The universal, collaborative and dynamic model of specialist and advanced nursing and midwifery practice: A way forward?

AIMS AND OBJECTIVES: To inform and guide the development of a future model of specialist and advanced nursing and midwifery practice. BACKGROUND: There is a sizable body of empirical literature supporting the unique contributions of specialist and advanced practice roles to health care. However, there is very little international evidence to inform the integration of a future model for advanced or specialist practice in the Irish healthcare system. DESIGN: A qualitative study was conducted to initiate this important area of inquiry. METHODS: Purposive sampling was used to generate a sample of informants (n = 15) for the interviews. Nurses and midwives working in specialist and advanced practice and participants from other areas such as legislative, regulatory, policy, medicine and education were included in the sampling frame. RESULTS: Arguments for a new model of specialist and advanced practice were voiced. A number of participants proposed that flexibility within specialist and advanced practitioner career pathways was essential. Otherwise, there existed the possibility of being directed into specialised "silos," precluding movement to another area of integrated practice. Future specialist and advanced practice education programmes need to include topics such as the development of emotional and political intelligence. CONCLUSION: The contribution of specialist and advanced practice roles to the health service includes providing rapid access to care, seamless patient flow across services, early discharge and lead coordinator of the patient's care trajectory. There was a recommendation of moving towards a universal model to cultivate specialist and advanced nurse and midwife practitioners. RELEVANCE TO CLINICAL PRACTICE: The model design has Universal application in a range of contexts "U." It is Collaborative in its inclusivity of all key stakeholders "C." The model is Dynamic pertinent to accommodating movement of nurses and midwives across health continua rather than plateauing in very specialised "silos" "D."

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.

Using rapid reviews: an example from a study conducted to inform policy-making.

AIM: A discussion of the potential use of rapid review approaches in nursing and midwifery research which presents a worked example from a study conducted to inform policy decision-making. BACKGROUND: Rapid reviews, which can be defined as outputs of a knowledge synthesis approach that involves modifying or omitting elements of a systematic review process due to limited time or resources, are becoming increasingly popular in health research. This paper provides guidance on how a rapid review can be undertaken and discusses the strengths and challenges of the approach. DESIGN: Data from a rapid review of the literature undertaken in 2015 is used as a worked example to highlight one method of undertaking a rapid review. IMPLICATIONS FOR NURSING: Seeking evidence to inform health policy-making or evidence based practice is a process that can be limited by time constraints, making it difficult to conduct comprehensive systematic reviews. Rapid reviews provide a solution as they are a systematic method of synthesizing evidence quickly. CONCLUSIONS: There is no single best way to conduct a rapid review but researchers can ensure they are adhering to best practice by being systematic, having subject and methodological expertise on the review team, reporting the details of the approach they took, highlighting the limitations of the approach, engaging in good evidence synthesis and communicating regularly with end users, other team members and experts.

The perceptions of key stakeholders of the roles of specialist and advanced nursing and midwifery practitioners.

AIM: To explore the perceptions of key stakeholders of the roles of specialist and advanced nursing and midwifery practitioners. BACKGROUND: There is evidence that the contribution of these roles to patient care is poorly understood. DESIGN: This research took place over 2 months in 2015 and is part of a larger study involving a rapid review to inform policy development on the specialist and advanced nursing and midwifery practice in Ireland. As an added value, a qualitative element involving thematic analysis was undertaken with key stakeholders. METHODS: A phenomenological qualitative study was conducted incorporating semi-structured interviews with key stakeholders (n = 15). Purposive sampling with maximum diversity was used to recruit a wide range of perspectives. FINDINGS: Participant's perspectives led to seven themes: Impact of these roles; role preparation, experience and organizational support; specialist and advanced practice roles in an interdisciplinary context; different folks but not such different roles; impact of specialist and advanced practice roles on patient outcomes; barriers and facilitators to enacting specialist and advanced practice roles; future development of these roles. CONCLUSION: There is acknowledgement of the positive impact of specialist and advanced practitioners; however, the evidence is currently not conclusive. Preparation for these roles needs to reflect changes in the calibre of today's professional applicants, and organizational support is paramount to their successful execution. The contribution of their activity to patient outcome needs to be made visible to enhance these roles and to justify the development of new roles across a variety of healthcare areas.

Psychometric Evaluation of the Service-Learning in Nursing Inventory.

AIM: The aim was to develop an instrument to assess undergraduate nursing students' experience of service-learning to reveal benefits and identify service-learning as a professional value that leads to civic and social responsibility. BACKGROUND: Service-learning is a teaching and learning approach that integrates academic learning with experiential community-centered foci. It provides structured opportunities for reflection on broader social and cultural dimensions of health. There is no valid and reliable instrument to measure service-learning experience of nursing students. METHOD: A psychometric evaluation was conducted through item analysis, validity, and reliability. RESULTS: Face validity agreement was 80 percent; the content validity index was adjusted until 1 was achieved for each item. Two factors explained 58.64 percent of the total variance. Cronbach's α was .940 for the skills subscale and .932 for the personal insight subscale. CONCLUSION: The inventory demonstrated strong psychometric properties. Future research should focus on replication on diverse populations.

An exploration of the practice of restricting a child's movement in hospital: a factorial survey.

AIMS AND OBJECTIVES: To identify the reported predictors of the practice of restricting a child for a clinical procedure in hospital. BACKGROUND: Previous work in this area is dominated by discussion papers and suggestions for addressing the issue of restriction. This is the first study to explore reported predictors of this practice with a view to implementing change based on research findings. DESIGN: A factorial survey was developed, which incorporated the use of vignettes with various scenarios. The factorial design enabled exploration of the interaction of multiple factors on the practice of restriction. METHODS: One hundred and sixty-six nurses caring for children were each sent 10 vignettes and asked to rate their likelihood to restrict a child based on the vignettes. A total of 105 nurses responded to the survey, representing a response rate of 63%. Hierarchical linear regression was used to identify reported predictors of restriction. RESULTS: Nurses were more likely to restrict a child if they had prior instruction on safe holding, if there was no play therapist available, if the nurse was a registered general nurse with no other registration qualification, if the child required cannulation or if the child was less than five years of age. CONCLUSION: This study identified predictors of restriction from the perspective of practicing nurses; the evidence needs to be used in developing clinical guidelines and in multidisciplinary education. RELEVANCE TO CLINICAL PRACTICE: There is a need to move from any presumption of restriction towards more critical consideration of the individual requirements of the child. There is a need to increase the numbers of nurses receiving specialist training on the care of a child in hospital. The importance of a well-resourced play therapy service is supported, and there is a need for multidisciplinary work to explore alternatives to restriction.

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.

Service impact of a national clinical leadership development programme: findings from a qualitative study.

AIM: The study reported here was part of a larger study, which evaluated a national clinical leadership development programme with reference to resources, participant experiences, participant outcomes and service impact. The aim of the present study was to evaluate the programme's service impact. BACKGROUND: Clinical leadership development develops competencies that are expressed in context. The outcomes of clinical leadership development occur at individual, departmental and organisational levels. METHODS: The methods used to evaluate the service impact were focus groups, group interviews and individual interviews. Seventy participants provided data in 18 separate qualitative data collection events. RESULTS: The data contained numerous accounts of service development activities, initiated by programme participants, which improved service and/or improved the culture of the work setting. CONCLUSION: Clinical leadership development programmes that incorporate a deliberate service impact element can result in identifiable positive service outcomes. The nuanced relationship between leader development and service development warrants further investigation. IMPLICATIONS FOR NURSING MANAGEMENT: This study demonstrates that clinical leadership development can impact on service in distinct and identifiable ways. Clinical leadership development programmes should focus on the setting in which the leadership competencies will be demonstrated.

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.

Cultures of control: A historical analysis of the development of infection control nursing in Ireland.

Responses to the rise of antimicrobial resistance in Europe and North America included establishment of special hospital infection control teams of a microbiologist and a nurse. Based on the testimonies of seven infection control nurses in Irish hospitals appointed during 1979-1990, this article examines the early development and expressions of their disciplinary practice. Fairman's model of collaborative practice was used to examine the context in which the role emerged, the places practice was negotiated and mutually constructed, and exemplars of collaborative practice. Aspects of the relationship between theory and method in Wengraf's biographical narrative interpretive method (BNIM) used to generate the nurses' accounts of their early experiences in the role are highlighted. Practice was contingent on effective negotiation of places of practice, and disciplinary practice bore hallmarks of collaborative practice. The infection control nurse transitioned from conspicuous outsider and object of suspicion to valued resource for patients and staff. Infection control nursing came to be a prototype for new specialist nursing roles in hospitals.

The image of you: constructing nursing identities in YouTube.

AIM: This article is a report on a descriptive study of nursing identity as constructed in the Web 2.0 site YouTube. BACKGROUND: Public images of the nurse carry stereotypes that rely on the taken for granted gender category of the nurse as woman. Nursing images represent a form of public discourse that has the capacity to construct nursing identity. METHODS: Critical discourse analysis was used to describe, analyse and explain how nurse and nursing identity were constructed in a purposive sample of ten video clips accessed on 17 and 18 July 2010. RESULTS: The ten most-viewed videos depicting the nurse and nursing on YouTube offered narratives that constructed three distinct nursing identity types, namely nurse as 'a skilled knower and doer', nurse as 'a sexual plaything' and nurse as 'a witless incompetent' individual. CONCLUSION: Nursing identities recoverable from the texts of YouTube images propagate both favourable and derogatory nursing stereotypes. To mitigate the effects of unfavourable nursing stereotypes in such areas as interprofessional working and clinical decision-making, nursing professional bodies need to act to protect the profession from unduly immoderate representations of the nurse and to support nurses in their efforts to maximize opportunities afforded by YouTube to promote a counter discourse.

A profile of older emergency department attendees: findings from an Irish study.

AIMS: This paper is a report of a study of older emergency department attendees' demographic, health and social profiles. BACKGROUND: Relative to the general population, older people are higher users of hospital emergency departments. Attendance is most often associated with medical need, including a chronic condition and related morbidities. METHOD: A series of standardized health and social profiling questionnaires was administered to a non-probability sample of 307 older emergency department attendees. The sample was recruited during the spring-summer and autumn-winter periods in 2008 and 2009 at two hospitals in the city of Dublin. Subjects who met the inclusion criteria were recruited as they presented to the emergency department during the hours 8 am to midnight. The sample was stratified into those admitted and those discharged, with the aim of equally representing each stratum. Data were collected at the time of the index visit or shortly following hospital admission. FINDINGS: Medical conditions accounted for almost half of all reasons for attendance and the health profile of the sample was characteristic of a population of chronically ill older people. Relative to the national picture for older people's social networks in Ireland, a proportion of the sample was at risk of social isolation. CONCLUSIONS: In the absence of other avenues to treatment and based on health profile and diagnostic category, older people's attendance at the emergency department was appropriate. The hospital emergency department remains a major arm of the Irish health service in dealing with the morbidity associated with enduring illness.

The visibility of the discipline on the websites of academic nursing schools.

Critical discourse analysis was used to examine the visibility of nursing as a distinct discipline on the websites of academic nursing schools in Ireland. The analysis focused on the content of the schools' websites, including the available undergraduate curricular materials. The websites of a purposive sample of academic nursing schools in Canada, Scandinavia, and Australia were also analyzed for comparative purposes. The texts revealed that the disciplinary distinctiveness of nursing was only minimally represented on nearly all of the Irish nursing schools' websites. There was little evidence that nursing theory was informing the form and content of nursing programs. Instead, there was evidence of eclecticism in their form and content, with much reliance on imported knowledge from other disciplines. In contrast, nursing's disciplinary specialism was coherently and clearly articulated in website texts of the selected Canadian, Scandinavian, and Australian schools. Representations of nursing on official websites convey important messages to prospective students and to the public about the self-conceptualisation of nursing, including its knowledge forms and knowledge claims.

Boundary matters: clinical leadership and the distinctive disciplinary contribution of nursing to multidisciplinary care.

AIMS: To describe Irish nurses' views of clinical leadership and to describe their clinical leadership development needs. BACKGROUND: Nurses are often unclear about the precise nature of clinical leadership and its impact on the processes and outcomes of care and little is known about their self-perceived clinical leadership development needs. DESIGN: Seventeen focus group interviews were conducted with a purposive sample of 144 nurses from 13 practice settings. A conceptual lens was provided by the work of Bernstein and Young who emphasise the epistemological, practical and relational significance of boundaries and how they relate in fundamental ways to professionals' sense of their distinctive disciplinary identities and membership of specialised communities of practice. METHODS: Focus group data were collected using semi-structured topic guides. Analysis was facilitated by NVivo 7© and interpretation was informed by a conceptual framework arising from the interplay of emerging themes and the literature review. RESULTS: The implications for clinical leadership development of two critical concepts, 'representing nursing' and 'compensatory action', are discussed in detail. CONCLUSIONS: Clinical leadership development should emphasise the development of all nurses as clinical leaders in the context of the delineation, clarification and articulation of their distinctive contribution in multidisciplinary care settings. RELEVANCE TO CLINICAL PRACTICE: Clinical leaders are recognised as practice experts and as leaders in their particular fields. Recognition and influence in and beyond the immediate context of care depends greatly on their ability to articulate the distinct nursing contribution to patient care. This ability provides an essential resource to resist the ongoing blurring, effacement and dilution of nurses' roles.

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.

The health of hospitals and lessons from history: public health and sanitary reform in the Dublin hospitals, 1858-1898.

AIMS AND OBJECTIVES: The aim was to examine, critically, 19th century hospital sanitary reform with reference to theories about infection and contagion. BACKGROUND: In the nineteenth century, measures to control epidemic diseases focused on providing clean water, removing waste and isolating infected cases. These measures were informed by the ideas of sanitary reformers like Chadwick and Nightingale, and hospitals were an important element of sanitary reform. DESIGN: Informed by the paradigmatic tradition of social history, the study design was a historical analysis of public health policy. METHOD: Using the methods of historical research, documentary primary sources, including official reports and selected hospital archives and related secondary sources, were consulted. RESULTS: Emerging theories about infection were informing official bodies like the Board of Superintendence of Dublin Hospitals in their efforts to improve hospital sanitation. The Board secured important reforms in hospital sanitation, including the provision of technically efficient sanitary infrastructure. CONCLUSIONS: Public health measures to control epidemic infections are only as effective as the state of knowledge of infection and contagion and the infrastructure to support sanitary measures. RELEVANCE TO CLINICAL PRACTICE: Today, public mistrust about the safety of hospitals is reminiscent of that of 150 years ago, although the reasons are different and relate to a fear of contracting antimicrobial-resistant infections. A powerful historical lesson from this study is that resistance to new ideas can delay progress and improved sanitary standards can allay public mistrust. In reforming hospital sanitation, policies and regulations were established--including an inspection body to monitor and enforce standards--the benefits of which provide lessons that resonate today. Such practices, especially effective independent inspection, could be adapted for present-day contexts and re-instigated where they do not exist. History has much to offer contemporary policy development and practice reform and is a relevant method for health professionals.

Long-Term Health-Related Quality of Life After Venovenous Extracorporeal Membrane Oxygenation.

This study examined the long-term health-related quality of life in adult patients treated with venovenous extracorporeal membrane oxygenation (V-V ECMO) for severe acute respiratory failure in Ireland. A retrospective, cross-sectional survey was conducted to elicit self-reported quality of life in V-V ECMO survivors who were discharged from the intensive care unit for ≥6 months. Twenty-nine patients with respiratory failure were treated with V-V ECMO from 2009 to 2013. Of the 19 (66%) patients who survived to hospital discharge, 13 participated in the study. The mean age was 44 ± 11 years, and seven were male. At a median follow-up of 36 (14-39) months, study participants reported decreased indices of physical health compared with age- and sex-matched general population in Ireland while their mental health was similar to age- and sex-matched general population in Ireland. Fifty-four percent of participants had symptoms of anxiety, 15 percent had symptoms of depression, while 23 percent of participants were at risk of posttraumatic stress disorder. Sixty-seven percent of previously employed participants had returned to work. This study highlights the protracted nature of physical and psychologic recovery in patients surviving up to three years after V-V ECMO for severe acute respiratory failure.

Models of initial training and pathways to registration: a selective review of policy in professional regulation.

AIM: To provide a synthesis of literature on international policy concerning professional regulation in nursing and midwifery, with reference to routes of entry into training and pathways to licensure. BACKGROUND: Internationally, there is evidence of multiple points of entry into initial training, multiple divisions of the professional register and multiple pathways to licensure. EVALUATION: Policy documents and commentary articles concerned with models of initial training and pathways to licensure were reviewed. Item selection, quality appraisal and data extraction were undertaken and documentary analysis was performed on all retrieved texts. KEY ISSUES: Case studies of five Western countries indicate no single uniform system of routes of entry into initial training and no overall consensus regarding the optimal model of initial training. CONCLUSIONS: Multiple regulatory systems, with multiple routes of entry into initial training and multiple pathways to licensure pose challenges, in terms of achieving commonly-agreed understandings of practice competence. IMPLICATIONS FOR NURSING MANAGEMENT: The variety of models of initial training present nursing managers with challenges in the recruitment and deployment of personnel trained in many different jurisdictions. Nursing managers need to consider the potential for considerable variation in competency repertoires among nurses trained in generic and specialist initial training models.