Advanced Nursing Roles Research Articles

Development of a tool to describe the role of the clinical nurse consultant in Australia

To develop a tool for defining and measuring the role characteristics and responsibilities of an advanced practice nursing role in Australia. Internationally, there is considerable confusion about the precise role responsibilities of advanced practice nursing positions. In Australia, the clinical nurse consultant is an advanced practice role with five nominated domains of practice. However, there are no tools for measuring the performance of clinical nurse consultants against the listed domains. Participants were 56 clinical nurse consultants at a tertiary public hospital. The existing literature, an online survey, and position descriptions were used to generate the a priori themes for the initial template. Semi-structured interviews were conducted (in 2010) to test the template characteristics. The template underwent multiple iterations in its development. A 50-item tool was devised, which consisted of five domains with a ten-point hierarchical scale within each domain. In preliminary testing, the revised template was found to provide greater clarity regarding roles and grades than the original position descriptions. Further testing and refinement of the modified rating scale is needed, but it offers the possibility of a new tool that can be used by health service managers to determine the grade of a clinical nurse consultant position and for evaluating role performance. This preliminary study suggests that the tool provides a useful means of measuring advanced nursing practice and responsibilities across different domains and levels of appointment. The tool may be able to be adapted for use with other advanced practice nursing roles both within Australia and internationally.

How does care coordination provided by registered nurses “fit” within the organisational processes and professional relationships in the general practice context?

The aim of this study was to develop understanding about how a registered nurse-provided care coordination model can "fit" within organisational processes and professional relationships in general practice. In this project, registered nurses were involved in implementation of registered nurse-provided care coordination, which aimed to improve quality of care and support patients with chronic conditions to maintain their care and manage their lifestyle. Focus group interviews were conducted with nurses using a semi-structured interview protocol. Interpretive analysis of interview data was conducted using Normalization Process Theory to structure data analysis and interpretation. Three core themes emerged: (1) pre-requisites for care coordination, (2) the intervention in context, and (3) achieving outcomes. Pre-requisites were adequate funding mechanisms, engaging organisational power-brokers, leadership roles, and utilising and valuing registered nurses' broad skill base. To ensure registered nurse-provided care coordination processes were sustainable and embedded, mentoring and support as well as allocated time were required. Finally, when registered nurse-provided care coordination was supported, positive client outcomes were achievable, and transformation of professional practice and development of advanced nursing roles was possible. Registered nurse-provided care coordination could "fit" within the context of general practice if it was adequately resourced. However, the heterogeneity of general practice can create an impasse that could be addressed through close attention to shared and agreed understandings. Successful development and implementation of registered nurse roles in care coordination requires attention to educational preparation, support of the individual nurse, and attention to organisational structures, financial implications and team member relationships.

Views of the Israeli public on expanding the authority of nurses

To explore the views of the Israeli public on expanding the authority of nurses and identify factors affecting these views. New advanced nursing roles are currently being introduced and nursing is undergoing dynamic change. Public views on expanding the authority of nurses and factors affecting public views await investigation. In a correlational study, a questionnaire was administered to 200 male and female Israelis aged 18 and older treated at a hospital or healthcare clinic at least once over the past year. Most respondents are in favour of expanding the authority of nurses, considered vital for patients. In addition, the public is in favour of certifying clinical nursing specialists in all fields. Influential factors were ethnicity, personal acquaintance with nurses, income and religiosity. The public has a positive perception of expanding the authority of nurses, and major determinants are familiarity with nursing, ethnicity, income and religiosity. Understanding public views on expanding the authority of nurses in Israel will help policymakers adjust their actions according to social perceptions and needs. This will help nursing managers further the process of expanding nurse authority, to the satisfaction of both nurses and the public they serve.

An ethnographic study exploring the role of ward‐based Advanced Nurse Practitioners in an acute medical setting

This article is a report of a study that aimed to examine the role of ward-based Advanced Nurse Practitioners and their impact on patient care and nursing practice. Revised doctor/nurse skill mix combined with a focus on improving quality of care while reducing costs has had an impact on healthcare delivery in the western world. Diverse advanced nursing practice roles have developed and their function has varied globally over the last decade. However, roles and expectations for ward-based Advanced Nurse Practitioners lack clarity, which may hinder effective contribution to practice. An ethnographic approach was used to explore the advanced nurse practitioner role. Participant observation and interviews of five ward-based Advanced Nurse Practitioners working in a large teaching hospital in the North West of England during 2009 were complemented by formal and informal interviews with staff and patients. Data were descriptive and broken down into themes, patterns and processes to enable interpretation and explanation. The overarching concept that ran through data analysis was that of Advanced Nurse Practitioners as a lynchpin, using their considerable expertise, networks and insider knowledge of health care not only to facilitate patient care but to develop a pivotal role facilitating nursing and medical practice. Sub-themes included enhancing communication and practice, acting as a role model, facilitating the patients' journey and pioneering the role. Ward-based Advanced Nurse Practitioners are pivotal and necessary for providing quality holistic patient care and their role can be defined as more than junior doctor substitutes.

Editor’s Choice

In times of global economic austerity, governments and healthcare systems look for more cost-effective ways to deliver the same, or increased, levels of health care for less. ‘Task shifting’ is fast becoming a byword for reassigning delivery of healthcare interventions and services from more expensive to less expensive cadres of staff. ‘Task shifting’ is also considered an essential component to delivering the Millennium Development Goals by 2015 (Save the Children Fund 2011). Although ‘task shifting’ feels like an inappropriate term to describe the redistribution and assignment of professional roles, there is growing evidence that ‘task shifting’ to a less highly trained and paid cadre of staff can be equally as effective. In a Cochrane review on doctor to nurse substitution, which is currently being updated, Laurant et al. (2004) found that nurses in mainly developed countries could provide care with similar outcomes to doctors. In another Cochrane review Lewin et al. (2010), found that lay health workers provided promising benefits in promoting immunization uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared with usual care. For other health issues, evidence was insufficient to draw conclusions about the effects of lay health workers. An additional series of qualitative syntheses on the barriers and facilitators to optimizing implementation of task shifting are currently being undertaken to complement existing quantitative systematic reviews of effectiveness (WHO Alliance 2011). Common to all of these reviews, however, is a lack of clarity on the roles and level of training and practice of nurses to, or from whom a ‘task’ is being shifted. A higher level of consistency and clarity about nursing and advanced nursing roles is urgently needed in published studies to support interpretation of evidence in systematic reviews, and practice development generally. In this issue of the JAN, Lowe et al. (2011) report a long overdue discussion of published literature in their article ‘Time to clarify – the value of advanced practice nursing roles in health care’. The discussion is based on a search of relevant literature published between 1995–2010. The authors eloquently articulate the lack of clarity regarding roles and the proliferation of roles across international boundaries. Lowe et al. conclude that: clarity around what each of the advanced nursing roles offer is paramount to take advantage of this opportunity to improve healthcare delivery and It is difficult to provide evidence of efficiency and cost effectiveness without clarity and consistency of roles. These findings echo the challenges encountered by review authors in synthesizing and interpreting evidence on ‘task shifting’, nursing roles and outcomes of care. The key message is that international nursing regulators need to standardize and clarify roles and definitions, and authors of primary research studies need guidance on the essential elements of nursing roles to report, such as level and type of training and competencies, local registration and regulatory frameworks, specified tasks, roles and responsibilities, and proximity of the nurse to supervision and, as appropriate, medical support. Lowe et al. argue that this type of clarity is required so that standardized measures can be used to establish efficiency, cost effectiveness and realization of patient outcomes. Evidence synthesis funders and authors would welcome this much needed clarity and support the call by Lowe et al. for international nursing regulators to urgently work together to resolve the differences in nursing role definitions and functions.

The way forward: the advanced endoscopy practitioner

In 2001, the British Society of Gastroenterology (BSG) described an increasing demand for all forms of endoscopy. To meet this demand, nurse endoscopists have been instrumental in providing the service delivery of diagnostic endoscopy. However, the cost effectiveness of this role has been questioned ( Richardson et al, 2009 ). It has been suggested that the advanced endoscopy practitioner may be a solution to this problem ( Chapman, 2009 ). There is evidence of overlap between advanced nursing and medical roles, with each group applying similar knowledge and skills in a different way ( Hunsberger and Mitchell, 1992 ). In this article, Kaye Drew, Mark E McAlindon, Reena Sidhu and David S Sanders describe initiatives to develop the advanced role within the capsule endoscopy speciality not just as the cheaper option but as a positive choice to enhance the quality of service delivery.

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

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. To identify the experience of being an advanced practice nurse working in Australian acute care settings. 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. 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. Studies were appraised for methodological quality by two independent reviewers using the Joanna Briggs Qualitative Assessment and Review Instrument. Data was extracted from the papers included in the review using the standardised Joanna Briggs Institute Qualitative Assessment and Review Instrument data extraction tool. Research findings were pooled using the Joanna Briggs Institute Qualitative Data and Review Instrument. 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. 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. 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. 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.

Nurse-led central venous catheter insertion—Procedural characteristics and outcomes of three intensive care based catheter placement services

BackgroundNurse-led central venous catheter placement is an emerging clinical role internationally. Procedural characteristics and clinical outcomes is an important consideration in appraisal of such advanced nursing roles. ObjectivesTo review characteristics and outcomes of three nurse-led central venous catheter insertion services based in intensive care units in New South Wales, Australia. DesignUsing data from the Central Line Associated Bacteraemia project in New South Wales intensive care units. Descriptive statistical techniques were used to ascertain comparison rates and proportions. ParticipantsDe-identified outcome data of patients who had a central venous catheter inserted as part of their therapy by one of the four advanced practice nurses working in three separate hospitals in New South Wales. ResultsBetween March 2007 and June 2009, 760 vascular access devices were placed by the three nurse-led central venous catheter placement services. Hospital A inserted 520 catheters; Hospital C with 164; and Hospital B with 76. Over the study period, insertion outcomes were favourable with only 1 pneumothorax (1%), 1 arterial puncture (1%) and 1 CLAB (1%) being recorded across the three groups. The CLAB rate was lower in comparison to the aggregated CLAB data set [1.3 per 1000 catheters (95% CI=0.03–7.3) vs. 7.2 per 1000 catheters (95% CI=5.9–8.7)]. ConclusionThis study has demonstrated safe patient outcomes with nurse led CVC insertion as compared with published data. Nurses who are formally trained and credentialed to insert CVCs can improve organisational efficiencies. This study adds to emerging data that developing clinical roles that focus on skills, procedural volume and competency can be a viable option in health care facilities.

Jordanian perspectives on advanced nursing practice: an ethnography

This study aimed to explore how different groups of participants perceived the concept of advanced nursing practice in Jordan. In Jordan, there are postgraduate educational programmes offering a Master's degree in clinical nursing for registered nurses. Intended to prepare nurses to practise at an advanced level as potential clinical nurse specialists in critical care, community health nursing and maternal newborn nursing, little was known prior to this study about the development of advanced nursing roles for nurses in Jordan and the drivers behind their establishment. Using ethnographic design, narratives from semi-structured interviews and non-participant observation with participants from five Jordanian hospitals and two public universities were collected and analysed according to thematic analysis. Four themes emerged from the data: core competencies, specific practice area vs. generic practice, beneficiaries of advanced nursing practice and drivers for educational change. The findings are similar to those found in other countries and highlight the need for a consensual understanding between nurse educationalists, professional bodies and employers about what advanced nursing practice in Jordan should be, so that a common framework can be identified. Paralleling the lack of consistency in understanding of advanced nursing practice in the broader literature, participants described a number of different elements of advanced practice that are relevant to the specific context of contemporary Jordanian nursing.

Time to clarify – the value of advanced practice nursing roles in health care

This article presents a discussion of the importance of providing meaningful advanced practice nursing role definition and clarity to improve international standards of nursing titles and scopes of practice. A plethora of international literature exists discussing advanced practice nursing roles and their contribution to healthcare delivery in various countries. However, lack of consistency around title, role definition and scope of practice remains. CINAHL and Medline databases were searched using 'nurse practitioner', 'nurse practitioner role', 'nurse practitioner practice', 'nurse practitioner in public health', 'advanced practice nursing roles' and 'development of new nursing roles' with articles limited to years 1995-2010. Citations used in those articles were also explored. All cited articles were in the English language. This article supports the need to strengthen the Nurse Practitioner role in health care and professional clarity is identified as a strategy to enhance this. Themes around role clarity, professional identity, ability to enhance healthcare provision and inter-professional issues are examined. The need to more clearly articulate advanced nursing roles in light of the evolution of the Nurse Practitioner role is highlighted. Much work has already occurred in this domain and a means of adapting and broadening these developments for a wider, more global audience whilst maintaining local context is discussed. Although evidence exists that advanced practice nursing roles are increasing internationally, uncertainty around role clarity remains. This is problematic because the valuable contribution of nursing roles is lost, if the ability to clearly express their function does not exist.

Influencing School Health Policy: The Role of State School Nurse Consultants

Background: The role of the State School Nurse Consultant has been well defined by the National Association of School Nurses. State School Nurse Consultants serve as a resource to school nurses on issues related to their practice, as well as a liaison between top-level educators and school nurses. The purpose of this article is to describe the role of the State School Nurse Consultant, and to present results of a survey of Louisiana school nurses related to their practice needs.Methods: A survey was administered via Survey Monkey to determine the perceived needs of Louisiana school nurses related to their professional practice. Eighty-eight members of the Louisiana School Nurse Organization participated in the online survey.Results: Louisiana is 1of 6 states that do not have a State School Nurse Consultant. Respondents to the survey indicated an overwhelming need to have a school nurse representative at the state level. Twenty-two of the respondents specifically stated that they would like to have a State School Nurse Consultant within the Department of Education.Conclusions: Budgetary constraints have resulted in a lack of funding for a State School Nurse Consultant in Louisiana. Partnerships with federally qualified health centers (FQHC) and billing of Medicaid for school nursing services are 2 examples of revenue sources for school nurses that Louisiana is investigating. Revenue from these sources may serve to supplement state funds so that this important resource for Louisiana school nurses can be put into place.

Nursing and nursing education in Haiti

Haiti has long had the largest proportion of people living in poverty and the highest mortality level of any country in the Americas. On January 12, 2010, the most powerful earthquake to hit Haiti in 200 years struck. Before the earthquake, half of all Haitians lacked any access to modern medical care services. Health care professionals in Haiti number around one-fourth of the world average and about one-tenth the ratio present in North America. The establishment of new primary care services in a country where half of the people had no access to modern health care prior to the earthquake requires advanced practice roles for nurses and midwives. With a high burden of infectious, parasitic, and nutritional conditions, Haiti especially needs mid-level community health workers and nurses who can train and supervise them for public health programs. As in many other developing countries, organized nursing lacks many of the management and planning skills needed to move its agenda forward. The public schools prepare 3-year diploma graduates. These programs have upgraded the curriculum little in decades and have mainly trained for hospital service. Primary care, public health program management, and patient education had often not been stressed. Specializations in midwifery and HIV care exist, while only informal programs of specialization exist in administration, surgery, and pediatrics. An advanced practice role, nonetheless, is not yet well established. Nursing has much to contribute to the recovery of Haiti and the revitalization if its health system. Professional nurses are needed in clinics and hospitals throughout the country to care for patients, including thousands in need of rehabilitation and mental health services. Haitian nursing colleagues in North America have key roles in strengthening their profession. Ways of supporting our Haitian colleagues are detailed.

Advanced Practice Nursing, Health Care Teams, and Perceptions of Team Effectiveness

This article summarizes the results of an extensive review of the organizational and health care literature of advanced practice nursing (APN) roles, health care teams, and perceptions of team effectiveness. Teams have a long history in health care. Managers play an important role in mobilizing resources, guiding expectations of APN roles in teams and within organizations, and facilitating team process. Researchers have identified a number of advantages to the addition of APN roles in health care teams. The process within health care teams are dynamic and responsive to their surrounding environment. It appears that teams and perceptions of team effectiveness need to be understood in the broader context in which the teams are situated. Key team process are identified for team members to perceive their team as effective. The concepts of teamwork, perceptions of team effectiveness, and the introduction of APN roles in teams have been studied disparately. An exploration of the links between these concepts may further our understanding the health care team's perceptions of team effectiveness when APN roles are introduced. Such knowledge could contribute to the effective deployment of APN roles in health care teams and improve the delivery of health care services to patients and families.

What Is the Role of the State School Nurse Consultant?

SSNCs provide statewide nursing leadership to ensure effective school nursing services, develop and promote quality standards, and foster a better understanding regarding the role of the school nurses and the relationship between students' health and their ability to learn (NASSNC, 2008). SSNCs use the nursing process to identify goals and plan interventions for meeting those goals. The interventions implemented by SSNCs are state-specific and are dependent upon assessment findings and available resources. Currently 40 states employ SSNCs. States use a variety of funding resources to secure the services of SSNCs (Taliaferro, 2011). For tips regarding how to advocate for a State School Nurse Consultant in your state, visit the National Association of State School Nurse Consultants' website at www.nassnc.org and click on "Advocacy".

The role of the nurse sedationist

This paper aims to provide a quality improvement review to identify the benefits and level of satisfaction for the role of the nurse sedationists. Traditionally procedural sedation was only administered by an anaesthetist or dentist and it was not until the early 1990s that nurses in America commenced administering procedural sedation. A literature review on the role of the nurse sedationist undertaken identified no documented evidence of such a role in Australia. The role of the nurse sedationist was pursued as a strategy to meet the increased demand for anaesthetic services, manage the shortage of anaesthetists and address concerns associated with the administration of procedural sedation by healthcare workers untrained in this area. Evaluation of the role of the nurse sedationist was essential to ensure that the role met both the needs of the organisation, patients and key stakeholders. Due to the variety of stakeholders and associated expectations a variety of evaluation methods were used. Results indicate that the introduction of the nurse sedationist role has been recognised as value adding through increases in patient safety, a more collaborative approach to patient care, improved work environments for all staff groups and strengthened multi disciplinary relationships. Patients also indicate a very high level of patient satisfaction with the service. The role of nurse sedationist has been successfully introduced in an Australian acute public hospital. The introduction of the role has assisted to address an increased demand for anaesthetic services and to address patient safety concerns. Recent years have seen an expansion of advanced practice nursing roles throughout Australia. This expansion of roles has resulted in an increase in nursing expertise, high quality patient outcomes and an improved multidisciplinary approach to healthcare. The role of the nurse sedationist has been a result of expansion in this area.

Caring for the pre-dialysis patient: the role of the clinical nurse specialist

Ann Jones looks at how the concept of advanced nursing practice developed in the UK and why there is now an increased demand for advanced nursing roles. She argues that an array of titles for highly skilled nurses may lead to misunderstandings and then explains how the role of the clinical nurse specialist (CNS), such as the pre-dialysis CNS, can improve patient care and outcomes.

Participants' engagement with and reactions to the use of on-line action learning sets to support advanced nursing role development

Professional role development in nursing is occurring at a rapid pace in the UK as elsewhere. Internationally, finding relevant, flexible, sustainable educational solutions to support the preparation of nurses for new roles presents significant challenges for Higher Education Institutions, health service managers and the clinical practitioners who are would-be students. The use of on-line learning is frequently advocated as one means of resolving these difficulties. This paper discusses participants' engagement with, and reactions to, the use of on-line Action Learning Sets (ALS) as part of a national pilot development pathway for Advanced Nursing Practice in Scotland. Data collection included: survey of participants' views of on-line ALS; survey comparing perceptions of ALS with other educational experiences within the pathway; in-depth interviews with case-site participants. A range of benefits and limitations of on-line ALS was identified. The benefit of flexible access and sharing experiences with others was emphasised. Conversely, multiple commitments and lack of group cohesiveness significantly interfered with the effectiveness of this process. Key recommendations for future implementation acknowledge participants' preference for a blended approach, with face-to-face sessions to provide 'getting-to-know-you' opportunities, enhancing commitment to the group process.

Evaluating health-related quality of life and priority health problems in patients with prostate cancer: A strategy for defining the role of the advanced practice nurse

A framework for the introduction and evaluation of APN roles emphasizes the importance of a systematic approach to role development based on the assessment of patient health needs. This study determined the health-related quality of life (HRQL) of patients with prostate cancer. The most frequent and severe patient health problems and their perceptions of priority health problems were identified and compared across five patient groups as a strategy to inform the supportive care role of the advanced oncology nurse for patients with advanced prostate cancer. The study found that the majority of men with early stage and advanced hormone sensitive prostate cancer can expect to enjoy good quality of life for several years following diagnosis. These two patient groups have common priority needs for improving their health related to sexual function, urinary frequency, urinary incontinence, and physical activity. Both groups may benefit from an advanced practice nursing (APN) role that can provide episodic supportive care for health problems occurring at different treatment stages. Conversely, it was found that men with advanced hormone refractory prostate cancer experience significantly poorer HRQL and have multiple severe health problems. These patients also have different priority needs including problems related to pain, fatigue, and decreased physical activity. Because of this, the focus of supportive care programs and interventions in advanced prostate cancer will differ for those with hormone refractory disease. They may benefit more from an APN role that can provide ongoing rather than episodic supportive care to assess and manage the multiple, new, and worsening health problems associated with progressive disease.

Role Development of Nurses Supervising Exercise Tolerance Tests

9 Chapter One: Introduction 10 The Exercise Tolerance Test 10 Background 12 The ETT Nursing Role 13 Development of Advanced Nursing Roles in New Zealand 13 Advancing Cardiovascular Nursing Roles and Role Expansion 15 The Research Question 16 Summary 17 Chapter Two: Literature Review 18 Introduction 18 Search Strategy 18 Historical Development of the ETT Nurse 19 Advancing Cardiovascular Nursing and Role expansion 27 Literature Discussion 32 Summary 35 Chapter Three: Methods 36 Interviews with ETT Nurses 37 Method 37 Participants 37 Data Collection 38 Ethical Issues 38 Data Analysis 39 Interview with Clinical Director of Cardiology 40

Nurses' and doctors' views about the prescribing programme

This article aims to explore the views of doctors and nurses, who care for people with diabetes, about the prescribing programme. Interviews with 10 nurse prescribers, nine doctors and three non-nurse prescribers were conducted in nine case study sites across England between October 2007 and September 2008. Prescribing was seen as a natural extension of advanced nursing roles adopted by nurses caring for people with diabetes. Nurses considered it important to obtain sound knowledge in areas in which they intended to prescribe before undertaking the course. Variation across prescribing programmes with regards to the level of work required of students and the way in which courses were run were reported. Most doctors thought it beneficial for nurses to be involved in mentorship, although doctors' continued involvement was considered necessary. Prescribing supports advanced nursing practice in the care of people with diabetes. Nurses considering undertaking the prescribing course need to beaware of the variations across prescribing programmes with regards to the level of work required. There is support for joint mentorship between nurse prescribers and doctors for students undertaking taking the prescribing course.