The formative evaluation and pre-testing of a SunSmart policy implementation support toolkit targeting sun safe hat-wearing in NSW primary schools.

ISSUE ADDRESSED: Strategies that support the implementation of the SunSmart program in primary schools are essential to optimising policy uptake. Evidence outlining the type of support required, however, is lacking. This project explored the usefulness of an implementation support approach to sun safe hat-wearing in schools. METHODS: Formative research was undertaken with 16 primary schools in Greater Western Sydney to explore current sun protection behaviours and practices, perceived barriers and motivators of sun safe hat-wearing, and resource needs. Based on these insights, a resource toolkit was developed and tested in 14 demonstration sites. Follow-up interviews evaluated the usefulness of the toolkit and implementation support approach. RESULTS: Sun safe hat-wearing practices varied among schools. Commonly reported motivators included school policies, role modelling, incentives and knowledge. Commonly reported barriers included negative social norms, forgetfulness, cost and lack of understanding. Formative insights informed the development of the 'Motivation, Access, Triggers' Model and a 23-resource toolkit. Following toolkit rollout, champions reported that the ability to select resources according to local needs was useful, and most found that the toolkit supported their school with sun safe hat-wearing. CONCLUSIONS: A toolkit with local champions and leadership buy-in has the potential to improve policy implementation. The opportunity to prioritise resource selection enables schools to address their specific needs in line with their sun protection policy. SO WHAT?: The provision of policy implementation support can help schools overcome the challenges of transforming a written SunSmart policy into practice.

Factors influencing the implementation of Epilepsy Specialist Nurse role: Using the Consolidation Framework for Implementation Research.

BACKGROUND: Research to support the added value of including Epilepsy Specialist Nurses as members of the multidisciplinary team is developing, yet little information exists on factors influencing the translation of these roles into practice. AIM: To describe the enabling and inhibiting factors to the implementation of the Epilepsy Specialist Nurse role in the Republic of Ireland. METHODS: A qualitative design involving semi-structure interviews, observation and analysis of documents, such as portfolios was used. The sample included 12 Epilepsy Specialist Nurses, 24 multidisciplinary team members, and 35 individuals with epilepsy and family members. Data were analysed using the Consolidation Framework for Implementation Research. Reporting rigour is demonstrated using the COREQ checklist (See Appendix S1). RESULTS: While there was overwhelming support for the role, barriers and enablers were identified across all domains of the Consolidation Framework for Implementation Research. Enablers included national policies and guidelines, leadership from senior nursing and medical colleagues, climate of learning and mentorship, networking opportunities, infrastructural supports and competence of Epilepsy Specialist Nurses. Barriers included the limited consideration of service expansion and the increasingly complex nature of clinical cases on workload capacity. Deficits in infrastructural supports, challenges in relation to role preparation, role implementation and role responsibility, including concerns around lone practitioner models and concerns that the role was a cost-saving measure, also emerged as potential barriers to future sustainability. CONCLUSION: The Consolidation Framework for Implementation Research offers researchers a pragmatic typology for analysing interrelationships between enabling and inhibiting factors that impact implementation of advanced practice roles, across different evidence sources, disciplines and boundaries. RELEVANCE TO CLINICAL PRACTICE: In order to secure role sustainability, managers need to address the rate of service expansion, models of role development, deficits in supports and perceived motivations for role development on the quality, acceptability and sustainability of services provided.

Disclosure strategies in adults with epilepsy when telling, "I have epilepsy": The How2tell study.

OBJECTIVE: To generate evidence-based knowledge about the strategies that adult people with epilepsy (PWEs) use in the process of telling others about their epilepsy. METHODS: In-depth, one-to-one interviews explored PWEs' first-hand experiences of self-disclosure (or not), and grounded theory methods of inductive-deductive analysis were used to identify strategies used in disclosing. Interviews were audio-recorded, transcribed, coded, and independently recoded by two researchers using a coding framework specifically developed in this study. To account for maximum variation, PWEs (aged 18+ years) with different life experiences and situations relating to (1) gender, (2) age, (3) employment status, (4) personal relationships, (5) family relationship, (6) support group involvement, and (7) seizure frequency were included. Given the many variables and psychosocial issues associated with epilepsy, demographic details and validated measures including Quality of Life in Epilepsy-10-P, Coping Inventory of Stressful Situations-Adult, and Patient Health Questionnaire-9 were used to describe the characteristics of participants and to contextualize the results. RESULTS: Forty-nine adults with epilepsy participated. Data analysis revealed six interrelated categories (with subcategories) of the strategies that PWEs reported using in the process of disclosure: (1) concerns about disclosing; (2) weighing up who and when to tell; (3) opportunities for telling; (4) moment of disclosure-how to construct the message; (5) tailoring the message to audience needs-altering the message when telling family members, partner, friends, children, or employer and workplace colleagues; and (6) managing reactions by making it ordinary. SIGNIFICANCE: People with epilepsy use a range of different strategies during the process of disclosing their epilepsy. These strategies were used to inform the development of the How2tell multimedia self-management resource for PWEs on self-disclosure in everyday social and life situations. How2tell is designed to benefit PWEs by empowering them with practical information about the process of telling another person, "I have epilepsy."

Supporting and empowering people with epilepsy: Contribution of the Epilepsy Specialist Nurses (SENsE study).

PURPOSE: To explore how Epilepsy Specialist Nurses in the Republic of Ireland enacted their clinical role. METHODS: Qualitative descriptive design that involved individual and focus group interviews, observation and documentary analysis. Data were collected from 12 Epilepsy Specialist Nurses working in five hospital-based epilepsy services in Ireland, 24 multidisciplinary team members, and 35 people with epilepsy and their family members were involved. Data were analysed in NVivo using an inductive and deductive approach. RESULTS: Epilepsy Specialist Nurses work out of a value base that gives primacy to collaboration. active participation, relationship-based care, and respect for the voices of PWE and family members. They are key players in empowering people to self-manage their illness, Core dimensions of their clinical role includes: performing a comprehensive assessment to inform care and treatment; providing person-centred education; monitoring the impact of care and treatment; providing education to family members and significant others; providing psychosocial care to optimise psychological wellness; co-ordinating care to enhance patients' journey; and quality assuring patient information. CONCLUSION: Findings from this study highlight the key role ESNs played as members of the MDT in building and supporting PWE's capacity to self-manage their illness. However, they also indicate deficits in the provision of information on sudden unexpected death in epilepsy and how to disclose a diagnosis of epilepsy by the ESN, as well deficits in their knowledge and confidence in supporting people experiencing significant mental health morbidities.

Evidence-based practice among epilepsy specialist nurses in the Republic of Ireland: Findings from the SENsE study.

AIM: To describe how epilepsy specialist nurses in Ireland enact the evidence-based practice dimension of their role. BACKGROUND: The importance of epilepsy specialist nurses (ESNs) delivering evidence-based care to people experiencing epilepsy is unquestionable, yet research into this aspect of the role is relatively sparse. METHODS: A qualitative design was used, involving 12 epilepsy specialist nurses working in five units in Ireland, 24 multidisciplinary team members working with them and 35 people with epilepsy and their family members. Data were collected using individual and focus group interviews, observation and documentary analysis. RESULTS: These ESNs were active in accumulating, translating, applying, generating and disseminating evidence. All were actively involved in, or leading audit and service evaluations, and used findings to improve practice. Their research activity mainly consisted of small-scale unfunded research projects. CONCLUSIONS: These ESNs acted as opinion leaders and role models in relation to evidence-based practice, including the generation of new knowledge through audit and research. IMPLICATIONS FOR NURSING MANAGEMENT: Organisations and managers need to support ESNs by ensuring that they have the necessary resources and competencies to accumulate, translate, apply, generate and disseminate relevant evidence. Future research should explore the impact of ESNs' evidence-based practice on patient outcomes.

Leadership capabilities of physiotherapy leaders in Ireland: Part 1 physiotherapy managers.

Background: Investigation of the leadership capabilities of physiotherapists is needed to allow understanding of current leadership practice and to enable appropriate training programs to be developed. Purpose: To explore physiotherapy managers´ perceptions of their leadership capabilities. Methods: Semi-structured interviews were conducted with a purposive sample of 18 physiotherapy managers from a range of public services and private practices in Ireland. The interviews were analyzed using template analysis and the coding template was based on the Bolman and Deal Leadership framework which details four leadership frames: structural, human resource, political, and symbolic. Results: The physiotherapy managers described demonstrating leadership capabilities associated with each of the four leadership frames. However, the language used by the physiotherapy managers suggested that they work predominantly through the structural and human resource frames. The employment of capabilities associated with the political frame varied between participants; some participants described working through this frame while others reported difficulties. The symbolic frame was underused; there were fewer examples given of capabilities such as communicating their vision, demonstrating passion and facilitating a positive workplace culture. Conclusions: Physiotherapy managers work predominantly through the structural and human resource frames. To successfully meet the leadership requirements of their roles physiotherapy managers may benefit from specific leadership development training to develop leadership capabilities in the political and symbolic frames.

Rising to the challenge: Epilepsy specialist nurses as leaders of service improvements and change (SENsE study).

PURPOSE: To report the leadership role and change activities of epilepsy specialist nurses (ESNs) in Ireland; findings from the SENsE study. METHOD: A mixed methods study design was used, involving 12 epilepsy specialist nurses working in five units in Ireland, 24multidisciplinary team members working with them, and 35 people with epilepsy and their family members. Data were collected using individual and focus group interviews, observation and documentary analysis. RESULTS: Five key areas in which ESNs demonstrated leading on the change agenda were identified. These included: Initiating new clinical practice developments; Building capability within the multidisciplinary team; Developing education programmes and resources for people with epilepsy, family and the public; Exerting influence through membership of committees and lobbying; and Advancing the ESN role. CONCLUSION: Though the epilepsy specialist nurse role was first established in the UK in 1988, much of the literature that discusses or describes the ESN role is founded on anecdotal evidence, or focusses on their clinical expertise. Findings from this study provide empirical evidence that the ESNs were involved as key players in leading changes within the services, in the education of others, and the continuous advancement of epilepsy care.

Patients with epilepsy care experiences: Comparison between services with and without an epilepsy specialist nurse.

The aim of this study was to determine whether there were differences in experiences of care, satisfaction with care and quality of life between those who were in receipt of care from a service with an epilepsy specialist nurse (ESN) and those who were receiving care from a service that did not include an ESN. A comparative design was used, which involved the completion of a confidential, self-completed survey. The survey was administered to a nonprobability convenience sample of patients with epilepsy who were attending services with an ESN (n = 244) and services where the treatment team did not include an ESN (n = 261) from each of the four health areas in Ireland. This study found that, in comparison to people with epilepsy (PWE) who attended a service without an ESN, PWE who attended a service with an ESN reported receiving greater amount of information, were more involved in their care, perceived care to be better coordinated, and had greater confidence in the information provided and greater comfort in discussing issues with an ESN. They also reported higher rates of satisfaction with the emotional and practical support offered. Thus, it may be concluded that models of care involving the input of ESNs enhance the quality of epilepsy care and care processes. The findings also emphasize the need to have an ESN as part of the multidisciplinary team.

Becoming comfortable with "my" epilepsy: Strategies that patients use in the journey from diagnosis to acceptance and disclosure.

OBJECTIVE: Proponents of resilience theory have highlighted the importance of understanding the processes of resilience. The objective of the study was to explore how people with epilepsy reach a stage of being comfortable with their epilepsy. Identifying the processes used is important to developing effective self-management for people who are newly diagnosed with epilepsy. METHOD: A grounded theory approach involving forty-nine consenting adult people with epilepsy (18 years and over), was used to explore their first-hand experiences of coming to terms with their epilepsy. Data were collected using one-to-one interview to elicit in-depth personal accounts of people with epilepsy's experiences of adjusting to their diagnosis of epilepsy. Using grounded theory's systematic inductive-deductive process data of analysis, the core findings that emerged from the open coding and inductive phase were analyzed independently by two researchers to ensure that findings were verified and validated across the interview dataset. FINDINGS: Three core categories emerged as central to the journey that people experience after receiving their diagnosis of epilepsy towards becoming comfortable with their epilepsy. These were: i) meaning of "my" epilepsy diagnosis, to capture people with epilepsy's feelings, reactions and concerns after being diagnosed with epilepsy, ii) useful strategies, to identify what people with epilepsy did to become comfortable with their diagnosis, and iii) being comfortable with my epilepsy, to account for the frame of mind of people with epilepsy when they reach a point of accepting their diagnosis. DISCUSSION: The findings provide important insights into the personal experiences of people with epilepsy after receiving their diagnosis and identifies a range of strategies they find useful in helping them reach a position of acceptance and being 'comfortable with my epilepsy'.

Building leadership capacity in advanced nurse practitioners - the role of organisational management.

AIM: To highlight the organisation-level management's role in building leadership capacity in advanced nurse practitioners and the need for appropriate supports to increase their becoming leaders. BACKGROUND: Little is published about the role of organisation-level management in building leadership capacity and in developing the next generation of nurse leaders. In times of economic constraint, organisations need to focus their efforts on targeted leadership initiatives. Advanced nurse practitioners are ideally positioned to act as leaders both within and beyond the health care organisation. EVALUATION: From the available research evidence, several support structures and mechanisms are identified as enablers for advanced nurse practitioners to enact their leadership role. CONCLUSION: Health care organisations need to include building leadership capacity as a priority in their strategic plan and take action to build-up the level of advanced nurse practitioner leadership. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse executives have a vital role in influencing the organisation's strategic plan and making a business case for prioritising leadership capacity building within advanced nurse practitioners. A challenge for nurse executives faced with competing service and leadership development demands, involves strategic decision-making regarding whether the advanced nurse practitioner's role is limited to service delivery or its potential in leading health care reforms is realised.

Barriers and enablers to advanced practitioners' ability to enact their leadership role: A scoping review.

BACKGROUND: Advanced roles such as nurse practitioner, nurse consultant and advanced nurse or midwife practitioner are increasing across the world. In most countries, clinical practice, education, leadership and research are the four components that define the advanced practitioner's role. Of these, leadership is perhaps the most important part of the role, but its study has largely been neglected. There is a risk that failure to identify and respond to barriers to enacting the advanced practitioners' leadership role will limit the extent to which they can become strategic leaders for professional development, and jeopardise the long-term sustainability of the role. OBJECTIVES: To identify the barriers and enablers to advanced practitioner's ability to enact their leadership role. DATA SOURCES: A search of the research literature was undertaken in electronic databases (PubMed, CINAHL, PsycINFO, ProQuest Dissertation and Theses, from inception to 4-6th June 2015), unpublished research in seventeen online research repositories and institutes, and hand search of 2 leadership journals (March/April 2010-4th June 2015). REVIEW METHODS: Using pre-set inclusion criteria, the 1506 titles found were screened by two authors working independently. The 140 full text reports selected were reviewed by two authors separately and 34 were included, and data extracted and cross-checked. Any disagreements were discussed by the scoping team until consensus was reached. Using content analysis, the barriers and enablers relating to leadership enactment were sorted into themes based on their common characteristics, and using a Structure-Process-Outcome conceptual framework were categorised under the four structural layers: (1) healthcare system-level, (2) organisational-level, (3) team-level, and (4) advanced practitioner-level. RESULTS: Thirteen barriers to, and 11 enablers of, leadership were identified. Of these a majority (n=14) were related to organisational-level factors such as mentoring, support from senior management, opportunity to participate at strategic level, structural supports for the role, and size of clinical caseload. Advanced practitioner-level factors relating to personal attributes, knowledge, skills and values of the advanced practitioner were identified. CONCLUSIONS: Although building leadership capabilities at advanced practitioner-level and team-level are important, without key inputs from healthcare managers, advanced practitioners' leadership enactment will remain at the level of clinical practice, and their contribution as change agents and innovators at the strategic level of service development and development of the nursing profession will be not be realised.

Utilizing Team Debate to Increase Student Abilities for Mentoring and Critical Appraisal of Global Health Care in Doctor of Nursing Practice Programs.

UNLABELLED: Although graduates of doctor of nursing practice (DNP) programs are expected to demonstrate competence in advanced clinical scholarship, mentoring, and leadership, little is published about how team debate on a global health care topic supports DNP student learning and skill development. PURPOSE: This article reports on an illuminative evaluation of DNP student learning experiences of team debate in the context of a 2-week international school program in Ireland. METHOD: A focused illuminative evaluation approach involving a cohort of seven DNP students, who had participated in an international school team debate, was used. Data were collected using a Web-based qualitative questionnaire designed to elicit in-depth reflective accounts of DNP students' learning experiences. RESULTS: Content analysis revealed that team debate on a global health care topic enhanced learning in relation to fostering critical thinking and critical appraisal skills; encouraging teamwork; providing opportunities for mentoring, relationship building, and socialization into profession; and, from the DNP student perspective, increasing knowledge and global understanding of health care. CONCLUSION: This evaluation provides insights for nurse educators into the benefits of introducing team debate as a group activity to enhancing scholarly inquiry and mentoring skills of DNP students. Further research to evaluate team debate in other nurse education programs is needed.

An exploration of clinical practice in sites with and without clinical nurse or midwife specialists or advanced nurse practitioners, in Ireland.

BACKGROUND: Clinical specialist (CS) and advanced practitioner (AP) roles have increased in nursing and midwifery internationally. This study explored clinical practice in sites with and without clinical nurse or midwife specialists or advanced nurse practitioners in Ireland. METHODS: Using a case study design, interview, observational and documentary data from postholding sites (CSs or APs employed) were compared with data from non-postholding sites (no CSs or APs employed). Interviews and observations were conducted with postholders (n = 23), and compared with data from healthcare professionals (nurses or midwives, doctors) (n = 23) in matched services. Interviews were held with Directors of Nursing and Midwifery (n = 23), healthcare professionals (n = 41), service users (n = 41) with experience of receiving care or working with postholders, and non-postholders in matched services. The data were analysed using Nvivo (Version 8). RESULTS: The findings suggest that postholders' practice appeared to differ from non-postholders' in relation to case management and service provision. Postholders were seen as having an impact on readmission rates, waiting lists/times, collaborative decision-making, continuity of care and workload management. Postholders' autonomy to manage caseloads was perceived to lead to smoother transition of patients/clients through the healthcare system. Service-users' self-reports appeared to appreciate the individualised holistic care provided by postholders. Postholders' role in facilitating person-centred care and promoting interprofessional team working, are essential elements in quality care provision and in global healthcare workforce planning. CONCLUSIONS: To meet changing healthcare demands, promote person-centred care, and improve service delivery, more specialist and advanced practice posts in nursing and midwifery should be developed and supported within healthcare.

Early warning scores: a sign of deterioration in patients and systems.

The early warning score system is a decision-making tool that has a simple design, yet its implementation in healthcare organisations is proving complex. This article reports the results of a survey that evaluated nurses' experiences of using the National Early Warning Score (NEWS) in an acute hospital in Ireland. Staff reported that the NEWS was easy to use, did not increase workload and enhanced their ability to identify deteriorating patients. However, they also identified problems related to doctors' delayed response times, doctors' lack of training in the use of the tool, and a failure by doctors to modify trigger parameters for patients with chronic conditions. NEWS enhances nurses' roles in early detection of patient deterioration, but delays in response times by doctors expose systematic flaws in health care. This suggests that it is not only an indicator of patient deterioration, but also of deteriorating healthcare systems.

Perceived outcomes of research and audit activities of clinical specialists in Ireland.

OBJECTIVES: The objectives of this study were to ascertain whether clinical specialists in Ireland were fulfilling role expectations in terms of their involvement in audit, evidence-based practice, and research activities; to examine the perceived impact on practice of clinical specialists'/advanced practitioners' research and audit roles and activities; and to compare research and audit activity in sites with and without clinical specialists/advanced practitioners. DESIGN: This was a sequential, mixed-methods case study. SETTING: The study was performed in clinical specialists'/advanced practitioners' hospital and community practice settings, and matched sites with no specialist/advanced practitioner, in each healthcare region in Ireland. SAMPLE: A purposive sample of 17 clinical nurse or midwife specialists and 6 advanced nurse practitioners was selected, and 23 "matched" sites in hospital/services that provided similar client care were chosen. Midwifery and all branches of nursing were included. METHODS: Data were collected January 2008 to December 2010, using nonparticipant observation (184 hours) of specialist/advanced practitioners and matched clinicians in practice, interviews with directors of nursing/midwifery (n = 23) and clinicians (n = 41), and analysis of documents from each case-study site. Pairs of researchers checked each other's work, negative case analysis was used, and the whole team agreed with the final findings. RESULTS: Clinical specialists/advanced practitioners demonstrated more evidence-based practice and greater use of audit than did other clinicians fulfilling comparable clinical roles in matched sites. Fifteen specialist/advanced practitioners (65%) compared with 7 clinicians in matched sites (30%) conducted research (P < .04). CONCLUSIONS: Clinical specialists in Ireland were fulfilling role expectations in terms of audit, evidence-based practice, and research. The impact of clinical specialists' activities in this area, as perceived by clinical colleagues and managers, is considerable and is documented as greater than the impact of nonspecialist colleagues in comparable sites. IMPLICATIONS: Increased investment in specialist/advanced practitioner posts, with resources and support for research activity, will increase evidence-based care, strengthen quality, and lead to improved practice.

Simultaneous Assessment of Speech Identification and Spatial Discrimination: A Potential Testing Approach for Bilateral Cochlear Implant Users?

With increasing numbers of children and adults receiving bilateral cochlear implants, there is an urgent need for assessment tools that enable testing of binaural hearing abilities. Current test batteries are either limited in scope or are of an impractical duration for routine testing. Here, we report a behavioral test that enables combined testing of speech identification and spatial discrimination in noise. In this task, multitalker babble was presented from all speakers, and pairs of speech tokens were sequentially presented from two adjacent speakers. Listeners were required to identify both words from a closed set of four possibilities and to determine whether the second token was presented to the left or right of the first. In Experiment 1, normal-hearing adult listeners were tested at 15° intervals throughout the frontal hemifield. Listeners showed highest spatial discrimination performance in and around the frontal midline, with a decline at more eccentric locations. In contrast, speech identification abilities were least accurate near the midline and showed an improvement in performance at more lateral locations. In Experiment 2, normal-hearing listeners were assessed using a restricted range of speaker locations designed to match those found in clinical testing environments. Here, speakers were separated by 15° around the midline and 30° at more lateral locations. This resulted in a similar pattern of behavioral results as in Experiment 1. We conclude, this test offers the potential to assess both spatial discrimination and the ability to use spatial information for unmasking in clinical populations.

The development of leadership outcome-indicators evaluating the contribution of clinical specialists and advanced practitioners to health care: a secondary analysis.

AIMS: To report a secondary analysis of data collected from the case study phase of a national study of advanced practitioners and to develop leadership outcome-indicators appropriate for advanced practitioners. BACKGROUND: In many countries, advanced practitioners in nursing and midwifery have responsibility as leaders for health care development, but without having leadership outcome measures available they are unable to demonstrate the results of their activities. In Ireland, a sequential mixed method research study was used to develop a validated tool for the evaluation of clinical specialists and advanced practitioners. Despite strong evidence of leadership activities, few leadership-specific outcomes were generated from the primary analysis. DESIGN: Secondary analysis of a multiple case study data set. METHODS: Data set comprised 23 case studies of advanced practitioner/clinical specialists from 13 sites across each region in Ireland from all divisions of the Nursing Board Register. Data were collected 2008-2010. Data sources included non-participant observation (n = 92 hours) of advanced practitioners in practice, interviews with clinicians (n = 21), patients (n = 20) and directors of nursing/midwifery (n = 13) and documents. Analysis focused on leadership outcome-indicator development in line with the National Health Service's Good Indicators Guide. RESULTS: The four categories of leadership outcomes for advanced practitioner developed were as follows: (i) capacity and capability building of multidisciplinary team; (ii) measure of esteem; (iii) new initiatives for clinical practice and healthcare delivery; and (iv) clinical practice based on evidence. CONCLUSIONS: The proposed set of leadership outcome-indicators derived from a secondary analysis captures the complexity of leadership in practice. They add to existing clinical outcomes measuring advanced practice.

Factors influencing advanced practitioners' ability to enact leadership: a case study within Irish healthcare.

AIM: To report the factors that influence clinical specialists' and advanced nurse practitioners' ability to enact their clinical and professional leadership roles; findings from the SCAPE study. BACKGROUND: The importance of leadership for specialist and advanced practitioners is highlighted in the international literature and is considered an important factor in the provision of improved patient outcomes. Despite many studies identifying the barriers in developing and integrating new specialist/advanced practice roles into health services, little is known about the factors that influence the leadership dimension of their role. METHOD: A case study design involving 23 clinical specialist/advanced practitioners working in Ireland and multidisciplinary team members working with them, was used. Data were collected using interview, observation and documentary analysis. RESULTS: Four mediating factors influence the specialist/advanced practitioner's ability to perform a leadership role, namely the presence of a framework for the professional development of the role; opportunities to act as leaders; mechanisms for sustaining leadership; and personal attributes of practitioners. CONCLUSION AND IMPLICATIONS FOR NURSING MANAGEMENT: Nursing/midwifery leaders and managers at all levels have a key role in supporting leadership potential, through countering the negative impact of professional isolation, expanding opportunities for specialist/advanced practitioners to influence policy and network with wider professional groups.

Using case study within a sequential explanatory design to evaluate the impact of specialist and advanced practice roles on clinical outcomes: the SCAPE study.

BACKGROUND: The role of the clinical nurse/midwife specialist and advanced nurse/midwife practitioner is complex not least because of the diversity in how the roles are operationalised across health settings and within multidisciplinary teams. This aim of this paper is to use The SCAPE Study: Specialist Clinical and Advanced Practitioner Evaluation in Ireland to illustrate how case study was used to strengthen a Sequential Explanatory Design. METHODS: In Phase 1, clinicians identified indicators of specialist and advanced practice which were then used to guide the instrumental case study design which formed the second phase of the larger study. Phase 2 used matched case studies to evaluate the effectiveness of specialist and advanced practitioners on clinical outcomes for service users. Data were collected through observation, documentary analysis, and interviews. Observations were made of 23 Clinical Specialists or Advanced Practitioners, and 23 matched clinicians in similar matched non-postholding sites, while they delivered care. Forty-one service users, 41 clinicians, and 23 Directors of Nursing or Midwifery were interviewed, and 279 service users completed a survey based on the components of CS and AP practice identified in Phase 1. A coding framework, and the generation of cross tabulation matrices in NVivo, was used to make explicit how the outcome measures were confirmed and validated from multiple sources. This strengthened the potential to examine single cases that seemed 'different', and allowed for cases to be redefined. Phase 3 involved interviews with policy-makers to set the findings in context. RESULTS: Case study is a powerful research strategy to use within sequential explanatory mixed method designs, and adds completeness to the exploration of complex issues in clinical practice. The design is flexible, allowing the use of multiple data collection methods from both qualitative and quantitative paradigms. CONCLUSIONS: Multiple approaches to data collection are needed to evaluate the impact of complex roles and interventions in health care outcomes and service delivery. Case study design is an appropriate methodology to use when study outcomes relate to clinical practice.