Nursing Colleagues Research Articles

Ageist comments by colleagues need to be challenged.

I was horrified to read about a senior nurse leaving because of colleagues' unkind ageist comments in 'Age discrimination by fellow nurses is forcing me to leave' (letters, April 27).

Age discrimination by fellow nurses is forcing me to leave.

I would like to share my upsetting experience of working in an acute hospital. I am an older, experienced nurse with a wide range of knowledge within different specialties. Due to a ward closure, I was transferred to another hospital to take charge of an acute receiving unit with a workforce of young, newly qualified nurses. Since then, I have been told to my face that I am too 'old' for the job and need to retire. Nurses seem to be sneering: 'Look at her, she is just an elderly nurse who is shockingly still working.'

The impact of a pilot continuing professional development module on hospital pharmacists' preparedness to provide contemporary advice on the clinical use of vancomycin.

BackgroundRevised international clinical guidelines for the antibiotic vancomycin have changed the advice pharmacists need to provide to medical and nursing colleagues.Objectives(1) To determine the self-reported confidence of hospital pharmacists to provide contemporary advice on vancomycin and (2) to evaluate hospital pharmacists’ knowledge to provide contemporary advice on vancomycin following a pilot continuing professional development (CPD) module.MethodsThe study was a prospective two-phase design in an Australian teaching hospital. Phase one: a survey of pharmacist self-reported confidence to eight questions on providing contemporary advice on vancomycin. Responses were recorded using a Likert scales. Phase two: The provision of a pilot online CPD module on vancomycin containing knowledge-based assessment based on a clinical vignette. Likert scales recorded self-reported confidence were reported as median and interquartile range (IQR). Knowledge assessment was reported using descriptive statistics. The main outcome measure were the self-reported confidence, and knowledge of pharmacists regarding provision of contemporary advice on clinical vancomycin use.ResultsResponse rates for surveys; confidence n = 35 (72.9 %) and knowledge n = 31 (58.5 %). Phase one: confidence was highest regarding vancomycin dosing and monitoring with 71.4–81.6 % of respondents agreeing or strongly agreeing that they were confident in these domains. Respondents agreeing or strongly agreeing were least confident regarding intravenous administration and infusion related reactions, 57.1 and 45.7 % respectively. Respondents who provided advice on vancomycin >10 times in the prior 12 months reported significantly higher confidence in; therapeutic range 1 (IQR 1–2) versus 2 (IQR 1–3) p = 0.02; amending dosage based on therapeutic drug monitoring results 2 (IQR 1–3) versus 3 (IQR 2–3) p = <0.001, and providing general advice to prescribers on vancomycin 2 (IQR 1–3) versus 2 (IQR 2–4) p = <0.009. Knowledge questions were answered correctly post CPD by >75 % of pharmacists.ConclusionPharmacists’ self-reported confidence to managing vancomycin was variable but generally high. Knowledge scores were consistently high after pharmacists completed a pilot CPD module on vancomycin. These data provides impetus for a randomised controlled study across multiple sites to determine the extent to which pharmacist knowledge on vancomycin can be attributed to completion of an online CPD.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-016-1966-2) contains supplementary material, which is available to authorized users.

Are the adverse psychiatric outcomes reflection of occupational stress among nurses: An exploratory study

Background: Stress-related disorders encompass a broad array of conditions, including psychological disorders such as depression and anxiety etc. Among healthcare professionals, nurses have been found to be most prone to burnout.Aims and Objective: 1) To find out the prevalence of recent stress among staff nurses in terms of somatic symptoms, anxiety, social dysfunction and depression and; 2) To find out the association between these psychiatric outcomes and various socio-demographic variables, inter-personal relationships, working environment and professional stress.Materials and Methods: Institutional based cross sectional study conducted on 100 staff nurses. Goldberg and Hillier’s 28-item scaled version of the General Health Questionnaire (GHQ-28) was used to measure the psychological aspect of quality of life of Staff nurses. Results: The most common psychological outcome noted was the social dysfunction (94%) among the staff nurses. For anxiety, potential stressor were doctors’ attitude, insufficient salary and separate wash room for females; whereas significant association was found between depression and unsatisfactory attitude of doctors, fellow nurses, not enough time for rest and not getting enough holidays.Conclusion: Social dysfunction could be cause or effect of other psychiatric manifestations like anxiety or depressionAsian Journal of Medical Sciences Vol.7(1) 2015 96-100

Sylvain Trepanier, DNP, RN, CENP

It is always great when an opportunity for nurse leaders to learn from others in the field presents itself, and this issue of Nurse Leader is no exception. Born and raised in Montreal, Canada, Sylvain Trepanier, DNP, RN, CENP began his nursing career in the United States as a clinical nurse at Bayonet Point Regional Medical Center in Florida. We are all fortunate to have this former "travel nurse" actively guide his career trajectory to being an accomplished nurse leader in this country! Dr. Trepanier is a talented nursing executive, with expertise in leadership, quality improvement, succession planning, nurse leader mentoring, organizational transformation, system standardization, and nursing research. His current position is in the inaugural position of system vice-president for Premier Health based in Dayton, Ohio.

PTU-287 Abdominal paracentesis – improving practice with a multi-disciplinary proforma

Introduction Abdominal paracentesis is a common procedure performed both on Gastroenterology wards and as a day procedure. Although Foundation Doctors and Core Medical Trainees do not have to be independent at this procedure for satisfactory progression of training, 1,2 it is an important part of any Gastroenterology rotation. Furthermore it is an essential sign-off for CCT in General Internal Medicine. Within the Core Medical Training curriculum it is identified as a “potentially life-threatening” procedure. 2 We sought to assess trainees’ attitudes to the procedure and implement a proforma to help improve both confidence in performing the procedure and documentation. Method Foundation doctors and Core Medical Trainees were surveyed about their attitudes towards abdominal paracentesis both before and after the implementation of a multi-disciplinary proforma. The survey consisted of four questions with free text responses: trainees’ confidence in performing the procedure, common worries about the procedure, what has previously gone wrong and whether a proforma would be useful. Documentation of important steps in the procedure and results were audited both before and after implementation of the proforma. Results Only 25 percent of respondents were confident in performing abdominal paracentesis independently and 67 percent of respondents felt a proforma would be useful. Common areas of uncertainty were surrounding bleeding risk and regimes of albumin replacement. Documentation of many key steps in the process of abdominal paracentesis was poor; following the introduction of the proforma documentation rates hit 100% for steps including informed written consent, number of passes to insert the drain and assessment of bleeding risk. The proforma was well received with 100% of respondents, both medical and nursing colleagues, agreeing it was a useful addition. Conclusion Introduction of a simple, multi-disciplinary proforma has improved documentation in abdominal paracentesis. In addition, it clearly sets out best practice and addresses many of the concerns identified by junior doctors. Disclosure of interest None Declared. References UK Foundation Programme Training Curriculum file:///home/chronos/u9d51564d35947b93f52a5afa31247c656f09b206/Downloads/Fp_Curriculum_2012_updated_for_2014_WEB_FINAL.pdf Specialty Training Curriculum for Core Medical Training, JRCPTB http://www.mrcpuk.org/sites/default/files/documents/2009-CMT-Curriculum

Creating systems that work

Sengstack PP, Boicey C (2015) Mastering Informatics: A Healthcare Handbook for Success. Sigma Theta Tau, Indianapolis IN. INFORMATION TECHNOLOGY is becoming so pervasive in health care it is almost impossible to find a care setting void of some type of electronic clinical system. Evaluating and managing these electronic tools require an understanding of patient care delivery and technology. They also require the knowledge to design systems with which nurses interact on a daily basis and the skills to evaluate care delivery effectiveness. Nurse informaticists are perfectly positioned to meet these requirements. The American Nursing Association recognised nursing informatics as a specialty in 1992. Some say, though, that the first nurse informaticist was Florence Nightingale back in the 1850s, when she compiled and processed data to advocate for appropriate nursing and medical protocols and to improve sanitation in military hospitals during the Crimean War. Fast forward to the 1960s, when the electronic medical record made its debut and continued to evolve as adoption increased over several decades. The Health Information Technology for Economic and Clinical Health Act, signed in 2009 as part of the American Recovery and Reinvestment Act, drove even higher levels of adoption. As of June 2014, three quarters of the nation’s eligible professionals, equivalent to more than 403,000 people, and more than nine out of ten eligible hospitals, equivalent to more than 4,500 organisations, had received incentive payments (Office of the National Coordinator for Health Information Technology 2014). Add to this the increasing use of mobile technologies, the expansion of telehealth, the proliferation of health-related apps, the demand for patient-engagement tools and the drive toward interoperability of patient data, and the need for nursing informatics expertise becomes imperative. Devices developed without the expertise of someone with clinical informatics skills typically result in end-user frustration and systems that do not support clinical workflows. Workforce survey results from the Healthcare Information and Management Systems Society (HIMSS) confirm that nurse informaticists play a crucial role in the development, implementation and optimisation of clinical applications including nursing clinical documentation, computerised practitioner-order entries and electronic health records (HIMSS 2014a). Other survey results show that four out of five healthcare organisations had plans to hire additional IT staff this year, with almost all vendors indicating similar plans. They also show, however, that more than one in three respondents working for a healthcare provider are scaling back or putting IT projects on hold because they cannot be fully staffed (HIMMS 2014b). Delaying IT projects to improve the support of clinician workflow and reduce system inefficiencies ultimately affect patient care. The bottom line is that nurse informaticists are needed more than ever. It is also important to engage nurses in the design, development, purchase, implementation and evaluation of medical and health devices and IT products (Institute of Medicine 2010). The education and training required to serve in the role of a nurse informaticist is not taught at the baccalaureate, or bachelor’s degree, level, nor is it learned on the job alone. Expertise requires graduate education in the field of informatics. There are universities around the world that offer nursing informatics education at master’s level and above and it is here that nurse informaticists and nursing informatics leaders are prepared. While nurses at baccalaureate level with no formal informatics training can assume informatics positions in some organisations, they will not have studied the science formally and developed the focused competencies that graduate informatics education provides. Additionally, nurses serving in informatics roles should obtain their board certification in nursing informatics offered by the American Nurses Credentialing Center. A career in nursing informatics will drive clinical transformation and care delivery. Clinicians and patients count on technology that works for them, not the other way around, so nurses must be there when decisions are made. If you’ve been thinking about a career focus, consider informatics. Our patients and fellow nurses need you.

G104(P) Resuscitation experience of professionals at a district general hospital (dgh)

Introduction The caseload of critically ill patients at a DGH is usually smaller compared to tertiary hospitals. There are some concerns that modern centralisation of services may deskill clinicians at DGHs. Technology Enhanced Learning has an important role to play in improving training. We aimed to analyse professionals’ experience, their role and confidence in performing resuscitation and also their opinion about simulation training. Method We conducted a survey at Ysbyty Gwynedd to determine experience of medical and nursing colleagues in managing critically ill children and neonates over last 6 months. A questionnaire asking various aspects of resuscitation was sent out to nursing colleagues and paediatric doctors working at all levels. Of the 50 distributed questionnaires, 40 were completed and returned to us. Results While only 30% had exposure to resuscitation more than twice over preceding 6 months period, approximately 35% had once or no experience. Those who had exposure more than twice felt confident in performing resuscitation. While only 10% were involved in full cardiopulmonary resuscitation, about 30% were involved in airway and breathing and another 20% in circulation. Over 90% stated that they would like to have regular simulation training at least monthly as they felt it will help in coping with actual resuscitation. Conclusion There is limited data available in literature to determine frequency of managing critically ill children at individual level. This study shows that most health professionals have limited exposure to resuscitation situations at a DGH and nearly all paediatric staff wishes to receive regular simulation training.

Can we learn from the Mid-Staffordshire Inquiry or is it always someone else's problem?

Every healthcare practitioner has a responsibility to put the well-being of patients first.Every healthcare practitioner has a responsibility in the maintenance of healthcare quality and each must take appropriate actions when alerted to poor standards.You cannot assume others will follow up patient concerns and take appropriate actions - the 'buck' stops with every practitioner on a professional register. The regrettable events at Stafford Hospital were avoidable and reading the inquiry report highlighted the extent to which the NHS, and those within it, neglected their duties of care. I was particularly ashamed of my Registered Nurse colleagues who appear to have forgotten that registration as a nurse requires attitudes and behaviours commensurate with the public trust that is attributed to their role. The shocking truth that emerges from the Francis Report(1) is that no organisation or profession emerges with any credit whatsoever - the Deanery, universities, general practitioners (GPs), the General Medical Council (GMC), the Nursing and Midwifery Council (NMC), Monitor…. It is clear that any number of healthcare professionals could have challenged what was happening and alerted the relevant regulatory and supervisory organisations. Those organisations could have then discharged their 'duties' rather than taking a benevolent and optimistic view of the emerging evidence and leaving it to others to act.

What information is provided in Australian emergency departments about fitness-to-drive after mild traumatic brain injury: a national survey.

Occupational therapists work together with their medical and nursing colleagues to ensure that patients are able to return to safe and legal driving upon discharge from the emergency department after a range of illnesses and/or injuries. This study aimed to determine the type of information that is provided nationally in emergency departments to people after mild traumatic brain injury (mTBI), with respect to fitness-to-drive. Cross-sectional electronic survey mailed to all emergency departments in Australia (N=110). Responses were invited from medical, nursing, and allied-health professionals. The survey asked respondents to comment about the existence and use of fitness-to-drive management guidelines, as well as their opinion on when clearance should be given to return to driving post injury. 104 clinicians completed the survey; the majority of respondents were medical staff (n=46, 51%) followed by allied-health staff (n=23, 25%), with the highest response rate provided from Victoria (n=41, 45%). Just over one-third of respondents' emergency departments (n=34, 36%) recommended a period of 'no driving' after mTBI, and within these departments, this recommendation was usually provided by medical staff (n=25, 80%). Consensus was not displayed with respect to the safest time to return to driving after mTBI. Opinions from respondents strongly suggested that a review of fitness-to-drive management guidelines was required for mTBI patients (n=78, 88%). No consensus exists in the fitness-to-drive recommendations provided to patients after mTBI, and clinicians have reported the need for a review of fitness-to-drive management guidelines in Australian emergency departments. With their understanding about the complex interplay of the skills required for safe driving, occupational therapists are positioned to help guide the development of protocols in this area.

Barriers to and Facilitators of Research Utilization among Iranian Nurses: a Literature Review.

Research utilization (RU), is an important strategy to promote the quality of patient care. The aim of this study was to present a comprehensive literature review describing barriers and facilitators of RU among Iranian nurses. Literature review was undertaken using the international databases including Pub Med/Medline, Scopus, Science Direct, and Google Scholar. Also, Persian electronic databases such as Magiran, SID and Iran Medex were searched up to May 2014. The search was limited to articles in the English and Persian languages that evaluate the barriers or facilitators of RU among Iranian nurses. A total of 11 articles were in the final dataset. The most important barriers to RU among Iranian nurses were related to the organization factors such as inadequate facilities; insufficient time on the job, lack of authority, physician cooperation, and administrative support. The most frequent facilitators of RU were education in enhancing nurses knowledge and skills in research evaluation, support from knowledgeable nursing colleagues and nursing faculty in the clinical setting, access to an expert committee for clinical appraisal, improving skills in English language and searching for articles, sufficient economic resources to carry out research, and having access to more facilities such as internet. Iranian nurses encounter with the same difficulties as to other countries regarding RU; while setting related barriers were the predominant obstacles to RU among them. Therefore, health managers are expected to plan appropriate strategies to smooth the progress of RU by nurses in their practice.

Rôle de l’infirmière de psychiatrie de liaison dans la prévention du risque suicidaire

From suicide risk prevention to treatment, the suicidal crisis process must be known to all carers to ensure appropriate and effective care. The psychiatry liaison team at the Nantes University Hospital advocates it with somatic teams through its liaison and consultation work. At the heart of this care network, the clinical expertise of the psychiatric liaison nurse educates nursing colleagues in identifying suicide risk. The nurse's clinical assessment and knowledge of the care system optimises the overall management and the path of patient care.

Investigation of working situation of trained wound care nurses

Objective To investigate the working situation of trained wound care nurses.Methods Twelve wound care nurses tested by the nursing department were surveyed by the self -evaluation questionnaire .And the satisfaction to the trained wound care nurses in 120 nurses and patients were investigated .The prevention of pressure ulcers were compared between 2011 and 2012 .Results The satisfaction rate of nurse colleagues to the wound care nurses was 90.8%.After the train, the satisfactions to wound care skills , wound care method, health education and skin care were 91.7%, 92.5%, 100.0%and 83.3%, respectively.The satisfaction rates of patients to skin care evaluation , skin clean methods , wound treatment process , treatment effect and health education were 84.0%, 93.3%, 70.0%, 79.2% and 85.5%, respectively.The mean score of pressure ulcers prediction was （97.56 ±1.14） in 2011 and （99.63 ±0.40） in 2012, and the difference was statistically significant （t=-6.444, P〈0.05）.Conclusions The work of wound care nurses has been accepted by their colleagues and the patients , but the research ability , professional identity and professional development and education need further be strengthened . Key words: Questionnaire survey Pressure ulcer Wound care Specialist nurse

Beyond moral distress

Every year, I meet a new group of postgraduate nursing students who come together to study ethics at an advanced level. For some, it is the first time in their careers that they have been able to express their ethical concerns in such a forum, or in some cases, in any formal setting; for others, it is a confirmation that not all perceived failures relating to moral issues are necessarily of their or their nursing colleagues’ own making. For all, it is a bitter-sweet confirmation of the difficulties involved in dealing with those sometimes painful moral problems that they have encountered over what is often several years of practice. Indeed, it is as if through the exchange of narratives, each student feels not only marginally unburdened but free to finally state those things that really matter to them in a forum where others actually appreciate their opinions. But then at some point, we come to an examination of what is currently called nursing ‘moral distress’, and slowly but surely, a rising degree of exasperation and annoyance emerges around the room, as one by one the students all focus on the same question, namely, ‘What are we to do about moral distress?’ Moral distress is a phenomenon that is a reality in nursing however it is labelled or packaged, and whatever the experts say it is or it is not. Whenever a group of experienced nurses identify a collection of unresolved or poorly resolved ethical issues in their workplaces, it will exist in one form or another. It is moral distress (as opposed to other possibilities of nursing distress) when there exists a moral element or threat to a nurse’s moral integrity that causes feelings of disquiet, and yes, even distress. It is moral distress (and not an ethical dilemma) when nurses feel that they have no ethical choice to make in a given situation; when there is ample evidence that nurses often feel devalued and ignored when attempting to resolve an ethical issue; and when nurses in numerous countries all appear to be saying the same things about their difficulties and frustrations when attempting to effectively respond to ethical issues in their practices. For my own part, I discovered just how pertinent all of this was when analysing my own research results on this topic this very year when it became clear that 16% of nurses in New Zealand were presently considering leaving their positions, and 48% had at least considered leaving a given nursing position in the past because of moral distress. The causes of moral distress in nursing practice are clearly many and varied, although in recent times, they are largely described as being related to either ‘internal’ or ‘external’ constraints. Many nurses are no doubt familiar with the first kind; it is often difficult to know what the right thing to do is because there are always a number of conflicting interpretations and possibilities. Here, admittedly, the boundaries between a moral dilemma and moral distress may become blurred; such is the nature of the mental gymnastics so often associated with any significant ethical problem. But the second kind, the external constraints, is a different matter. Then, as is often argued, most nurses know what is the right thing to do, but cannot do so because of these constraints. It is not that there is even the illusion of choices in this instance because many of the constraints are related to factors outside the control of nurses. The list grows yearly, but lack of organisational

Being at peace as an important factor in acquiring teaching competency by Iranian nurse teachers: a qualitative study.

It is imperative to understand the factor that influence teaching competency. Therefore, it is necessary to study those that have an impact on the process of acquiring teaching competency. Competent nurse teachers have an important role in the achievement of nursing students and improving the quality of nursing education. However, few researches have focused specifically on the process of acquiring teaching competency in nurse teachers and its related factors. This study as a part of more extensive research aims to explore the factors influencing acquisition of teaching competency by Iranian nurse teachers. Grounded theory was chosen as the method. Eleven teachers from three nursing schools in Tehran were recruited. Data was generated by semi structured interviews during May 2011 to March 2013 and was analyzed through using constant comparison. Three main categories were emerged including “individual characteristics” (spirituality, professional interest, ethical conducts, knowledge expansion and reflective practice), “organizational factors” (management of educational systems, solidarity culture, student characteristics) and “socio-cultural factors” (social situations, and public definition of nursing). Nurse teachers who deal peacefully with the nursing profession and colleagues are responsible and committed to acquiring teaching competency. A suitable organization in nursing educational systems that is structured and ordered also encourages a peaceful approach by nurse teachers.

A Night in the Emergency Department: A Nursing Narrative

It was a very slow night in the emergency department—the kind of night you don’t discuss, you simply enjoy. I had the corner assignment, which consisted of just 3 rooms that usually held patients with challenging problems. The benefit of this assignment is that only 3 instead of 4 patient rooms make up the nurse’s assigned load. In addition, I was working a “princess shift,” which is what our staff calls a short, 4-hour shift to bridge the gap in staffing. As “The Princess,” I was lightening the load of my fellow nurses and thus enjoyed a great deal of good will.

Nurse satisfaction with working in a nurse led primary care walk-in centre: an Australian experience

Objective: The aim of this study was to gain insight into the nursing staff’s experiences and satisfaction with working at the ACT nurse led Walk-in Centre. Design and Setting: Interviews with nursing staff working at the ACT Walk-in Centre were informed by a phenomenological approach. Questions were developed within inter, extra and intra-personal variables of satisfaction, underpinned by theprinciples of role theory. Subjects: Twelve nurses were interviewed; three nurse practitioners and nine advanced practice nurses. Their ages ranged from 31 to 63 years and they had a minimum of 15 years of nursing experience. Interviews ranged from 30 minutes to two hours duration. Results: Walk-in Centre nurses’ satisfaction with a number of inter and extra-personal factors was associated with their previous education and experience (intra-personal factors). Role stressors included adapting to autonomy, role incongruity and lack of access to appropriate education, training and sources of collaboration and mentorship. Sources of satisfaction were the autonomous role, relationships with the team and the capacity to deliver quality nursing care. Conclusion: Whilst autonomy is valued by nurses, this does not translate to isolation or independence. Autonomy is only a source of satisfaction when coupled with supportive and cohesive professional relationships with both nursing and medical colleagues. Organisations implementing advanced nursing roles must have a comprehensive understanding of the requirements of nursing autonomy to ensure effective role implementation and associated job satisfaction. These findings add impetus to the need for the development of nursing education programs tailored specifically to primary health care.

How Military Service Affects Our Nurse Colleagues: A Personal Account

How Military Service Affects Our Nurse Colleagues: A Personal Account Kyung Jun, RN, MSN, CNOR I wrote the story “How Military Service Affects Our Nurse Colleagues: A Personal Account”, Nurse Leader,Volume 11, Issue 5,1 to try to capture the essence of what it’s like to be a nurse in a war zone. The article is a personal account; I met with Brigitte again and hope the following will clarify a few things, including the confusion over military ranks. She enlisted in the navy, then became a nurse. She then joined the army reserve as a commissioned officer (second lieutenant, first lieutenant, and then captain). On all other matters, I would like to thank the reader for the corrections.

Transformation of admission interview to documentation for nursing practice

The admission interview is usually the first structured meeting between patient and nurse. The interview serves as the basis for personalised nursing and care planning and is the starting point for the clinic's documentation of the patient and his course of treatment. In this way, admission interviews constitute a basis for reporting by each nurse on the patient to nursing colleagues. This study examined how, by means of the admission interview, nurses constructed written documentation of the patient and his course of treatment for use by fellow nurses. A qualitative case study inspired by Ricoeur was conducted and consisted of five taped admission interviews, along with the written patient documentation subsequently worked out by the nurse. The findings were presented in four constructed themes: Admission interviews are the nurse's room rather than the patient's; Information on a surgical object; The insignificant but necessary contact; and Abnormalities must be medicated. It is shown how the nurse's documentation was based on the admission interview, the medical record details on the patient (facts that are essential to know in relation to disease and treatment), as well as the nurse's preconception of how to live a good life, with or without disease. Often, the patient tended to become an object in the nurse's report. It is concluded that in practice, the applied documentation system, VIPS, comes to act as the framework for what is important to the nurse to document rather than a tool that enables her to document what is important to the individual patient and his special circumstances and encounter with the health system.

Nurses' perspectives on stroke care in London

Aim: This paper is a report of a study exploring nurses' perspectives on their developing roles in specialist stroke care in London. Method: Nine paired semi-structured interviews with nurses working across the stroke care pathway in London were completed in 2011, recorded and transcribed verbatim. The data were analysed using interpretative phenomenological analysis. Results: The emergent themes included receiving support from fellow nurses, good communication but minimal involvement with the multidisciplinary team, unclear career pathways, and a positive ethos among the nurses. The nurses' responses indicate that they remain passionate and caring. They expressed interest in being more closely involved with the decision-making process within the multidisciplinary team. Conclusion: An understanding of the complex nursing roles within the new London stroke care pathway has emerged. Clear pathways of progression from band 5 to band 6 are being developed.