From expert to tasks,expert nursing practice redefined?

Aim. The aim of this paper was to explore the concept of expertise in nursing from the perspective of how it relates to current driving forces in health care in which it discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas. Background. Expert nursing practice can be argued to be central to high quality, holistic, individualized patient care. However, changes in government policy which have led to the inception of comprehensive guidelines or protocols of care are in danger of relegating the ‘expert nurse’ to being an icon of the past. Indeed, it could be argued that expert nurses are an expensive commodity within the nursing workforce. Consequently, with this change to the use of clinical guidelines, it calls into question how expert nursing practice will develop within this framework of care. Method. The article critically reviews the evidence related to the role of the Expert Nurse in an attempt to identify the key concepts and ideas, and how the inception of care protocols has implications for their role. Conclusion. Nursing expertise which focuses on the provision of individualized, holistic care and is based largely on intuitive decision making cannot, should not be reduced to being articulated in positivist terms. However, the dominant power and decision‐making focus in health care means that nurses must be confident in articulating the value of a concept which may be outside the scope of knowledge of those with whom they are debating. Relevance to clinical practice. The principles of abduction or fuzzy logic may be useful in assisting nurses to explain in terms which others can comprehend, the value of nursing expertise.     

Exploring nursing expertise: nurses talk nursing

It has become increasingly important for practitioners to articulate their expertise in modern healthcare settings that demand high levels of accountability and evidence-based practice. The material presented within this article has been interpreted drawing from discourse analysis1 to help explore the discourses that shape and influence understandings of nursing practice. What we present are extracts from four of the 35 participant nurses who applied to take part in the Royal College of Nursing Institute's Expertise in Practice (pilot) Project (EPP). The material presented is used to provide a starting point for exploring how nurses talk about and construct expertise in nursing practice. The four nurse participants' clinical practice areas cover palliative care, mental health, intensive care and fertility care. The material reveals high levels of intensity in the nurse-patient relationship, 'maverick' nursing practices and ongoing reflexivity. All of these aspects appear to capitalize on expertise as a 'catalyst' that alters treatment pathways and maximizes patient-centred outcomes. Exploring a discourse of nursing expertise exposes the tacit situated nature of professional practice that is heterogeneous and most difficult to articulate and explain. It is proposed that expertise tends to be understood from traditional and dominant discourses of medicine, management and technology. Explaining expertise in practice exposes non-conventional practice that in itself can be isolating and challenging to the status quo of contemporary health-care.     

An international approach to master's-level preparation for clinical nurse specialists*

Nursing is seen as being increasingly a research-based profession with a developing knowledge base that demands a continuing programme of education This is necessary to enable the practitioner to function with the level of expertise and skill required in today's health care systems There have been repeated calls for and developments in the establishment of a higher-education approach to nursing, with degree courses for the advanced practitioner It is also argued that in terms of the European perspective there are many commonalities in nursing and health care in Europe, and although cultural and national differences are important there can be advantages to nurses from different countries studying together An example of a course which offers this European approach to higher education for nurses is described     

A comparative analysis of lay-caring and professional (nursing) caring relationships

Acceptable definitions of the terms care and nursing have yet to be reached. Some may feel that lack of agreement on the meaning of these concepts is a rather esoteric or academic point: the argument put forward in this paper is that until a clearer perception of the concepts of care and nursing is arrived at, the profession will be limited in its ability to develop its expertise or to set standards related to the quality of care. The paper outlines the extent to which these concepts have been explored and details the developments and some of the limitations of present modes of thought. An alternative perspective is offered, based on a comparative analysis of the professional (nursing care) and lay-caring relationships. By this means, a set of characteristics similar in both relationships, has been identified. Quality of care in the professional caring relationship is thought to relate to the extent to which aspects of caring activities implicit in the lay-caring relationship are carried into the professional nurse-patient relationship and made explicit. The ability of the nurse to do this emerges as one aspect of her therapeutic nursing function.     

A comparative analysis of lay-caring and professional (nursing) caring relationships

Acceptable definitions of the terms care and nursing have yet to be reached. Some may feel that lack of agreement on the meaning of these concepts is a rather esoteric or academic point: the argument put forward in this paper is that until a clearer perception of the concepts of care and nursing is arrived at, the profession will be limited in its ability to develop its expertise or to set standards related to the quality of care. The paper outlines the extent to which these concepts have been explored and details the developments and some of the limitations of present modes of thought. An alternative perspective is offered, based on a comparative analysis of the professional (nursing care) and lay-caring relationships. By this means, a set of characteristics similar in both relationships has been identified. Quality of care in the professional caring relationship is thought to relate to the extent to which aspects of caring activities implicit in the lay-caring relationship are carried into the professional nurse-patient relationship and made explicit. The ability of the nurse to do this emerges as one aspect of her therapeutic nursing function.     

Involvement of older people in care, service and policy planning

In line with other helping professions nursing has moved from traditional views of technical expertise as the prime shaper of health care, to a more equal relationship with service users and patients which respects their expertise, knowledge, goals and choices. This philosophy has underpinned the movement to involve older people in care, policy and planning activities. The literature review presented in this paper highlights the growing literature on this subject with respect to older people and maps the key issues and debates for nursing.     

Need to know: essential survival skills for the information age

Twenty-five years ago, health care information technology was dramatically different from what it is today. Twenty-five years from now, it promises to be worlds away from what it is today. How good a job has nursing done at keeping up with this exponential change? This article addresses the evolution of technology in health care and nursing's track record of technology expertise. It also discusses the price nursing will pay if it does not keep up with technology and the benefits it can gain if it does.     

From vocation to profession: the quest for professionalization of nursing

This article examines some of the complex factors in the transition of nursing from vocation to profession. These factors include university education, knowledge, gender, and workplace environment. It argues that the conventional definitions and characteristics of the professions and knowledge are tainted with gender bias. The uniqueness of nursing knowledge lies in the combination of scientific and holistic knowledge required for patient care, which is different from other healthcare professions. It suggests an alternative means of recognizing the clinical expertise of frontline nurses so that their contribution to patient care can be acknowledged. Together with the extended and expanded role of specialist nurses and nurse managers, nurses can impose their presence and consolidate their power base in the quest for professionalization.     

Expert thinking in nursing practice: implications for supporting expertise

Abstract The complexity of the art of expert nursing practice is an elusive phenomenon, which is difficult to articulate in concrete terms that can be translated into achieving quality patient care outcomes. The present study describes the findings of two hermeneutic (interpretive) studies on expert thinking that captured the holistic practice of expert clinicians. The findings from these studies provide insight into how expert practice can be administratively supported. These findings also have strong implications for strategies to facilitate the development of expertise in practice. In order to provide holistic care, nurses must spend time with their patients so that the particularities and meaning inherent in each unique patient situation can be understood. The art of expert thinking is a temporal and ethical activity, which needs to be supported and cultivated in a changing health-care delivery system.     

Cultural competency and nursing care: an Australian perspective

AIMS: To propose a process that will facilitate cultural competence in Australian nursing practice. BACKGROUND: Cultural diversity is a prominent feature of the Australian health system and is impacting significantly on nursing care quality. A fictitious, but typical clinical exemplar is profiled that identifies cultural insensitivity in care practices leading to poor quality outcomes for the health consumer and her family. Strategies are proposed that will reverse this practice and promote culturally competent nursing care and that locates overseas qualified nurses in this process. CONCLUSION: This paper contributes to nursing care quality internationally by articulating strategies to achieve cultural competence in practice. Nurses must pay attention to interpersonal relationships and develop respect for the health consumer's value systems and ways of being, in order to protect their rights and avoid the tendency to stereotype individuals from particular cultures. The expertise of qualified nurses from different cultures can greatly assist this process.     

The Zebra index: one method for comparing units in terms of nursing care

levenstam a.-k. & bergbom i. (2011) Journal of Nursing Management 19, 260–268
The Zebra index: one method for comparing units in terms of nursing care Aim To describe an approach for developing a nursing index that is based on the patients’ needs of nursing care and enables nursing costs to be calculated. Background Usually staffing resources are calculated as the ratio between the number of staff and the number of occupied beds per unit. Method The index was developed from two parts of the Zebra method. The index factor per patient category of care was calculated first. The patient days per category of care was multiplied next with the index factor for the category, which gives the same value in terms of nursing care given for all the patient days. The third step was the calculation of the Zebra index (ZI). Results The ZI shows ‘the intensity of nursing care’ given. The index makes it possible to follow changes in the nursing care given over a period of time and it can also explain why two similar units with the same number of staff per patient can have a totally different workload situation. Conclusion The ZI obtains reliable information about the changing nursing situations over a period of time. Implications for nursing management The approach described can be used in different settings and is not bound to Sweden but can be looked upon as a general method. The index is useful for comparing different units and clinics in terms of nursing care and staffing.     

Managing the burden: nursing older people in England, 1955-1980

This article is a historical exploration of the work undertaken, by both nurses in training and qualified ward level nurses, on older adult wards of the National Health Service hospitals in England between 1955 and 1980. It focuses particularly on the personal care given to older patients, including pressure area care, the importance of meal times for the patients and the central role of the ward sister in the administration of food, and the training of the student nurses. These key practice themes will be examined in turn and related to the realities that the nurses faced in terms of the shortages of equipment, expertise, training, and also the low status accorded to the care of older people. It will be demonstrated that the care received by the elderly patients was often uncaring, routine and regimented. However, the blame for this treatment cannot be laid solely at the feet of the nurses themselves, but the system which conspired against them and their patients - a system, based on a prevailing attitude in which the older adult population was considered to be a 'burden', or the 'cuckoos in the nest of the acute general hospital' (Grimley Evans 1997, 1076). It is hoped that this article will contribute to the emerging and important area of the history of nursing work.     

儿童福利机构护士工作现状研究

目的研究儿童福利机构护士的工作现状，为提高护理管理水平提供理论依据。方法采用自设问卷调查26所儿童福利机构中44名护上的基本情况和护理工作状况。结果儿童福利机构护士的护理对象及工作状况具有特殊性，其护理专业知识不能满足实际工作需要，护理业务知识的学习和培训相对滞后。结论医疗卫生系统应建立统一的护理常规和操作标准，促进护士专业知识的继续教育学习，提高护理水平，促进儿童福利事业的发展。     

Transcultural nursing: the relationship between individualist ideology and individualized mental health care

This article attempts to clarify and underpin the view that individualized mental health nursing is culture biased and politically instrumental, adding weight to the transcultural argument that mental health care should be more culture sensitive than is often the case within conventional UK settings. It examines the political history of individualist ideology, and then uses social conflict theory to explore the potentially counter-therapeutic relationship of individualism and individualized nursing care in the UK mental health sector. The article challenges the widespread idea that individualized mental health nursing is 'liberal', 'democratic', 'holistic' and 'scientific', and in so doing extends the transcultural agenda to large scale infracultural differences within the UK population. It also explores the potential for policy change towards a more pluralistic service, and outlines some of the practical steps which may be taken to access alternative care approaches. It is a power analysis, which may be of transferable value to nurses in mental health care inpatient units where conventional individualized approaches are failing to reintegrate service users into the community. A glossary of terms is presented at the end of this article.     

Critical thinking and intuitive nursing practice

In this paper, we analyse how critical thinking and intuitive practice are related to expertise in nursing We examine how intuitive practice, when performed automatically without care, vigilance, and criticism, can result in prejudice and patterns of practice which are misinformed We will show that the student nurse develops intuitive, skilful performance in nursing by reasoning about nursing knowledge and applying reflective, critical thought m practice situations, thereby gaming increasing expertise in reasoning as a reliable professional ensuring quality client care The elements of thought necessary for sound reasoning in clinical practice will be explored Finally, we suggest educational strategies and tactics which promote the development of the intellectual capacities of student nurses as independent critical thinkers     

Intersectional perspectives on family involvement in nursing home care: rethinking relatives' position as a betweenship

This study seeks to understand, in the context of intersectional theory, the roles of family members in nursing home care. The unique social locus at which each person sits is the result of the intersection of gender, status, ethnicity and class; it is situational, shifting with the context of every encounter. A content analysis of 15 qualitative interviews with relatives of nursing home residents in Sweden was used to gain a perspective on the relationships between relatives and residents, relatives and the nursing home as an institution, and relatives and the nursing home staff. We sought to understand these relationships in terms of gendered notions of the family and the residents, which are handed down from generation to generation and thus condition who and how relatives should be involved in care, and the ways in which relationships change as care moves from home to nursing home. It requires knowledge and awareness that the nursing home culture is based on intersectional power structures in order for relatives to be involved in nursing home care in alternative and individual ways.     

Understanding clinical expertise: Nurse education,experience, and the hospital context

Clinical nursing expertise is central to quality patient care. Research on factors that contribute to expertise has focused largely on individual nurse characteristics to the exclusion of contextual factors. To address this, we examined effects of hospital contextual factors and individual nurse education and experience on clinical nursing expertise in a cross‐sectional analysis of data from 8,611 registered nurses. In a generalized ordered logistic regression analysis, the composition of the hospital staff, particularly the proportion of nurses with at least a bachelor of science in nursing degree, was associated with significantly greater odds of a nurse reporting a more advanced expertise level. Our findings suggest that, controlling for individual characteristics, the hospital context significantly influences clinical nursing expertise. © 2010 Wiley Periodicals, Inc. Res Nurs Health 33:276–287, 2010     

Re-defining nursing expertise in the United kingdom

There is now international recognition of the importance of practice expertise in modern and effective health services. The Expertise in Practice Project in the United Kingdom began in May 1998 and continued to 2004. It included nurses working in all four countries of the United Kingdom, and it covered clinical specialists from pediatrics to palliative care. The project added to the current understanding of what nursing practice expertise is, through the identification and verification of attributes and factors which enable expert practice. The proposed framework offers a language for sharing what constitutes practice expertise and offers insight into what occurs between the expert practitioner and the people that experience their care. The Expertise in Practice Project demonstrates that nurses affect change and facilitate performance and organizational development.     

Nursing models in a special hospital: a critical analysis of efficacity

Models of care from the general field of nursing applied in special hospitals appears to be unworkable in this type of environment in terms of their inability to affect patient care. It is argued that these external models, adopted due to a crisis of confidence in special hospitals, fail because their fundamental constructs clash with that of the institution's particular sociology. A historical analysis of the development of special hospitals and nursing models reveals a dichotomy of emergent values, highly complex in nature, which conflict from the notion of Parsonian role-adoption. From this position, it is suggested that the strength of value systems are such that this leads to a non-negotiable stalemate of forensic elements of client and institution, and the 'treatment' ethic as prescribed by the medicalization of criminology. This article critically analyses the six most commonly-used nursing models in special hospitals and pinpoints the areas of breakdown within this type of environment from a sociological perspective. Finally, it argues for a new direction away from 'generalist' ideals of nursing towards a theoretical construction of 'specialism' in forensic care.     

The acquisition and exercise of nephrology nursing expertise: a grounded theory study

Aims and objectives. This purpose of this study was to describe the process of expertise acquisition in nephrology nursing practice. Background. It has been recognized for a number of decades that experts, compared with other practitioners in a number of professions and occupations, are the most knowledgeable and effective, in terms of both the quantity and quality of output. Studies relating to expertise have been undertaken in a range of nursing contexts and specialties; to date, however, none have been undertaken which focus on nephrology nursing. Design. This study, using grounded theory methodology, took place in one renal unit in New South Wales, Australia and involved six non‐expert and 11 expert nurses. Methods. Simultaneous data collection and analysis took place using participant observation, semi‐structured interviews and review of nursing documentation. Findings. The study revealed a three‐stage skills‐acquisitive process that was identified as non‐expert, experienced non‐expert and expert stages. Each stage was typified by four characteristics, which altered during the acquisitive process; these were knowledge, experience, skill and focus. Conclusion. This was the first study to explore nephrology nursing expertise and uncovered new aspects of expertise not documented in the literature and it also made explicit other areas, which had only been previously implied. Relevance to clinical practice. Of significance to nursing, the exercise of expertise is a function of the recognition of expertise by others and it includes the blurring of the normal boundaries of professional practice.