology, grounded theory and ethnography.

SEARCH STRATEGY

A three step search strategy was used to identify published and unpublished studies. The search process was conducted from August to October 2011 and considered published and unpublished studies from 1990 to October 2011.

METHODOLOGICAL QUALITY

Studies were appraised for methodological quality by two independent reviewers using the Joanna Briggs Qualitative Assessment and Review Instrument.

DATA EXTRACTION

Data was extracted from the papers included in the review using the standardised Joanna Briggs Institute Qualitative Assessment and Review Instrument data extraction tool.

DATA SYNTHESIS

Research findings were pooled using the Joanna Briggs Institute Qualitative Data and Review Instrument.

RESULTS

Three published studies and one unpublished dissertation were included in the review. From these four studies, 216 findings were extracted, forming 18 categories which were then analysed to create six synthesised findings. Six meta-syntheses under the headings of expert knowledge, confidence, education, relationships, negative experiences and patient centred experience were formed from the findings.

CONCLUSIONS

The synthesised findings confirm that the experience of advanced practice nurses in Australian acute care settings is complex and greatly influenced personally and professionally by the organisation as well as the unpredictable nature of working with people.

IMPLICATIONS FOR PRACTICE

A deeper understanding of the essence of being an advanced practice nurse may be of benefit for recruitment and retention planning. Health care organisations must also be aware of the impact they have on the nurse's experience if they are to commit to retention of nurses and to patient safety.

IMPLICATIONS FOR RESEARCH

If the topic of advanced practice is to remain current in the Australian nursing profession then ongoing research must be conducted to identify if the title is being used more frequently within the nursing research. Nurses must be supported in publishing quality research if they are to improve articulation of their experiences.

Role stress and job satisfaction for nurse specialists

AIM

This paper is a report of a study to illustrate the unique relationship between role stress and job satisfaction and provide recommendations for advanced nursing practice in Taiwan.

BACKGROUND

International literature has shown that work role-related stress experienced by staff nurses predicts role strain, which in turn influences job satisfaction and intention to leave the job. In this study, the direct relationship between role stress and job satisfaction of nurse specialists was examined after controlling for personality trait and personal characteristics.

METHOD

In 2004 a convenience sample of 129 nurse specialists from five acute care teaching hospitals in Taiwan participated. They completed a questionnaire (response rate 81%) focusing on personal characteristics, the Five Factor Model of personality traits, role stress (i.e. ambiguity, conflict, overload, incompetence) and job satisfaction (i.e. professionalism, interaction, demand/reward, control/recognition). Data were analysed using hierarchical regression models.

RESULTS

After controlling for personality traits and personal characteristics, role stress variables predicted 24.8% of the variance in job satisfaction. Role ambiguity (P < 0.001) and role overload (P < 0.01) were the best predictors, but role conflict was not statistically significant. Role stress explained statistically significant proportions of the variance for each component of job satisfaction: professionalism (10.6%), interaction (16.7%), demand/reward (27.1%) and control/recognition (18.5%). Role ambiguity predicted all four satisfaction components, role overload predicted demand/reward and role incompetence predicted interaction.

CONCLUSION

Organizational restructuring and administrative support are recommended to address the issues raised. Appropriate training, sufficient communications and supportive legislation are required. Future research should be conducted to evaluate the impact of these interventions.

The role and scope of the clinical nurse consultant in Wentworth area health service, New South Wales, Australia

AIMS

This paper reports phase one of a two-part study in a New South Wales area health service, which aimed to evaluate the grading system for clinical nurse consultants.

BACKGROUND

Since its inception in 1986, the role and scope of practice of clinical nurse consultants in New South Wales has been viewed with differing expectations leading to role conflict from the nurse consultants themselves and others in health care including managers and other clinicians.

METHOD

A quantitative approach was used for this study. A survey comprising of open and closed questions was mailed to all clinical nurse consultants (n = 42) employed in the area.

RESULTS

The data presented suggest that ambiguity continues about the role, the scope and the differences within the grading system of clinical nurse consultants.

CONCLUSIONS

Clinical nurse consultants need leadership training and support from their managers to fulfil their role. More work is required to clarify the role of clinical nurse consultants.

The role and scope of the Clinical Nurse Consultant in Wentworth Area Health Service: a qualitative study

New South Wales Health introduced the role of the Clinical Nurse Consultant in 1987. A review of the role was undertaken by an area health service in Western Sydney, NSW, Australia in 1992 and a number of issues were highlighted in the review process, including diverse roles and responsibilities. In 2000, New South Wales Health acknowledged the diversity of roles and developed a grading system based on five domains of practice. This paper reports the second phase of a two-part study that investigated the scope of practice and perceived level of organisational support provided for the Clinical Nurse Consultants in the area health service. Focus group interviews, one for managers and two for nurse consultants, were conducted in order to collect data. Ten Clinical Nurse Consultants, representative of each grade and seven managers, covering various clinical streams, took part in the study. Data were analysed using content analysis and coded using constant comparison and contrast of codes. Results of the study reveal a lack of clarity and understanding of the new grading system. There is an indication that the role is very individual and the incumbents are often overloaded by work and the maze of demands put on them by numerous competing forces. Many of the Clinical Nurse Consultants felt they were working at a grade higher than their position classification. There appears to be a significant need to clarify the roles of each of these members of the health care system and to provide a better reporting scheme.

The nurse specialist role in Hong Kong: perceptions of nurse specialists, doctors and staff nurses

AIM

The purpose of this study is to review and delineate the impact in terms of the perceived importance as well as the role components of nurse specialists in Hong Kong.

RATIONALE

The Nurse Specialist Scheme was launched in 1994 in Hong Kong. Studies in the West showed that there were impacts on the roles of other members among the health care team. However, minimal local published work has been carried out in reviewing the scheme.

DESIGN

The design of the study was nonexperimental. Data were collected by self-administered questionnaires. The questionnaire adopted was developed by O'Mullan (1995), and the five roles studied were administration, clinical practice, consultation, education and research. To ensure the contextual relevancy and consistency of the questionnaire, content validity and test-retest reliability tests were performed. The content validity index was 0.85 and the test-retest reliability (Spearman's rho coefficient) ranged from 0.57 to 0.97. Subjects were obtained by stratified convenience sampling technique. The ratios for subject selection among the doctors, ward managers, nursing officers and registered nurses were 3:1:3:10, respectively. Because of the small numbers for nurse specialists, they were all included in the study. The final sample consisted of 11 nurse specialists, 47 ward managers, 56 nursing officers, 110 registered nurses and 15 doctors (n=239).

RESULTS

The results showed that there were significant differences in the perceptions of importance of the administration, clinical practice, education and research roles, and the frequency of occurrence of the clinical practice and research roles. This was further verified by the Fisher's Least Significant Differences (LSD) test.

CONCLUSIONS

A regulatory system of the nurse specialist was recommended to monitor the development of the nurse specialist role and practice and to ensure the safety of the public with regard to the emerging role. Both the implications and limitations are discussed.

Specialist nurse: an investigation of common and distinct aspects of practice

Over the past decade the discipline of nursing has been reviewing its practice, especially in relation to specialty areas. There has been an appreciation by nursing leaders that specialisation brings with it concerns related to a disuniting effect on the discipline and a fragmentation of nursing's traditional generalist practice. Accompanying these concerns is a debate over what is a specialty and how to define a specialist. This qualitative study drew upon a constructivist methodology, to explore how nurses, working in specialty areas, define and give meaning to their practice. Three groups of nurses (n=20) from the specialty of critical care were interviewed using a focus group technique. The data were analysed to build constructions of specialty practice. A distinct and qualitative difference was recognised in the practice behaviours of nurses working in the specialty area. The qualitatively different practice behaviours have been identified as 'nursing-in-a-specialty' and 'specialist nurse'. Two constructions emerged to differentiate the skill behaviours, these were 'practice' and 'knowledge'. The specialist nurse practices were based on two distinct types of practice, that of 'discretion' and 'incorporation'. 'Knowledge' was constructed as a synthesis of propositional and practice knowledge. By Carrie Fairweather and Glenn Gardner.

Specialisation in nursing. A survey of reactions of Victorian nurses to the national review of specialist nurse education

This article reports on the opinions of specialist nurses practising in Victoria toward recommendations proposed in the National Review of Specialist Nurse Education (Specialist Review) (Russell et al 1997). Seventy-five nurses undertaking a range of specialist nursing courses offered by three educational providers (a university, major teaching hospital and professional organisation) completed a survey questionnaire to establish the extent to which they agreed with the major recommendations from the Specialist Review. Results showed strong endorsement for most recommendations but with less agreement about issues of minimum credentials and future provisions. Comparison of responses across age, experience, employment and professional education subgroups identified significant differences of opinions on some recommendations. Findings from this study are discussed in relation to the Specialist Review and to implications for the future development of specialist nursing education in Australia.

'Having a say': negotiation in fourth-generation evaluation

In this paper, research guided by the principles of fourth-generation evaluation, which has negotiation as its centre, will be scrutinized. The role of stakeholders will be discussed with reference to negotiation issues. Throughout this discussion, observations will be based on the actual process of conducting three project evaluations in this tradition. Attention will be drawn to the consequences of negotiating at an uneven table.

The contingent nature of advanced nursing practice

This paper examines the issues faced by advanced nurse practitioners in the United Kingdom as they attempt to implement a new role in practice. The discussion draws on evidence gathered during a longitudinal study of a small number of graduates from a Master's degree programme who subsequently took up posts as advanced nurse practitioners. The paper focuses on one of the key findings to emerge from the inquiry, that of the identification of the contingent nature of advanced nursing practice. The data for the study were collected over a 2-year period via interviews, observation of clinical practice and self-report role development diaries. Following analysis it was revealed that, whilst the passage from experienced nurse to advanced nurse practitioner can be considered to be highly individual and complex, practitioners appear to move through three discrete stages during the transitional process. The first of the three stages is represented by a state of 'idealism' on the part of advanced practitioners. During the second phase, termed 'organizational governance', practitioners discover that, in contrast to their initial optimism, the orientation, goal and delivery of their role is controlled by key stakeholders within the organization. The final stage, 'resolution', is only reached when practitioners have been in post for more than 1 year and can be summarized as a state of acquiescence and compromise. A conceptual model is presented which illustrates the contingent nature of advanced nursing practice.

Career structures for South Australian nurses: developing a research agenda

Career structure models are central to the organisation of the work of professionals like nurses, to their remuneration and other forms of recognition, and for the organisation of employing institutions. It has been little more than a decade since the implementation of a career structure model for nurses in South Australia in 1986-7. Since that time a number of changes to the profession, and to the health care system more generally, have resulted in ad hoc adaptations to, and sometimes an erosion of, the career structure as originally envisioned. As we approach the new millennium, an assessment and evaluation of the efficacy of the SA career structure in meeting the professional needs of nurses and their employing organisations is both timely and necessary. This paper provides the historical background to the development of the SA career structure, and highlights some of the major issues that have emerged as problematic since implementation. The paper then identifies some issues that might contribute towards guiding a more systematic approach to the re-appraisal of nurses' career structures.

Specialist education and practice in nursing: an Australian perspective

In this paper, we argue that specialist nurses occupy a strategic position in the Australian health care system and will continue to do so in the future. From a careful consideration of the literature describing past, present and future nursing practice and education, we conclude that specialist nurses with appropriate skills gained through lifelong learning and experience are the nurses to lead and foster the future practice of nursing. The role of current nurse educators is to provide time-sensitive education programmes that will facilitate the development of such skills.

Being a clinical nurse consultant: a hermeneutic phenomenological reflection

This paper describes the lived experiences of clinical nurse consultants. The research approach was that of hermeneutic phenomenology, and the participants in the study were 10 clinical nurse consultants who work in a range of clinical specialty services in a large Sydney referral hospital. The paper provides a phenomenological account of two themes that emerged from the study: the experience of diversity, and the experience of working with people. The experience of diversity relates to the different clinical specialties in which nurse consultants are employed and to the diverse nature of the role. The experience of working with people requires that nurse consultants focus on particular disease symptoms while simultaneously caring for the whole person.