Revealing how language builds the identity of the advanced nurse practitioner.

AIMS AND OBJECTIVES: To explore how language works to enable and constrain the role of the advanced nurse practitioner (ANP) in the health system. BACKGROUND: Nurses and doctors are produced within historically established disciplinary boundaries. These boundaries are becoming more porous, offering the possibility of a more liberated identity for ANPs that will allow them to reach their full potential. Current uncertainty and confusion about ANPs' identity result in their role being underutilised. DESIGN: A critical discourse analysis design was used to explore participants' language-in-use. Findings are reported according to the COREQ research checklist. METHOD: Data were collected through seven in-depth interviews and four focus groups and analysed using Gee's (2010) Identity Building Tool. Participants included ANPs, nurses (including nurse managers), doctors and allied healthcare professionals. RESULTS: Four discourses were revealed. Participants' language-in-use worked to privilege the ANP's uniquely holistic identity. However, this aspect is also associated with a controlled identity, predominantly constrained by medics and restricted from advancing. The third discourse, the medicalised identity builds an identity that positions ANPs as medical replacements who are assigned trivial medical tasks. The final discourse constructs an independent powerful identity for the ANP that is influential and autonomous. CONCLUSIONS: Circulating discourses and conversations can influence and shape the construction of the ANP identity. Healthcare professionals need to identify and counter discourses and conversations that construct ANPs' ways of knowing and knowledge as inferior and their role as subservient. Otherwise, ANPs' identity will continue to be controlled and their advancement restricted. RELEVANCE TO CLINICAL PRACTICE: Confusion concerning the role and identity of the ANP can limit their contribution to the healthcare system. Healthcare professionals need to be aware of how language-in-use can prevent the role from developing and reaching its full potential in enhancing healthcare provision and delivery. Reporting follows the COREQ criteria.

A Rapid Realist Review of Quality Care Process Metrics Implementation in Nursing and Midwifery Practice.

Quality measurement initiatives promote quality improvement in healthcare but can be challenging to implement effectively. This paper presents a Rapid Realist Review (RRR) of published literature on Quality Care-Process Metrics (QCP-M) implementation in nursing and midwifery practice. An RRR informed by RAMESES II standards was conducted as an efficient means to synthesize evidence using an expert panel. The review involved research question development, quality appraisal, data extraction, and evidence synthesis. Six program theories summarised below identify the key characteristics that promote positive outcomes in QCP-M implementation. Program Theory 1: Focuses on the evidence base and accessibility of the QCP-M and their ease of use by nurses and midwives working in busy and complex care environments. Program Theory 2: Examines the influence of external factors on QCP-M implementation. Program Theory 3: Relates to existing cultures and systems within clinical sites. Program Theory 4: Relates to nurses' and midwives' knowledge and beliefs. Program Theory 5: Builds on the staff theme of Programme Theory four, extending the culture of organizational learning, and highlights the meaningful engagement of nurses and midwives in the implementation process as a key characteristic of success. Program Theory 6: Relates to patient needs. The results provide nursing and midwifery policymakers and professionals with evidence-based program theory that can be translated into action-orientated strategies to help guide successful QCP-M implementation.

Integrative review; identifying the evidence base for policymaking and analysis in health care.

AIM: The aim of this was to identify and synthesize the evidence underpinning the health policymaking process to inform the development of a health-related policy analysis framework. DESIGN: A mixed methods review using "Best Fit" Framework synthesis. DATA SOURCES: PUBMED and CINAHL+ databases for English language papers published between March 2013 - March 2017. REVIEW METHODS: Titles were screened, data abstracted and analysed by two authors at each stage. Findings from included studies were coded against six a priori categories which had been constructed through a preliminary literature review, consultation and consensus. RESULTS: Sixty-eight papers were included. There exists empirical support for six key domains which require to be addressed in the policymaking and analysis process: (1) Context; (2) Process; (3) Content; (4) Stakeholder Consultation; (5) Implementation; and (6) Evaluation. Failure to contextualize and integrate these six domains in problem identification, policy analysis, strategy and policy development, policy enactment and policy implementation is problematic. CONCLUSION: There is a need to test and refine the constructs linked to the policymaking cycle taking cognizance of the context where these are developed, implemented and evaluated. IMPACT: This review makes a novel contribution to the synthesis of evidence to inform the policymaking and analysis process. Findings illuminate the complexity of policymaking, the competing pressures involved and the importance of the local, national and international context. These findings have international relevance and provide empirical support for key criteria to guide those involved in context specific policymaking and/or the analysis of existing policy.

Enablers and challenges to advanced nursing and midwifery practice roles.

AIM: To describe the enablers and challenges to the development and implementation of advanced nursing and midwifery practice roles in Ireland. BACKGROUND: Leadership strategies need to be put in place to enhance the development and implementation of advanced nursing and midwifery practice roles. METHOD: A descriptive qualitative approach using semi-structured interviews with key stakeholders (n = 15) was undertaken with nurses and midwives working in specialist and advanced practice roles and participants from other areas such as legislative, regulatory, policy, pharmacy, medicine and education. RESULTS: Participant's perspectives on the enablers and challenges to enacting specialist and advanced practice roles resulted in the generation of three themes: organisational factors; collegial, interprofessional and interpersonal support; and role clarity, economic and regulatory contexts. CONCLUSION: Addressing organisational factors, encouraging collegial and interprofessional support and establishing role clarity contribute to the effective development and implementation of the role of advanced practitioners. IMPLICATIONS FOR NURSING AND MIDWIFERY MANAGEMENT: Managers of nursing services need to provide leadership in developing strategies to enhance the enablers and overcome the challenges to advanced practice role development in their own organisation.

Developing and sustaining specialist and advanced practice roles in nursing and midwifery: A discourse on enablers and barriers.

AIMS AND OBJECTIVES: To collate, synthesise and discuss published evidence and expert professional opinion on enablers and barriers to the development and sustainability of specialist and advanced practice roles in nursing and midwifery. BACKGROUND: Expanded practice is a response to population health needs, healthcare costs and practitioners' willingness to expand their scope of practice through enhanced responsibility, accountability and professional autonomy. DESIGN: This discursive paper is based on a rapid review of literature on enablers and barriers to the development and sustainability of specialist and advanced practice roles and is part of a wider policy analysis. METHODS: We analysed and synthesised of 36 research articles, reviews and discussion papers on enablers and barriers in the development and sustainability of expanded practice roles. RESULTS: Several factors enable role expansion, including: role clarity; credentialing and endorsement; availability of education for expanded roles; individual practitioners' dispositions towards role expansion; support from peers, other professionals and the work organisation; and costs. Where limited or absent, these same factors can constrain role expansion. CONCLUSIONS: Enabling nurses and midwives to practice to their full scope of education and expertise is a global challenge for disciplinary leadership, a national challenge for professional regulation and a local challenge for employers and individual clinicians. These challenges need to be addressed through multistakeholder coordinated efforts at these four levels. RELEVANCE TO CLINICAL PRACTICE: This discursive paper synthesises empirical evidence and expert professional opinion on the factors that enable or hinder the development and sustainability of specialist and advanced practice roles. Providing a critical appraisal of current knowledge, it provides a reference source for disciplinary debate and policy development regarding the nursing and midwifery resource and informs clinicians of the myriad issues that can impact on their capacity to expand their scope of practice.

An overview of the outcomes and impact of specialist and advanced nursing and midwifery practice, on quality of care, cost and access to services: A narrative review.

OBJECTIVES: This paper presents the results of a systematic rapid review and narrative synthesis of the literature of the outcomes and impact of specialist and advanced nursing and midwifery practice regarding quality of care, cost and access to services. DESIGN: A rapid review was undertaken of the relevant national and international literature, regulatory and policy documents relating to the establishment and definition of nurses' and midwives' specialist and advanced practice roles. DATA SOURCES: A search of the Cumulative Index to the Nursing and Allied Health Literature (CINAHL), PubMed (MEDLINE) was undertaken from 2012 to 2015. The study also included primary data collection on the perceived impact of specialist and advanced practice nursing and midwifery roles and enablers and barriers to these roles using semi-structured interviews. These are not included in this paper. REVIEW METHOD: To facilitate a systematic approach to searching the literature, the PICO framework, was adapted. RESULTS: The database search yielded 437 articles relevant to the analysis of specialist and advanced practice in relation to quality care, cost and access to services with additional articles added in a manual review of reference lists. In the final review a total of 86 articles were included as they fulfilled the eligibility criteria. CONCLUSION: The evidence presented in the 86 articles indicates that nursing and midwifery practitioners continue to be under-utilised despite the evidence that greater reliance on advanced nurse practitioners could improve accessibility of primary care services while also saving on cost. Results point to continued difficulties associated with accurate measurement of the impact of these roles on patient outcomes. This review demonstrates that there is a need for robust measurement of the impact of these roles on patient outcomes.

A randomized pilot study on the effect of niacin on pulmonary arterial pressure.

BACKGROUND: Niacin induces the release of vasodilating prostaglandins, for which receptors are present within the pulmonary arterial circulation. We hypothesized that immediate-release niacin would reduce right ventricular systolic pressure in patients with pulmonary hypertension in a randomized, double-blinded, single-dose provocation study. METHODS: We recruited inpatient subjects with a Doppler echocardiogram showing a peak tricuspid regurgitation (TR) jet velocity of 2.7 m/s or greater, and who were free of known pulmonary vascular disease. Subjects were randomized in a 1:2:2 ratio to receive a single dose of either placebo, niacin 100 mg or niacin 500 mg, respectively. TR jet velocities were measured immediately before, and 1 hour post dose, corresponding to peak niacin absorption and prostaglandin release. The primary endpoint was the change in mean TR jet velocity measured over ten successive cardiac cycles. RESULTS: The baseline mean estimated right ventricular systolic pressure (RVSP) for all 49 subjects (25 male) was 51.9 ± 12.1 mm Hg. The primary endpoint of mean change in TR jet velocity was 0.016 ± 0.065 m/s in the placebo group, compared to -0.017 ± 0.065 m/s with niacin 100 mg, and -0.063 ± 0.038 m/s with niacin 500 mg (P = 0.63). The change in maximum estimated RVSP across the three drug groups was 0.2 ± 1.6 mm Hg, -1.3 ± 1.8 mm Hg and -2.2 ± 1.2 mm Hg (P = 0.62). In exploratory pairwise analysis in the high-dose niacin group (500 mg), the reduction in mean RVSP was from 50.9 ± 9.4 mm Hg to 48.7 ± 10.0 mm Hg (P = 0.09). CONCLUSIONS: A single dose of immediate-release niacin (100 mg or 500 mg) had no significant effect on RVSP 1 hour post administration. A nonsignificant dose-dependent trend for a modest reduction in RVSP, most notable in the 500 mg group, was noted. (ISRCTN number 12353191, registered April 23, 2015).

Facilitators and barriers in expanding scope of practice: findings from a national survey of Irish nurses and midwives.

AIMS AND OBJECTIVES: The aim was to examine current scope of practice among nurses and midwives in Ireland. The objectives were to describe practitioners' self-reported facilitators and barriers to expanding scope of practice and to develop a scope of practice barriers scale. BACKGROUND: Regulatory authorities permit practice expansion, so long as it falls within accepted parameters of scope of practice. Enduring difficulties in relation to scope of practice include the difficulty of balancing practice restriction with practice expansion. DESIGN: A postal survey design was used to examine registered nurses' and midwives' current scope of practice, including their experiences of facilitators and barriers to expanding practice. METHODS: A stratified random sample of registered nurses and midwives in Ireland was surveyed using the Scope-QB, a 19-item self-report scope of practice barriers scale. RESULTS: Based on a sample of 1010 respondents, the self-reported perceived barriers to practice expansion included fear of legal consequences, time restrictions and lack of remuneration. Professional satisfaction, patients' needs, organisational support and having access to continuing professional education were perceived as facilitators of practice expansion. Older nurses and midwives as well as nurses and midwives holding more senior promotional grades, such as clinical nurse manager grades, perceived fewer barriers than their younger and more junior counterparts. CONCLUSIONS: Nurses and midwives continue to experience difficulties in relation to expanding their practice. Practitioners can operate to optimal scope of practice when practitioner-centred and workplace-based circumstances are optimal. The optimal circumstances for practice expansion exist when the facilitators of practice expansion outweigh the barriers. RELEVANCE TO CLINICAL PRACTICE: Given the critical role that nurses and midwives play in modern health services, it is important that they are empowered and enabled to expand their practice and to work to full scope of practice when patient needs and service requirements warrant it.

'Am I covered?': an analysis of a national enquiry database on scope of practice.

AIM: Analysis of a national database of enquiries to a professional body pertaining to the scope of nursing and midwifery practice. BACKGROUND: Against a backdrop of healthcare reform is a demand for flexibility in nursing and midwifery roles with unprecedented redefinition of role boundaries and/or expansion. Guidance from professional regulatory bodies is being sought around issues of concern that are arising in practice. DESIGN: Qualitative thematic analysis. METHOD: The database of telephone enquiries (n = 9818) made by Registered Nurses and midwives to a national regulatory body (2001-2013) was subjected to a cleaning process and examined to detect those concerns that pertained to scope of practice. A total of 978 enquiries were subjected to thematic analysis. FINDINGS: Enquiries were concerned with three main areas: medication management, changing and evolving scope of practice and professional role boundaries. The context was service developments, staff shortages and uncertainty about role expansion and professional accountability. Other concerns related to expectations around responsibility and accountability for other support staff. CONCLUSION: Efforts by employers to maximize the skill mix of their staff and optimally deploy staff to meet service needs and/or address gaps in service represented the primary service context from which many enquiries arose. The greatest concern for nurses arises around medication management but innovation in healthcare delivery and the demands of service are also creating challenges for nurses and midwives. Maintaining and developing competence is a concern among nurses and midwives particularly in an environment of limited resources and where re-deployment is common.

Scope of practice decision making: findings from a national survey of Irish nurses and midwives.

AIMS AND OBJECTIVES: The aim was to examine and describe aspects of the current scope of practice among nurses and midwives in Ireland. The objective was to describe practitioners' decision making associated with the scope of practice. BACKGROUND: Regulatory frameworks on the scope of practice describe the roles and activities an individual registrant is permitted to undertake in the course of professional practice. Research into the scope of practice has examined practitioners' perspectives on particular frameworks or their experiences of practice expansion, and suggests that frameworks are helpful in guiding practitioners; however, local circumstances and practitioner competence often determine scope of practice. DESIGN: A national postal survey of registered nurses and midwives was conducted to elicit self-reports of current scope of practice. METHODS: A stratified random sample of 2354 registered nurses and midwives in Ireland were surveyed using the Scope-Q, a 64-item self-report questionnaire. RESULTS: While over half of the respondents consulted others when making scope of practice decisions, the majority relied on their own professional judgement, acted only when they believed that they were competent to act, and recognised the limitations of their own competence. Although a small number of statistically significant associations were observed between respondents' age and self-reported scope of practice, respondents' current scope of practice was independent of either grade or gender. CONCLUSIONS: When making a decision about scope of practice, practitioners may consult other resources, including published frameworks, professional colleagues and line managers; however, most particularly, older, more experienced practitioners, rely on their own professional judgement when making scope of practice decisions. RELEVANCE TO CLINICAL PRACTICE: While published scope of practice frameworks guide practitioners on how they may act in circumstances of uncertainty, regulatory authorities should continue to emphasise individual accountability and self-reliance in everyday decision making, so that practitioners' actions are grounded in local circumstances and self-assessed practitioner competence.

Comparative analysis of nursing and midwifery regulatory and professional bodies' scope of practice and associated decision-making frameworks: a discussion paper.

AIMS: To review, discuss and compare nursing and midwifery regulatory and professional bodies' scope of practice and associated decision-making frameworks. BACKGROUND: Scope of practice in professional nursing and midwifery is an evolving process which needs to be responsive to clinical, service, societal, demographic and fiscal changes. Codes and frameworks offer a system of rules and principles by which the nursing and midwifery professions are expected to regulate members and demonstrate responsibility to society. DESIGN: Discussion paper. DATA SOURCES: Twelve scope of practice and associated decision-making frameworks (January 2000-March 2014). IMPLICATIONS FOR NURSING: Two main approaches to the regulation of the scope of practice and associated decision-making frameworks exist internationally. The first approach is policy and regulation driven and behaviour oriented. The second approach is based on notions of autonomous decision-making, professionalism and accountability. The two approaches are not mutually exclusive, but have similar elements with a different emphasis. Both approaches lack explicit recognition of the aesthetic aspects of care and patient choice, which is a fundamental principle of evidence-based practice. CONCLUSION: Nursing organizations, regulatory authorities and nurses should recognize that scope of practice and the associated responsibility for decision-making provides a very public statement about the status of nursing in a given jurisdiction.

Nurses', midwives' and key stakeholders' experiences and perceptions of a scope of nursing and midwifery practice framework.

AIM: This paper reports on the qualitative findings from a national review of a nursing and midwifery scope of practice framework. BACKGROUND: Scope of professional practice frameworks offers a system of rules and principles to regulate its members and demonstrate its responsibility to society. Key issues in reviewing the scope of practice include notions of specialist and advanced practice, accountability, autonomy, competence, supervision, continuing professional development and delegation. Evaluation of scope of practice frameworks has particular application value to nurses, midwives, regulatory bodies and healthcare employers across the globe. DESIGN: A mixed methods approach was used. This included a national survey of nurses and midwives and focus groups and interviews with key stakeholders. The qualitative data are reported in this paper. METHODS: Focus groups and interviews were conducted among a convenience purposive sample of key stakeholders, including nurses and midwives working in the widest range of services and settings in 2014. The participants contributed to thirteen focus groups and thirteen interviews. FINDINGS: Six global themes, as follows: Evolution of the nursing and midwifery professions and practice; Scope of practice: understanding and use; Expanding scope of practice; Professional competence; Practice setting and context; Reflections on the current framework. CONCLUSION: Practitioners understand the scope of professional practice and while some see it as empowering others see it as potentially restrictive. Nurses and midwives are generally willing to expand their scope of practice and see it as resulting in improved patient care, improvement in overall quality of standards and increased job satisfaction.

Mentoring, coaching and action learning: interventions in a national clinical leadership development programme.

AIMS AND OBJECTIVES: To evaluate mentoring, coaching and action learning interventions used to develop nurses' and midwives' clinical leadership competencies and to describe the programme participants' experiences of the interventions. BACKGROUND: Mentoring, coaching and action learning are effective interventions in clinical leadership development and were used in a new national clinical leadership development programme, introduced in Ireland in 2011. An evaluation of the programme focused on how participants experienced the interventions. DESIGN: A qualitative design, using multiple data sources and multiple data collection methods. METHODS: Methods used to generate data on participant experiences of individual interventions included focus groups, individual interviews and nonparticipant observation. Seventy participants, including 50 programme participants and those providing the interventions, contributed to the data collection. RESULTS: Mentoring, coaching and action learning were positively experienced by participants and contributed to the development of clinical leadership competencies, as attested to by the programme participants and intervention facilitators. CONCLUSIONS: The use of interventions that are action-oriented and focused on service development, such as mentoring, coaching and action learning, should be supported in clinical leadership development programmes. Being quite different to short attendance courses, these interventions require longer-term commitment on the part of both individuals and their organisations. RELEVANCE TO CLINICAL PRACTICE: In using mentoring, coaching and action learning interventions, the focus should be on each participant's current role and everyday practice and on helping the participant to develop and demonstrate clinical leadership skills in these contexts.

Barriers to clinical leadership development: findings from a national survey.

AIMS AND OBJECTIVES: To describe self-reported barriers to clinical leadership development among nurses and midwives in Ireland. BACKGROUND: Effective clinical leadership is essential for optimising care and improving patient outcomes. Clinical leadership development is concerned with intrapersonal and interpersonal capabilities and is context bound. Barriers to clinical leadership development among nurses and midwives are associated with interdisciplinary and organisational factors, such as lack of influence in interdisciplinary care planning and policy. DESIGN: A national postal survey of nurses and midwives was administered to a simple random sample of 3000 nurses and midwives in Ireland. METHOD: The method of data collection was the Clinical Leadership Analysis of Need Questionnaire (CLAN-Q) Barriers Scale (CLAN-QBS), a self-administered, self-report questionnaire developed to measure the barriers to clinical leadership development. RESULTS: Mean scores for the CLAN-Q barriers subscales showed that barriers to clinical leadership development were perceived as lower in the dimension 'quality care factors', when compared with the dimensions 'interdisciplinary relationships, recognition and influence'. Staff and other promotional grades differed significantly in self-perceived barriers related to interdisciplinary working, influence and recognition of the disciplinary contribution. CONCLUSIONS: Differential experiences of barriers among higher and lower grades suggest that grade level may influence ability to negotiate work-related and organisational barriers to clinical leadership development. RELEVANCE TO CLINICAL PRACTICE: Overcoming the barriers to clinical leadership development requires attention to interdisciplinary relationships in the practicum and to the actual and perceived degree of relative influence that nurses and midwives have at wider departmental and organisational levels.

Nurses' and midwives' clinical leadership development needs: a mixed methods study.

AIM: This paper is a report of a descriptive study of nurses' and midwives' clinical leadership development needs. BACKGROUND: Nurses and midwives are expected to fulfil a leadership role at all levels, yet efforts to strategically support them are often unfocused. An analysis of clinical leadership development needs can provide the foundation for leadership initiatives to support staff. METHOD: A mixed methods design was used. A questionnaire was sent to 911 nurses and midwives and 22 focus groups comprising 184 participants were conducted. Data were collected between March and June 2009 across all promotional grades of nurses and midwives in Ireland. Repeated measures anova with Greenhouse-Geisser adjustment was used for post hoc pair wise comparisons of the subscale dimensions of clinical leadership. anova with Tukey's post hoc method was used for comparison between grades on each individual subscale. Thematic analysis was undertaken on the focus group data. RESULTS: Results reveal that needs related to development of the profession were the highest for all grades. The staff grade expressed a higher need in relation to 'managing clinical area', 'managing the patient care' and 'skills for clinical leadership' than managers. Qualitative analysis yielded five themes; (1) clinical leadership and leaders from a nursing and midwifery perspective; (2) quality service from a nursing and midwifery perspective; (3) clinical leaders' roles and functions; (4) capital and (5) competences for clinical leaders and leadership and the context of clinical leadership. CONCLUSION: Clinical leadership concerns quality, safety and effectiveness. Nurses and midwives are ideally placed to offer the clinical leadership that is required to ensure these patient care outcomes. Development initiatives must address the leader and leadership competencies to support staff.