How do CNCs construct their after hours support role in a Major Metropolitan Hospital

Article Outline

• Summary
• Introduction
• Methodology
  • Data collection
    • Data collection
    • Video data
    • Interviews
    • Analysis
• Results
  • Performance indicator
  • Competencies
  • Domains of Practice
• Discussion
• Limitations
• Conclusion
• Acknowledgements
• Appendix A. 
• References
• Copyright

Summary 

Aim

To explore how CNCs who provide hospital wide support after hours (AHCSs) construct their role.

Methods

This is an ethnographic study involving two AHCSs as participants. Audio visual data was collected in 2007 at a Major Metropolitan Hospital, Sydney during after hours shifts. The data was coded using the standards defined in the Nurse Practitioner (NP) competencies.

Results

Four hours of videotape (observed clinical practice) and 2h of audio tape (interviews) were coded. They performed procedures (22%), gathered information to identify at risk patients (21%), conducted patient assessments (20%) and relayed information/findings to ward nurses (12%) and doctors (12%). The roles/responsibilities of AHCSs were similar to those defined for NPs. For the domain “dynamic practice” 388 activities were identified. The two participants used advanced and comprehensive assessment skills and demonstrated a high level of proficiency in performing procedures/interventions. For the domain “professional efficacy” 174 activities were coded, for “clinical leadership” there were 135 activities. “Pro-actively identifying at risk patients in general wards” was added as a new performance indicator within the domain “clinical leadership”. An analysis of the interviews corroborated the results derived from the visual data.

Conclusion

A significant capacity for critical thinking and clinical decision making were the hallmarks of the performance of the two AHCSs; their style of practice was collaborative, flexible and autonomous. While their formal role were as CNCs the two participants operationalised their roles/responsibilities as would a Nurse Practitioner. Their practice demonstrated a new competency: “the pro-active identification of at risk patients”.

Keywords: Advanced practice, Nurse Practitioner, Competencies, Competency standards, Clinical support, Outreach

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Introduction 

Rapid changes in health care delivery, financial constraints and consumer demands have influenced the practice of healthcare providers; these factors have been influential in the development of the advanced practice role in nursing (Coombs, Chaboyer, & Sole, 2007; Furlong & Smith, 2005).

Advanced practice was first introduced by Benner in 1984 as part of the concept “novice to expert” (Benner, 2000). An Advanced Practice Nurse (APN) is “an experienced and knowledgeable nurse practicing in a general area at a level of practice higher than that expected” (The National Nursing Organisations in Australia (NNO) cited in Pearson & Peels (2002, p. S2)). The UK literature defines the practice of the APN/Nurse Consultant as a higher level of clinical autonomy brought about by new demands, and perceived shortcomings in the current quality of patient care, as well as resource constraints within health care (Daly & Carnwell, 2003).

In Australia the implementation of the advanced practice role varies by state and territory. There are two awards that recognise advanced nursing practice: Nurse Practitioner (NP) and Clinical Nurse Consultant (CNC). Historically the NP role is conceptualised as a clinical one; the CNC role has a focus on policy, research, and education (Davies & Hughes, 2002). In 2001, the CNC role was incorporated into the NSW Nurses Award with the following domains:

Within the domains is a list of functions, which have been selected to differentiate between the grades of the CNC and are not intended to describe the whole range of functions of the CNC (NSW, 2000).

Australian studies to quantify the time spent on each component of the CNC role were conducted in the 1990s (Dawson & Benson, 1997; Elliott et al., 1992). Recent Australian studies evaluating the CNC role have demonstrated that the role remains diverse and lacking perhaps in definition with respect to its specific domains and competencies (Chiarella, Hadford, & Lau, 2007; O’Baugh, Wilkes, Vaughan, & O’Donohue, 2007). For the CNCs to fulfil their role effectively, they need leadership training and support from their managers (Wilkes, Vaughan, & O’Donohue, 2007). It has also been identified that “there is a need to clarify the elements of the various overlapping roles, such as CNC, NP, Nursing Unit Manager and Clinical Nurse Educator, in order to ensure role clarity and best fit in terms of workforce planning” (Chiarella et al., 2007, p. 47).

Advanced practice is perceived to be synonymous with a NP; and refers to any “practitioner carrying out accredited professional roles with no mention of the level of competency required in either general or specific areas” (Pearson & Peels, 2002, p. S1). Formally, a NP is a Registered Nurse educated and formally accredited to function autonomously and collaboratively in an advanced and extended role. The scope of practice of the NP is determined by the context in which he/she is authorised to practice (ANMC, 2006; Gardner, Carryer, Gardner, & Dunn, 2006). It has also been noted that there are examples of nurses who function as NPs in an informal capacity (not accredited) (Read, Jones, & Williams, 1992).

It is generally accepted that NPs represent a type of APNs who undertake a wide variety of roles. In rural and remote areas APNs have become key health figures who provide information, make preliminary diagnosis, and provide advice and treatment for a range of clinical and social problems. The shortage of doctors has been an important factor in shaping their role (Offredy, 2000).

In the literature there are inconsistencies and substantial complexity in the definition of the NP role, and what constitutes an APN (Coombs et al., 2007; Daly & Carnwell, 2003; Gardner, Carryer, Dunn & Gardner, 2004; Offredy, 2000). Some emphasise the varying opinions of what constitutes advanced practice, and the difficulties associated with actually assessing APN competencies (Pearson & Peels, 2002). The terminology to describe advanced practice is therefore not clear; and agreement on what constitutes core competencies and roles (Daly & Carnwell, 2003; Mantzoukas & Watkinson, 2007) is lacking; while other authors refute that the APN competencies have not been clearly defined (Davies & Hughes, 2002; Hamric & Spross, 1989) cited in Gardner et al. (2004), Mantzoukas and Watkinson (2007), and Pearson and Peels (2002).

Amidst concern that competencies may not be culturally sensitive, the profession in Australia has been critical of the use of the competency standards framework. There is a view that the contextual richness pivotal to nursing practice might be missed (Chenowethm, Jeon, Goff, & Burke, 2006). Some (Fisher, Marshall, & Kendrick, 2005) also question the validity of the competency standards as a tool to assess the practice of specialist critical care nurses; they claim that the elements contained herein do not fit uniquely into a single competency. It has been recommended that it be clarified and that the constituents of competencies are found not only in the nurse, but in the relationships between the nurse, his/her colleagues, patients, families and with the situation itself (McMurray, 2004).

Chiarella, Thoms, Lau, and McInnes (2008) has cautioned the nursing profession of simply dismissing the immense amount of time and effort already expended in the development of competency standards; she suggests nurses take pride in these achievements. She is advocating that the validity and suitability of the documents be further examined in relation to the purposes for which they were designed. She recommends the competency documents be mapped to identify themes of similarity and difference; the findings will likely provide valuable insight into the nature of both specialist and advanced nursing practice (Chiarella et al., 2008).

Despite an abundance of the literature that describes advanced practice, little is known about CNCs acting in a clinical support role out of hours; particularly that which utilises the competency standards in an ethnographic framework. This study aims to explore how CNCs who provide hospital wide, clinical support, out of hours (AHCSs) contextualise advanced practice competencies.

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Methodology 

Data collection 

The setting is a Major Metropolitan Hospital, Sydney, Australia. It is an ethnographic study with a major focus on visual data (video graphs) as well as interviews (audio data). The aim of the study was to explore the performance of expert clinicians (two AHCSs), using the competency standards to guide the analysis of the visual and audio data (ANMC, 2006).

The research question was developed collaboratively between the researchers, the participants and their environment. These discussions were transcribed. They involved the background and genesis of the role; how at risk patients were identified; and how the AHCSs interacted with other professionals in the out of hours hospital environment.

The participants were videoed (2–4 consecutive hours) during the evening part of their shifts, between August and November 2007. Semi structured interviews were conducted with both participants (1h×2) during November 2007.

The participants were videoed between 14:00 and 22:00h. A Sony (HDV 1080i) and a Panasonic (AG DVX100E) digital video camera recorder with attached shotgun microphones were used (Santiano, Baramy, Young, Saggu, Cabrera, & Parr, 2008). The camera was operated by one experienced researcher accompanied by an observer (clinical researcher). Patient consent was obtained, only one patient declined. Mental health patients were excluded from the study.

The project has ethical approval within a larger visual anthropological study, exploring at risk patients in the hospital environment.

The two participant's knowledge of the terms describing advanced nursing practice (leadership, change agent, enabling, consultant, educator, expert practitioner and patient safety advocate) were explored in an interviewing process. Whenever possible, the AHCSs were encouraged to illustrate each of these terms using examples from their clinical practice.

The Eudico Linguistic Annotator (ELAN 2.6.3) software was used to annotate (code) and manage the video data (Helwigg, 2006). QSR NVivo software (Version 7) was used to code and analyse the interview data.

We used the Competency Standards for Nurse Practitioners (CSNP) to guide our coding of the multimodal data (ANMC, 2006). During the development of the research question the CSNP was identified as a potentially good fit with the data. The CSNP was developed based on an inductive process, with an emphasis on the meaning bearing behaviour of nursing performance (ANMC, 2006, Benner, 2000). In keeping with this methodology we adopted a multi-layered approach to coding and interpreting the data.

One of the strengths of the study was the availability of visual data. Both audio and visual recordings of human social activity may provide more accurate and complete data than that obtained by unaided human observation (Bottorff & Morse, 1994; Harrison, 2002, Santiano et al., 2008, Spiers, 2004). Video recordings enable the capture of rich information regarding complex human interactions that can be shared with other researchers (Morse, Penrod, Kassab, & Dellasega, 2000; Santiano et al., 2008, Spiers, 2004).

We coded the data in four stages reflecting the layered structure of our tool, the CSNP (ANMC, 2006). During the first and more concrete level of coding, we identified the discrete tasks performed by the AHCSs using all the data. For the second level of analysis all these tasks (n=697) were grouped, applying the definitions of the performance indicators (PI) of the CSNP. For the third level of analysis the PI's were categorised based on the competency statements. During the fourth and final level of coding the competency statements were allocated to the appropriate Domains of Practice, the CSNP. Table 1 lists the CSNP.

Table 1. Competency standards for Nurse Practitioners (Gardner et al., 2004).

Competency	Performance indicators
NP 1: Dynamic practice that incorporates application of high level knowledge and skills in extended practice across stable, unpredictable and complex situation
NP 1.1: Conducts advanced, comprehensive and holistic health assessment relevant to a specialist field of nursing practice	NP 1.1.1: Demonstrates advanced knowledge of human sciences and extended skills in diagnostic reasoning
	NP 1.1.2: Differentiates between normal, variation of normal and abnormal findings in clinical assessment
	NP 1.1.3: Rapidly assesses a patient's unstable and complex health care problem through synthesis and prioritisation of historical and available data
	NP 1.1.4: Makes decisions about use of investigative options that are judicious, patient focused and informed by clinical findings
	NP 1.1.5: Demonstrates confidence in own ability to synthesise and interpret assessment information including client/patient history, physical findings and diagnostic data to identify normal and abnormal states of health and differential diagnoses
	NP 1.1.6: Makes informed and autonomous decisions about preventive, diagnostic and therapeutic responses and interventions that are based on clinical judgment, scientific evidence, and patient determined outcomes
NP 1.2: Demonstrates a high level of confidence and clinical proficiency in carrying out a range of procedures, treatments and interventions that are evidence-based and informed by specialist knowledge	NP 1.2.1: Consistently demonstrates a thoughtful and innovative approach to effective clinical management planning in collaboration with the patient/client
	NP 1.2.2: Exhibits a comprehensive knowledge of pharmacology and pharmacokinetics related to specific field of clinical practice
	NP 1.2.3: Selects/prescribes appropriate medication, including dosage, routes and frequency pattern, based upon accurate knowledge of patient characteristics and concurrent therapies
	NP 1.2.4: Is knowledgeable and creative in selection and integration of both pharmacological and non-pharmacological treatment interventions into the management plan in consultation with the patient/client
	NP 1.2.5: Rapidly and continuously evaluates the patient/client/’s condition and response to therapy and modifies the management plan when necessary to achieve desired patient/client outcomes
	NP 1.2.6: Is an expert clinician in the use of therapeutic interventions specific to, and based upon, their expert knowledge of specialty practice
	NP 1.2.7: Collaborates effectively with other health professionals and agencies and makes and accepts referrals as appropriate to specific model of practice
	NP 1.2.8: Evaluates treatment/intervention regimes on completion of the episode of care, in accordance with patient/client-determined outcomes
	NP 1.3.1: Actively engages community/public health assessment information to inform interventions, referrals and coordination of care
NP 1.3: Has the capacity to use the knowledge and skills of extended practice competencies in complex and unfamiliar environments	NP 1.3.2: Demonstrates confidence and self-efficacy in accommodating uncertainty and managing risk in complex patient care situations
	NP 1.3.3: Demonstrates professional integrity, probity and ethical conduct in response to industry marketing strategies when prescribing drugs and other product
	NP 1.3.4: Uses critical judgement to vary practice according to contextual and cultural influences
	NP 1.3.5: Confidently integrates scientific knowledge and expert judgement to assess and intervene to assist the person in complex and unpredictable situations
NP 1.4: Demonstrates skills in accessing established and evolving knowledge in clinical and social sciences, and the application of this knowledge to patient care and the education of others	NP 1.4.1: Critically appraises and integrates relevant research findings in decision making about health care management and patient interventions
	NP 1.4.2: Demonstrates the capacity to conduct research/quality audits as deemed necessary in the practice environment
	NP 1.4.3: Demonstrates an open-minded and analytical approach to acquiring new knowledge
	NP 1.4.4: Demonstrates the skills and values of lifelong learning and relates this to the demands of extended clinical practice
NP 2: Professional efficacy whereby practice is structured in a nursing model and enhanced by autonomy and accountability
NP 2.1: Applies extended practice competencies within a nursing model of practice	NP 2.1.1: Consistently demonstrates a thoughtful and innovative approach to effective clinical planning in collaboration with the patient/client
	NP 2.1.2: Communicates a calm, confident and knowing approach to patient care that brings comfort and emotional support to the client and their family
	NP 2.1.3: Demonstrates the ability and confidence to apply extended practice competencies within a scope of practice that is autonomous and collaborative
	NP 2.1.4: Creates a climate that supports mutual engagement and establishes partnerships with patients/carer/family
	NP 2.1.5: Readily articulates a coherent and clearly defined Nurse Practitioner scope of practice that is characterised by extension and parameters
NP 2.2: Establishes therapeutic links with the patient/client/community that recognise and respect cultural identity and lifestyle choices	NP 2.1.1: Demonstrates respect for the rights of people to determine their own journey through a health/illness episode while ensuring access to accurate and appropriately interpreted information on which to base decisions
	NP 2.1.2: Demonstrates cultural competence by incorporating cultural beliefs and practices into all interactions and plans for direct and referred care
	NP 2.1.3: Demonstrates respect for differences in cultural and social responses to health and illness and incorporates health beliefs of the individual/community into treatment and management modalities
NP 2.3: Is pro-active in conducting clinical service that is enhanced and extended by autonomous and accountable practice	NP 2.3.1: Establishes effective, collegial relationships with other health professionals that reflect confidence in the contribution that nursing makes to client outcomes
	NP 2.3.2: Readily uses creative solutions and processes to meet patient/client/community defined health care outcomes within a timeframe of autonomous practice
	NP 2.3.3: Demonstrates accountability in considering access, clinical efficacy and quality when making patient care decisions
	NP 2.3.4: Incorporates the impact of the Nurse Practitioner service within local and national jurisdictions into the scope of practice
	NP 2.3.5: Advocates for the expansion to the Nurse Practitioner model of service that will improve access to quality, cost-effective health care for specific populations
NP 3: Clinical leadership that influences and progresses clinical care, policy and collaboration through all levels of health service
NP 3.1: Engages in and leads clinical collaboration that optimise outcomes for patients/clients/communities	NP 3.1.1: Actively participates as a senior member and/or leader of relevant multidisciplinary teams
	NP 3.1.2: Establishes effective communication strategies that promote positive multidisciplinary clinical partnerships
	NP 3.1.3: Articulates and promotes the Nurse Practitioner role in clinical, political and professional contexts
	NP 3.1.4: Monitors their own practice as well as participating in intra and inter-disciplinary peer supervision and review.
NP 3.2: Engages in and leads informed critique and influence at the systems level of health care	NP 3.2.1: Critiques the implication of emerging health policy on the Nurse Practitioner role and the client population
	NP 3.2.2: Evaluates the impact of social factors (such as literacy, poverty, domestic violence and racial attitudes) on the health of individuals and communities and acts to moderate the influence of these factors on the specific population/individual
	NP 3.2.3: Maintains current knowledge of financing of the health care system as it affects delivery of care
	NP 3.2.4: Influences health care policy and practice through leadership and active participation in workplace and professional organisations and at state and national government levels
	NP 3.2.5: Actively contributes to and advocates fro the development of specialist, local and national, health service policy that enhances Nurse Practitioner practice and the health community

The coding and analysis were conducted by two researchers in collaboration with the two AHCSs. The researchers and the AHCSs share a common professional background (critical care nursing) and therefore posses the contextual knowledge and culture that is nursing; and as such they were cultural insiders (Dufon, 2002; Lykkeslet & Gjengedal, 2007; Santiano et al., 2008; Van Der Geest & Finkler, 2004). The first and more concrete level of coding (tasks) was done individually by two clinical researchers, followed by a grouped based (the researchers and participants) appraisal of the codes. The codes and coding structure were modified in the light of these appraisals and revised to reflect the consensus of all the group participants. All changes and the reasoning behind them were documented in detail (agreements were signed and dated) to provide a comprehensive audit trail (transparency and reflexivity) of the analytical process.

The same coding and analysis strategy were used to explore the interview data. Hence we combined direct observation of practice (visual data) with the experience and perceptions of clinical practice of the participants (audio data) using the CSNP tool as a guide to coding. The audio data (interviews) informed “a truth testing process” in relation to the observational data (video graphs). We approached the AHCSs role as it was performed, not as a skill or a task to be done.

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Results 

Four hours and 37min of visual data inform the following results. A total of 697 discrete tasks were identified as part of the first and more concrete level of analysis. Tasks that were predominantly psychomotor were listed under the heading: “performing procedures” (oxygen therapy, nitrous oxide administration and arterial blood gas analysis); the AHCSs allocated 22% of their time to these activities. The remaining tasks were listed under the following headings: “identifying at risk patients” (gathering information through interviewing the nurses and reading medical records) (21%); “drawing clinical conclusions either before or after a full physical assessment of a patient” (20%); “sharing information and relaying findings to and/or with nurses and collaborating with doctors” (12%); “establishing rapport with staff”, “documentation”, “education” and “advocacy” (12%). The tasks listed under these seven headings are predominantly cognitive.

Performance indicator 

During the second layer of analysis, the 697 discrete tasks were categorised based on the CSNP performance indicators (PI). Of the thirty-six PI's, thirty were used to classify the tasks. The participants spent most of their time (1:09h) on the PI, NP 1.1.3 (“rapidly assesses a patient's unstable and complex health care problem through synthesis and prioritisation of historical and available data”). The PI NP 3.1.2 (“establishing effective communication strategies that promote positive multidisciplinary clinical partnerships”) took up 35min of their total time (57 activities), closely followed by the PI NP 2.3.1 (“establishing effective, collegial relationships with other health professionals that reflect confidence in the contribution that nursing makes to client outcomes”) at 33min (78 activities).

Two PI's that address the “selection and prescription of appropriate pharmacological and non pharmacological interventions” were not reflected in our data. A new PI: NP 3.1.5 “applying a pro-active strategy for identifying at risk patients on general wards” was established as part of our analysis (0:25h). The distribution of the 697 discrete activities across the 3 domains of NP practice can be seen in Appendix A.

Competencies 

At the third level of annotations, it was established that the two participants met the criteria for eight of nine NP competencies. They included all of the competencies of the NP 1 domain, two out of the three for NP 2, and all of the ones for NP 3. Thirty-five percent of the observed time (270 discrete activities) was spent “conducting advanced comprehensive and holistic health assessment relevant to a specialised field of nursing practice” (NP 1.1); followed by NP 3.1, “engaging in and leading clinical collaboration that optimised outcomes for patients” (0:54h). See Appendix A.

Domains of Practice 

During the fourth layer of coding, it was established that the two participants were active in all three Domains of Practice as defined in the CSNP. “Dynamic practice that incorporated application of high level knowledge and skills in extended practice across stable, unpredictable and complex situations” (NP 1) consumed almost half of their time (46%); followed by the domain “clinical leaders influencing and progressing clinical care, policy and collaboration through all levels of the health service” (NP 3=28%, 1:16h); the domain, “professional efficacy, whereby practice is structured in a nursing model and enhanced by autonomy and accountability” accounted for 26% of the participants time (1:11h). See Appendix A.

We applied a similar analytical strategy to the interview data. These results corroborated with the results from the visual data. The reflexivity engendered during the interview process added to the number of PIs and competencies (particularly the NP 3 Domain). See Appendix A.

Two exemplars illustrate these:

The participants implemented interventions to minimise complications and made informed and autonomous decisions (NP 1.1.6):

“…through relevant questioning and use of different sources of information…preventing the insertion of an incorrect type (fine bore for feeding versus salem sump for draining)…They couldn’t get the NG tube in…I was called…They had a feeding tube (prepared)…I asked what the NG tube was for. They said, that the patient is not eating well…Just didn’t fit well…It was a simple task of re-evaluating…The patient was admitted by a medical team, for surgical review for a query small bowel obstruction…It was a medical ward…only dealt with fine feeding tubes…was a huge education for staff…”.

They were confident with extended practice competencies as well as their ability to operate autonomously and collaboratively (NP 2.1.3). The following quote demonstrated that the AHCS in collaboration with the ward staff managed a patient “at risk”:

I put the line in, I drew the bloods, we gave her some nitrates, we gave some oxygen, we did a mobile chest x-ray, we did everything that needed to be done - everything that the RMO would’ve done anyway.…made sure that she's pain free, symptom free, and that…, physiologically we’re maximising supply and minimising demand and all those things, and all she needs now is someone to come…Cardiology.”

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Discussion 

In this case study of two CNCs providing out of hours support in a Major Metropolitan Hospital, Sydney, Australia, role extension, role expansion and role development were prominent features of their practice (Benner, 2000; Daly & Carnwell, 2003; Gardner et al., 2004). We used the CSNP as a tool to analyse video graphs of the clinical practice of the two participants as they shouldered the responsibility of diagnosing and managing at risk patients out of hours (ANMC, 2006, Gardner et al., 2006). The practice of the two participants was anchored within the essence of nursing: as demonstrated at the more concrete level of our analysis (first layer), out of 697 discrete tasks 153 related to ‘performing procedures’. Within the extended role, they accepted responsibility for important aspects of care, such as nitrous oxide administration to secure continuity of care. This was substantiated in the fourth and final layer of analysis. For almost a quarter of the total time they demonstrated “professional efficacy, whereby practice is structured in a nursing model and enhanced by autonomy and accountability” (ANMC, 2006, Gardner et al., 2006). Hence their role evolved into one of even greater responsibility, accountability and autonomy, as they responded to a need for facilitation of the broader aspects of management of specialised care for at risk patients (Daly & Carnwell, 2003; Fairley, 2003). Thus this study provides new knowledge about the performance of expert nurses, as they are faced with the new demands and perceived shortcomings in the quality of patient care as presented to them in the after hours setting (Daly & Carnwell, 2003).

As discussed by Durham and Hancock (2006), the participants demonstrated an ability to draw on and apply several areas of expertise (intensive care, emergency care, general medical and surgical care) in an integrated and purposeful manner.

“…extensive knowledge and skills…mine would be Critical Care…relating that back to the wards. At an expert level…do put across an opinion in a pathway for a patient.”

Their style was confident and calm (NP 2.1.2), creating a climate of mutuality (NP 2.1.4) and effective collegial relationships in relation to a range of staff (NP 2.3.1). These attributes enhanced their clinical decision making.

For almost half (46%) of the observed time, they were engaged in “dynamic practice” (NP 1, 388 activities). They had a focus on addressing inadequate skill mix of ward nurses in situations where the clinical status of patients was deteriorating. They did this based on their knowledge of patients and the physiological and psychological processes deemed central to the management of their conditions (Banning, 2008).

Our results add new knowledge about the CSNP. The two AHCSs took a pro-active approach to identifying at risk patients out of hours, while providing support to ward staff responsible for the care of these patients. This new PI is relevant for clinical leadership (NP 3, Domain of Practice). Some of the means and strategies used to find at risk patients were: power charts, probes and other interviewing techniques; a relatively modest number of their cases were referrals per say. These findings support the recommendations of Scholes and Endacott (2003). They have argued that the introduction of core competencies does not preclude the addition of new competencies developed in response to local needs. They state that this can be evidenced through the portfolio of practitioners; we provide evidence for this phenomenon based on the observed practice of the two participants.

Our analysis of both the video graphs and the interviews supported the concept that ward staff construed the two AHCSs as figures of authority and a source of security.

“I do have strong leadership skills…more authority. I can escalate so that that patient can get home at a reasonable time. They (staff) can feel free to call, ask, query…from a leadership point of view, we have changed some of the practices, some of the constraints, or the cultures, or the drivers…

Perceptions that were reinforced by ward staff observing the skilled advocacy of the two participants (NP 3.1.1). By focusing on the needs of ward staff and encouraging personal responsibility, the AHCSs demonstrated how much they valued their colleagues on the floor (Manley, 1997). Their actions were aimed at facilitating a culture conducive to ward staff taking up leadership. The two CNCs deliberately presented themselves as role models that would facilitate a collaborative culture, intent upon building capacity to minimise system risks (NP 3.1.2). The PIs reflected in the observed practice of the two AHCSs are conducive to promoting quality and evidence-based practice as recommended by Coombs et al. (2007).

During the third stage of analysis using the CSNP as our guide, we were able to establish that the two participants demonstrated all the competencies defined under the first Domain of Practice (“dynamic practice”). We argue that these results suggest that the out of hours context has reconfigured the CNC role towards a clinical focus; whereas historically it is more policy and research orientated (Pearson & Peels, 2002). For the second Domain of Practice (“professional efficacy”) only one competency was absent from the clinical practice of the two participants (NP 2.2). This competency relates to the need to address cultural barriers in relation to patients from culturally diverse backgrounds, or who have particular beliefs and spiritual needs. As there were no such patients in our data, this competency was not relevant. For the third Domain of Practice the competency NP 3.1, “engages in and leads clinical collaboration…” was established based on the video graphs and the interviews; whereas the second competency NP 3.2 “engages in and leads informed critique…” was reflected upon during the interviews.

“…patients who had central lines that needed regular changing and the policy just didn’t fit the patient…brought that up…policy needed to be reviewed…”.

Based on this case study where the CNC role was actively constructed by two expert nurses to minimise patient risk out of hours; we argue that their role was more akin to that of a Nurse Practitioner. The only exception was the PI “prescribing and selection of pharmacological interventions”. As yet there is no medico-legal framework that supports CNCs in exercising this PI. The AHCSs were functioning at a higher level of clinical autonomy brought about by new demands, and perceived shortcomings in the current quality of patient care, as well as resource constraints within health care (Daly & Carnwell, 2003). Complex reasoning, critical thinking, reflection and analytical skills are involved in the practice of the AHCSs in order to synthesise information gathered from assessments and guide complex clinical decisions (Fairley, 2003).

Congruent with the AHCSs’ level of responsibility and clinical expertise, as such higher level practitioners will command higher level salaries (Fairley, 2003). It should however be noted that the NP role is specifically regulated by legislation and by professional regulation. In addition to clinical practice (direct client care), regulatory authorities has developed NP practice criteria which needs to be met such as those related to educational preparation and collaborative arrangements. Health departments may also maintain the authority for approving and ratifying NP positions (Gardner et al., 2004).

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Limitations 

When selecting the CSNP as a guide for our analysis, we were cognisant of the lack of agreement in the literature about what constitutes competency and competencies in the nursing profession. There are divergent opinions both in relation to the theories that underpin the construction of competencies in nursing, how to measure them and whether valid tools are available. The CSNP was a potentially good fit with our research question and we share the view of Chiarella et al. (2008). They recommend that the vast amount of work that has gone into developing competency standards be used to explore nursing practice. We had a major emphasis on reflexivity during the coding and analysis of the multimodal data. We were committed to using the data we had collected without forcing the data to fit the template provided by the CSNP standards. Another strategy to establish the “truth” of the findings was our consensus-based approach to both the coding and the analysis of the visual data in particular. The interview data reflecting the experience of the two AHCSs captured in the videos, provided another form of validation of the video-based conclusions (observed behaviour). Transparency was maintained throughout the study. A documented trail of all the revisions of the codes, the coding structure and associated discussions are available. All changes and revisions are dated and signed by the group that included clinical researchers and the participants.

This study was conducted in only one Major Metropolitan Hospital in one area health service and as such our findings may not be generalisable to other settings. In addition, only 4h and 37min out of the total recording time of over 8h were included in this report. Video recording of the AHCSs as they fast tracked and/or attended medical emergency team calls were excluded. The ethnographic framework of the study however, provided us with a thick description or a descriptive explanatory interpretive account of the role of the two AHCSs (Dufon, 2002). We gathered naturalistic data in a variety of ways. We used interviews and video recorded the AHCSs in the clinical context (after hours, weekdays and weekends), while they typically participate in their day-to-day activities. The data was interpreted and explained in terms of the AHCSs’ relationship to the system of which they were a part and checked it with them. The triangulation process in the interpretation and collection of the data, built in layers of description, thus yielding a thicker description and increased credibility and validity (Dufon, 2002). In contrast to experimental research, the purpose of ethnographic studies is not to generalise, comparisons of similar group of AHCSs however, can be made in a more abstract level (Davies, 1995, Dufon, 2002).

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Conclusion 

The AHCSs operationalised their roles/responsibilities at the level of a NP. They are leaders in patient care and within the health care system; influencing change, promoting quality and evidenced-based practice that improves patient outcomes and safety (Coombs et al., 2007). A significant capacity for critical thinking and decision making were the hallmarks of their performance; reinforced by a collaborative and flexible style of practice.

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Acknowledgements 

We would like to acknowledge the staff and patients at Campbelltown Hospital for their major contribution in the success of the data collection process. A special thank you to Emily May and Rebecca Wegener who assisted in the design and conception of the project, all staff at the Simpson Centre and Linda Whyte who assisted in the preparation of the manuscript.

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Appendix A. 

Nurse Practitioner competency standards (ANMC, 2006).

Competency	Performance indicators	Visual Data		Interviews
		Time spent (n=4:37:52)	Number of activities (n=697)	Number of quotes
NP 1: Dynamic practice that incorporates application of high level knowledge and skills in extended practice across stable, unpredictable and complex situations.		2:10:14 (46%)	388 (56%)	40
NP 1.1: Conducts advanced, comprehensive and holistic health assessment relevant to a specialist field of nursing practice.	NP 1.1.1: Demonstrates advanced knowledge of human sciences and extended skills in diagnostic reasoning.	0:00:46	1	2
	NP 1.1.2: Differentiates between normal, variation of normal and abnormal findings in clinical assessment.	0:01:26	5
	NP 1.1.3: Rapidly assesses a patient's unstable and complex health care problem through synthesis and prioritisation of historical and available data.	1:09:45	201	1
	NP 1.1.4: Makes decisions about use of investigative options that are judicious, patient focused and informed by clinical findings.	0:05:43	14	2
	NP 1.1.5: Demonstrates confidence in own ability to synthesise and interpret assessment information including client/patient history, physical findings and diagnostic data to identify normal and abnormal states of health and differential diagnoses.	0:13:18	47	6
	NP 1.1.6: Makes informed and autonomous decisions about preventive, diagnostic and therapeutic responses and interventions that are based on clinical judgment, scientific evidence, and patient determined outcomes.	0:10:11	28	9
NP 1.2: Demonstrates a high level of confidence and clinical proficiency in carrying out a range of procedures, treatments and interventions that are evidence-based and informed by specialist knowledge.	NP 1.2.1: Consistently demonstrates a thoughtful and innovative approach to effective clinical management planning in collaboration with the patient/client.	0:01:19	4
	NP 1.2.2: Exhibits a comprehensive knowledge of pharmacology and pharmacokinetics related to specific field of clinical practice.	0:00:56	1
	NP 1.2.5: Rapidly and continuously evaluates the patient/client/’s condition and response to therapy and modifies the management plan when necessary to achieve desired patient/client outcomes.	0:00:39	3
	NP 1.2.6: Is an expert clinician in the use of therapeutic interventions specific to, and based upon, their expert knowledge of specialty practice.	0:05:26	24	1
NP 1.2: Demonstrates a high level of confidence and clinical proficiency in carrying out a range of procedures, treatments and interventions that are evidence-based and informed by specialist knowledge.	NP 1.2.7: Collaborates effectively with other health professionals and agencies and makes and accepts referrals as appropriate to specific model of practice.	0:05:23	17
	NP 1.2.8: Evaluates treatment/intervention regimes on completion of the episode of care, in accordance with patient/client-determined outcomes.	0:01:08	6	1
NP 1.3: Has the capacity to use the knowledge and skills of extended practice competencies in complex and unfamiliar environments.	NP 1.3.2: Demonstrates confidence and self-efficacy in accommodating uncertainty and managing risk in complex patient care situations.	0:01:06	4	1
	NP 1.3.4: Uses critical judgement to vary practice according to contextual and cultural influences.	0:02:46	11
	NP 1.3.5: Confidently integrates scientific knowledge and expert judgement to assess and intervene to assist the person in complex and unpredictable situations.	0:09:35	20	10
NP 1.4: Demonstrates skills in accessing established and evolving knowledge in clinical and social sciences, and the application of this knowledge to patient care and the education of others.	NP 1.4.4: Demonstrates the skills and values of lifelong learning and relates this to the demands of extended clinical practice.	0:00:47	2	7
NP 2: Professional efficacy whereby practice is structured in a nursing model and enhanced by autonomy and accountability.		1:11:12 (26%)	173 (25%)	17
NP2.1: Applies extended practice competencies within a nursing model of practice.	NP 2.1.1: Consistently demonstrates a thoughtful and innovative approach to effective clinical planning in collaboration with the patient/client.			1
	NP 2.1.2: Communicates a calm, confident and knowing approach to patient care that brings comfort and emotional support to the client and their family.	0:04:23	25
	NP 2.1.3: Demonstrates the ability and confidence to apply extended practice competencies within a scope of practice that is autonomous and collaborative	0:08:53	20	10
	NP 2.1.4: Creates a climate that supports mutual engagement and establishes partnerships with patients/carer/family.	0:08:16	19
	NP 2.1.5: Readily articulates a coherent and clearly defined Nurse Practitioner scope of practice that is characterised by extension and parameters.			1
NP 2.3: Is pro-active in conducting clinical service that is enhanced and extended by autonomous and accountable practice.	NP 2.3.1: Establishes effective, collegial relationships with other health professionals that reflect confidence in the contribution that nursing makes to client outcomes.	0:33:13	78	4
	NP 2.3.2: Readily uses creative solutions and processes to meet patient/client/community defined health care outcomes within a timeframe of autonomous practice.			1
	NP 2.3.3: Demonstrates accountability in considering access, clinical efficacy and quality when making patient care decisions.	0:22:50	31
NP 3: Clinical leadership that influences and progresses clinical care, policy and collaboration through all levels of health service.		1:16:26 (28%)	136 (19%)	36
NP 3.1: Engages in and leads clinical collaboration that optimise outcomes for patients/clients/communities.	NP 3.1.1: Actively participates as a senior member and/or leader of relevant multidisciplinary teams.	0:08:38	19	7
	NP 3.1.2: Establishes effective communication strategies that promote positive multidisciplinary clinical partnerships.	0:35:31	57	7
	NP 3.1.4: Monitors their own practice as well as participating in intra and inter-disciplinary peer supervision and review.			6
	New NP 3.1.5: Utilises innovative approaches in the identification of patients at risk and facilitates the progress of their care.	0:25:53	60	2
NP 3.2: Engages in and leads informed critique and influence at the systems level of health care.	NP 3.2.1: Critiques the implication of emerging health policy on the Nurse Practitioner role and the client population.			1
	NP 3.2.4: Influences health care policy and practice through leadership and active participation in workplace and professional organisations and at state and national government levels.			9
	NP 3.2.5: Actively contributes to and advocates fro the development of specialist, local and national, health service policy that enhances Nurse Practitioner practice and the health community.			4

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