Clinical nurse specialists as entrepreneurs: constrained or liberated

Aims. This qualitative study explored the experiences of two groups of clinical nurse specialists – continence advisors and tissue viability nurses – working in primary care in the UK. In particular, the study focused on how clinical nurse specialists’ relationships with other health‐care professionals had an impact on their role. Background. Clinical nurse specialists are recognized worldwide as having expertise in a given field, which they use to develop the practice of others. Additionally, clinical nurse specialists share many of the characteristics of entrepreneurs, which they use to develop services related to their speciality. However, little research has been conducted in relation to clinical nurse specialists’ experiences as they attempt to diversify nursing practice. Design/methods. An ethnographic approach was adopted comprising many elements of Glaserian grounded theory. Data were collected via participant observation and face‐to‐face interviews with 22 clinical nurse specialists. Findings. Services provided by clinical nurse specialists were not static, clinical nurse specialists being the main drivers for service developments. However, clinical nurse specialists encountered difficulties when introducing new ideas. Given their role as advisors, clinical nurse specialists lacked authority to bring about change and were dependent on a number of mechanisms to bring about change, including ‘cultivating relationships’ with more powerful others, most notably the speciality consultant. Conclusions. The UK government has pledged to ‘liberate the talents of nurses’ so that their skills can be used to progress patient services. This study highlights the fact that a lack of collaborative working practices between health‐care professionals led to clinical nurse specialists being constrained. Relevance to clinical practice. Health‐care organizations need to provide an environment in which the entrepreneurial skills of clinical nurse specialists may be capitalized on. In the absence of an outlet for their ideas regarding service developments, clinical nurse specialists may remain dependent on the mechanisms witnessed in this study for some time.     

A pluralistic evaluation of nursing/practice development units

Nursing/practice development units (N/PDU) are perceived as centres for pioneering, evaluating and disseminating innovative practice development and facilitating the professional development of practitioners. This paper reports on a pluralistic evaluation research study of the nursing/ practice development unit accreditation programme provided by the University of Leeds, UK. Individual and focus group interviews were undertaken with key stakeholders involved in six nursing/practice development units. These included: clinical leaders, team members, executive nurses, trust board members, general medical practitioners, nursing/practice development unit steering group members, and accreditation panel members. Stakeholder perceptions of what constituted a successful nursing/practice development unit were elicited and then used to judge the success of the programme. Seven criteria for judging the success of nursing/practice development units were identified. These were: achieving optimum practice; providing a patient-orientated service; disseminating innovative practice; team working; enabling practitioners to develop their full potential; adopting a strategic approach to change and autonomous functioning. The findings highlighted differences between the rhetoric of a successful nursing/practice development unit and the reality in which they function. Whereas all the units were actively involved in innovative practice development, evaluation, dissemination and networking activities, several factors influenced the success of the units, in particular, the role of the clinical leader, the motivation and commitment of nursing/practice development unit members, financial resources, and the nature of support from managers, medical staff and education institutions. Although the nursing/practice development units had made significant progress in developing both healthcare practice and practitioners, there is still a need to consider how the claim that nursing/practice development units benefit patients can be substantiated.     

Advanced nursing practice: an idea whose time has come

Aims and objectives. This paper aims to analyse the concept of advanced nursing practice critically and to demonstrate an appreciation of the development of the role of the advanced nurse practitioner in the Irish context. Background. The concept of advanced nursing practice has existed in the US since the 1960s and in the UK since the early 1980s. The first signs of the advanced nurse practitioner began to emerge in Ireland in the late 1990s as a result of increasing demands and changes occurring within nursing and health care. Currently, there are 31 advanced nurse practitioners in the country, many of whom practice in the general setting. Strategies are in place to introduce advanced nursing practice into other nursing disciplines in the future. Methods. A literature review was conducted to address the various issues inherent within this concept. Results. There is a body of evidence indicating that advanced nursing practice has brought about an improvement in patient outcomes. In light of this, the advanced nurse practitioner has a valuable role to play in providing a beneficial contribution and filling a gap in healthcare services. Conclusion. This paper has demonstrated that nursing continues to be a dynamic and ever‐changing phenomenon where the onus is firmly on the advanced nurse practitioner as expert, leader and collaborator, to capture the hearts and minds of nurses and healthcare workers, so as to challenge traditional values and transform clinical practice. Failure to do so may allow medicine or other interested parties to shape the future of nursing or even absorb it. Relevance to clinical practice. Nurses working at an advanced level are striving to develop their expertise, initiate nurse‐led services and practice, in collaboration with other professionals in an effort to provide the highest quality care to the patient. Although the idea of the advanced nurse practitioner is relatively new to nursing in Ireland, it is the result of an idea whose time has come and there is nothing more powerful than an idea whose time has come.     

Clinical nurse specialist practice within the Acute Care for Elders interdisciplinary team model

As the complexity of care increases for hospitalized older adults, the clinical nurse specialist is essential for ongoing development of nursing practice and care standards. This article describes the Acute Care of the Elderly (ACE) model for interdisciplinary management of older adults and clinical specialist responsibilities within this interdisciplinary team. Within the model, clinical care specialists utilize clinical expertise and consultation skills reflecting three spheres of practice related to care of high-risk community-dwelling older adults admitted an acute medical unit. The goal for this patient group is to achieve medical stability while preserving maximum functioning. The Acute Care of the Elderly team members include primary nurses (staff nurses), physicians, clinical care specialists, therapies, social workers, dietitians, pharmacists, and a discharge planner. Under the leadership of the primarily nurse, the team develops a comprehensive care and discharge plan, implemented across a care continuum. Using protocols and working together, the team delivers cost-effective, coordinated care that promotes process improvement resulting in practice that is in alignment with current standards of care.     

Value of wireless personal digital assistants for practice: perceptions of advanced practice nurses

Aims and objectives. The aims were to explore advanced practice nurses’ perceptions on wireless Personal Digital Assistant technologies, to establish the type and range of tools that would be useful to support their practice and to identify any requirements and limitations that may impact the implementation of wireless Personal Digital Assistants in practice. Background. The wireless Personal Digital Assistant is becoming established as a hand‐held computing tool for healthcare professionals. The reflections of advanced practice nurses’ about the value of wireless Personal Digital Assistants and its potential to contribute to improved patient care has not been investigated. Design. A qualitative interpretivist design was used to explore advanced practice nurses’ perceptions on the value of wireless Personal Digital Assistant technologies to support their practice. Methods. The data were collected using survey questionnaires and individual and focus group interviews with nurse practitioners, clinical nurse specialists and information technology managers based in British Columbia, Canada. An open‐coding content analysis was performed using qualitative data analysis software. Results. Wireless Personal Digital Assistant’s use supports the principles of pervasivity and is a technology rapidly being adopted by advanced practice nurses. Some nurses indicated a reluctance to integrate wireless Personal Digital Assistant technologies into their practices because of the cost and the short technological life cycle of these devices. Many of the barriers which precluded the use of wireless networks within facilities are being removed. Nurses demonstrated a complex understanding of wireless Personal Digital Assistant technologies and gave good rationales for its integration in their practice. Conclusions. Nurses identified improved client care as the major benefit of this technology in practice and the type and range of tools they identified included clinical reference tools such as drug and diagnostic/laboratory reference applications and wireless communications. Relevance to clinical practice. Nurses in this study support integrating wireless mobile computing technologies into their practice to improve client care.     

Clinical nurse specialists shaping policies and procedures via an evidence-based clinical practice council

In the practice of nursing, organizations with progressive evidence-based practice programs implement structures and processes whereby nurses are engaged in the review of existing research and in the development of clinical practice documents to better align nursing practices with the best available scientific knowledge. At our academic hospital system, clinical nurse specialists (CNSs) took the lead to help transform a traditional nursing policy and procedure committee into a hospital-wide, staff-represented Clinical Practice Council (CPC) that ensures evidence-based nursing practices are reflected in the organization's nursing practice documents for the provision of patient care. Clinical nurse specialists function as mentors and cochairs who are dedicated to ensuring that nursing practice is supported by the latest evidence and committed to guiding staff nurses to continually move their practice forward. The success of the CPC is due to the leadership and commitment of the CNSs. This article describes the structure, process, and outcomes of an effective CPC where CNSs successfully engage frontline clinicians in promoting nursing care that is evidence based. Clinical nurse specialist leadership is increasingly made visible as CNSs effectively involve staff nurses in practice reforms to improve patient outcomes.     

Clinical coaching: a strategy for enhancing evidence-based nursing practice

PURPOSE: The purpose of this article is to describe how clinical nurse specialists can promote the development of knowledge and skills in nurses as one step toward making evidence-based nursing practice the norm in all patient care settings. BACKGROUND: The need for the use of evidence in nursing practice has been highlighted for several decades. Moving evidence more quickly into practice requires that nursing use many strategies. DESCRIPTION OF STRATEGY: The strategy of clinical coaching is proposed in this article for the development of skills in nurses specifically to promote evidence-based nursing practice. Clinical coaching is a relationship for the purpose of building skills. This strategy is aimed at increasing foundational staff nurse knowledge and skills. CONCLUSION: The achievement and maintenance of evidence-based nursing practice take continuous attention from clinical nurse specialists. Clinical coaching is only one part of a comprehensive approach for establishing and sustaining evidence-based nursing practice.     

Working relationships between practice nurses and general practitioners in Australia: a critical analysis

This research set out to explore shared care between practice nurses and general practitioners in South Australia. Nine practice nurses (PNs), two nurse practitioners and 10 general practitioners (GPs) were interviewed in urban and rural practices in order to build up a picture of how GPs and PNs worked together. The interviews showed that shared care was not a reality, although practice nurses were very busy, enjoyed their work and were no longer performing as receptionists doing a little nursing on the side, but as highly skilled nurses. Questions that emerged included whether or not practice nurses are specialists or generalists; their relationship to nurse practitioners; the extent to which the doctor–nurse game explains the relationship between practice nurses and general practitioners; and the potential for expanding the practice nurse role.     

Strategic directions and actions for advanced practice nursing in China

There is a need and opportunity for China to develop education and practice innovations given that advance practice nurses (APNs) improve health care and outcomes. The China Medical Board (CMB) China Nursing Network (CCNN) began planning for an Advanced Nursing Practice Program for education and career development that will facilitate CCNN's contributions to meeting national nursing policy priorities. This paper presents the discussion, recommendations and action plans developed at the inaugural planning meeting on June 26, 2015 at Fudan University in Shanghai. The recommendations are: Develop standards for advanced nursing practice; Develop Master's level curricula based on the standards; Commence pilot projects across a number of University affiliated hospitals; and Prepare clinical tutors and faculty. The strategic directions and actions are: Develop a clinical career ladder system; Expand the nursing role from hospital to community; and Build a specialty nurse accreditation system.     

Nursing work in Jordan: an example of nursing work in the Middle East

Aim. The study aimed to investigate Jordanian nurses’ perceptions of their role in clinical practice. Background. The lack of regulation of nursing practice by the profession across the Middle East until now has led to each institution setting its own policies regarding the role of the nurse and the practice of nursing. No study to date has examined the role of the nurse working in the acute hospital environment nor explored the practice of nursing in this region. Design and methods. A cross‐sectional questionnaire survey was conducted using a quota sample. A total of 348 medical‐surgical staff nurses and practical nurses from the three healthcare sectors in Jordan participated in the study with a response rate of 77%. The results were analysed by constructing multiple response tables, chi‐square test, anova and log‐linear analysis. Results. Staff nurses in Jordan were expected to carry out the majority of nursing care activities. The role of the practical nurse was limited to the physical and professional domains of nursing care. Activities requiring higher levels of emotional or intellectual labour and interdisciplinary communication were attributed only to the staff nurse. The majority of the respondents reported nursing had not been their first choice of career. Male nurses had a higher intention to leave the nursing profession. The predominant method of care delivery used by nurses was task‐oriented. Conclusion. There was a general consensus regarding what constituted the nurse's work in the clinical area across the three healthcare sectors in Jordan. Role delineation between the two levels of nurses was also clear. There is a need to move from task‐oriented to patient‐centred care to promote quality patient care. Relevance to clinical practice. This study explores the role of the nurse working in the acute hospital environment in Jordan.     

Perceptions of the benefits and challenges of the role of advanced practice nurses in nurse‐led out‐of‐hours care in Hong Kong: a questionnaire study

Aims and objectives. The aim of the study was to identify the factors that nurses perceive may facilitate or hinder the development of advanced practice nurse roles in Hong Kong. Background. Advanced practice nurses are increasingly prominent in nurse‐led out‐of‐hours care in Hong Kong in response to changes to junior doctors’ hours of work. Setting. Three five‐day workshops for Hong Kong‐based advanced practice nurses were offered in partnership with UK clinicians. The aim of the workshops was to share UK experiences of implementation of the ‘Hospital at Night’ model of care delivery. The questionnaire study undertaken was not part of the workshop programme. However, the workshops gave the authors a unique opportunity to access relatively large numbers of Hong Kong‐based advanced practice nurses. Participants. The workshops were attended by experienced nurses who had been or were about to be appointed as advanced practice nurses. All nurses who attended one of the three workshops (n = 120) agreed to participate in the study. Methods. Responses to two open questions posed in the questionnaire were the subject of a content analysis. Results.  A prominent finding of the study was that respondents viewed the benefits of introducing advanced practice nurse roles in Hong Kong as outweighing any challenges. One of the main features of the perceived benefits relates to improving the quality and safety of patient care. The greatest challenges associated with the role related to acceptance of the role by other healthcare professionals, and difficulties associated with the general public’s traditional attitudes to healthcare provision in Hong Kong. Conclusions. Education of the public concerning the implementation of such roles is of crucial importance. Relevance to clinical practice. Findings from this study enhance understanding of the factors that hinder or facilitate advanced practice roles in out‐of‐hours care in Hong Kong.     

Reflections by clinical nurse specialists on changing ward practice

In September 2010, palliative care clinical nurse specialists at North Middlesex University Hospital Trust introduced competencies for all nurses in setting up and using syringe drivers. This was done after the trust identified a high level of clinical incidents involving syringe drivers. This article discusses how the competencies were implemented and assessed, explores the importance of understanding change management to achieve change, and how different leadership styles affect changes to practice.     

The role of the advanced practice nurse in neuroscience nursing: results of the 2006 AANN membership survey.

The need for a scope of practice for advanced practice neuroscience nurses was identified by the American Association of Neuroscience Nurses (AANN) in 2006. A task force consisting of advanced practice nurses (nurse practitioners and clinical nurse specialists) was commissioned by AANN and charged with the development of the document. Current information regarding the practices of advanced practice neuroscience nurses was needed as the task force began to develop this document. To best obtain this information, an electronic survey was created and distributed to advanced practice nurses within the AANN database. The survey questions included basic demographic data and sought information regarding activities and procedures performed by the advanced practice nurse. The results of this survey clearly reflect the diversity in practice and the integral role advanced practice neuroscience nurses play in the management of patients' care.     

Achieving evidence-based nursing practice: impact of the Caledonian Development Model

Aim To determine the impact of the Caledonian Development Model, designed to promote evidence‐based practice. Background The model features practice‐development activities, benchmarking, knowledge pooling and translation through membership of a community of practice and a virtual college. Methods Twenty‐four nurses, from 18 practice sites formed three communities of practice, each selecting evidence‐based guidance to implement. A modified group supervision framework empowered nurses to champion local implementation. Outcomes were determined at 6 months. Results Eighty per cent of the patient‐related criteria and 35% of the facilities criteria were achieved. The Revised Nursing Work Index indicated these nurses experienced greater autonomy (P = 0.019) and increased organizational support (P = 0.037). Focus groups revealed a deepening organizational support for the initiative over time, illuminated work‐based learning challenges and overall enthusiasm for the approach. Conclusion Implementation of the model effectively promoted evidence‐based practice, most notably at the level of the individual patient. Implications for nursing management Time and budgetary constraints necessitate smart, value for money approaches to developing evidence‐based practice and improved care standards. This work demonstrates an effective model that strikes a balance between individual and group learning, virtual and real‐time activities, coupled with resource pooling across organizations and sectors.     

A baseline description of the research, clinical practice and development needs of urology nurses in the United Kingdom

The research, clinical practice and development needs of urology nurses in the UK are poorly understood. Through a postal questionnaire all current members of the British Association of Urological Nurses (BAUN) were surveyed to obtain baseline data related to their views on research, clinical practice and development needs. Fifty‐one per cent of BAUN members (n = 292) responded. The results of the survey produced a mixed picture of issues in British urological nursing. While the majority of respondents had considerable experience and enthusiasm for their specialty, a number of issues were identified that have implications for the development and delivery of clinical practice in the future. A plethora of different titles used by nurses was uncovered, raising questions on the dual issues of public identity and protection, and the lack of nationally recognized education programmes leading to recognition of nursing practice at an advanced level. Urology nurse specialists were identified as having considerable input into the design and delivery of services in contrast to non‐specialists who suggested that their input was not valued to the same degree. Difficulties were identified in relation to not only the availability of education but also in the areas of employer release and funding to support ongoing clinical development. The findings of the survey have great significance for the development of British urological nursing. The results offer an opportunity to understand urological nursing needs within a political context, offering an opportunity to explore changes that may be required to address areas of need in research, clinical practice and development. The study also offers a view of UK‐ based practices and issues to an international community for comparison and contrast.     

Children's nurses and nurse prescribing: a case study identifying issues for developing training programmes in the UK

Aims and objectives. (1) To develop an insight into the opportunities and barriers to nurse prescribing for a case study of children's nurses. (2) To consider the implications of independent nurse prescribing for children's nurses and the potential for nurse prescribing to be developed in acute children's care settings. (3) To use research data to develop a training strategy. Background. Nurse prescribing in the UK is evolving and current initiatives aim to extend the range and scope of prescribing. Children's nursing presents interesting challenges because of off‐license drugs. Successful nurse prescribing lies in practice area preparation, local policy and practice development and identifying precourse training needs. Design. Case study. Research questions. (1) What opportunities do children's nurses identify as being appropriate for nurse prescribing? (2) Can children's nurses identify the benefits of patient group directives and the different levels of nurse prescribing? (3) What preparation do children's nurses need for nurse prescribing? Methods. Focus group of health visitors/district nurses to inform a survey of 500 nurses working in acute and specialist care settings in a large Children's Hospital. Results. Focus group main themes – training, supervision and the development of confidence, record keeping, benefits of nurse prescribing, autonomous practice, the formulary and its use in practice. Response rate was 27%. Senior nurses and specialists identified potential benefits for their practice. Course content needed to focus on children, i.e. children's physiology and pharmokinetics. Children's nurses frequently advise junior medical colleagues on prescribing issues. Patient group directives are a useful alternative to prescribing. Conclusions. The results provide an insight into the training needs of children's nurses and specialist nurses which may be used to develop nurse prescribing training and practice. Training may need to be targeted at senior nurses/specialist nurses initially to develop a critical mass to change organizational culture. Relevance to clinical practice. Pertinent for senior nurses responsible for developing children's nursing practice and services for children in acute settings.     

A training package for primary care nurses in conducting medication reviews: their views and the resultant outputs

Aims. To ascertain nurses’ views about training in and undertaking of medication reviews and to analyse documented pharmaceutical care issues (PCI) and outputs from nurse reviews. Background. Primary‐care nurses in the UK are increasingly expected to contribute effectively to chronic disease management for example by undertaking medication reviews. There are concerns that nurse education is inadequate for these new roles. Little research is published about nurse medication reviews. A pilot study in one Scottish medical practice demonstrated that, after training in systematic medication review, practice‐based nurses could identify medication‐related problems. The training, consisting of reading material, including self‐assessment questions and a training event, was subsequently offered to all practice‐based nurses in the Community Health Partnership (CHP); participants then undertook six reviews to achieve CHP accreditation. Design. Survey of participant nurses and analysis of completed documentation from reviews. Methods. A self‐completion, postal questionnaire distributed three months post‐training. Analysis of documentation from reviews for PCI and outputs. Results. Eighty‐one nurses were offered training: 64 (79%) participated; 38 (59%) returned questionnaires. Low confidence levels before training (0, very confident; 6, 16% confident) rose afterwards (8, 21% very confident; 19, 50% confident). Thirty‐two (84%) nurses indicated the training had completely or mostly met their needs. A total of 120 nurse reviews were analysed and 188 PCI documented, mean 1·6/patient, with 117 outputs, mean 1·0/patient. Twenty‐seven outputs (23%) involved prescribed medicine changes. Conclusions. A pharmacist‐supported training package in medication reviews for primary‐care nurses is feasible and generally welcome. The training met the needs of most respondents although concerns were expressed regarding time pressures and knowledge base for extended roles. Relevance to clinical practice. Medication reviews are vitally important for both patients and the NHS; this approach may be useful for nurse prescribers and non‐prescribers alike although concerns expressed will require attention.