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Clarifying Clinical Nurse Consultant work in Australia: A phenomenological study

Open AccessPublished:September 30, 2014DOI:https://doi.org/10.1016/j.colegn.2014.09.002

      Summary

      The Clinical Nurse Consultant role in Australia is an Advanced Practice Registered Nurse Role (APRN). This role has been conceptualized from the discrete pillars of research, education, practice, system support and leadership, articulated in the Strong Model of Advanced Practice. This conceptualization has been manifested in job descriptions, workforce planning and course design. This paper explored whether there was a more refined way of conceptualizing the unique ‘value add’ of the role. A hermeneutic phenomenological approach was employed to explore the lived experience of the role. It was identified that the pillars of education, practice, leadership and research are interconnected and expressed in the system work of the Clinical Nurse Consultant. The findings have implications for education and workforce planning.

      Keywords

      1. Introduction

      Clinical Nurse Consultants (CNCs) are a type of advanced practice nurse in the Registered Nurse scope in the state of New South Wales (NSW), Australia (
      • NSW Health
      Clinical Nurse Consultants – Domains and functions.
      ). The CNC position was introduced into the NSW state award structure in 1986 (
      • O’Baugh J.
      • Wilkes L.M.
      • Vaughan K.
      • O’Donohue R.
      The role and scope of the clinical nurse consultant in Wentworth area health service, New South Wales, Australia.
      ), and was modeled on the Clinical Nurse Specialist (CNS) role in the UK and USA (
      • Baldwin R.
      • Duffield C.M.
      • Fry M.
      • Roche M.
      • Stasa H.
      • Solman A.
      The role and functions of Clinical Nurse Consultants, an Australian advanced practice role: A descriptive exploratory cohort study.
      ). The role was created to provide a career pathway for experienced nurses who wished to maintain a clinical role, rather than moving into administration or education (
      • Elsom S.
      • Happell B.
      • Manias E.
      The Clinical Nurse Specialist and Nurse Practitioner roles: Room for both or take your pick?.
      ). Similar roles exist in other Australian states and territories, but some have different position titles. At the most general level, a NSW CNC is a Registered Nurse who possesses at least five years full-time equivalent post registration experience, and who, in addition, has attained approved post-registration nursing/midwifery qualifications relevant to the specialty field in which he or she is appointed (
      • NSW Health
      Public Health System Nurses’ and Midwives’ (State) Award 2011.
      ). Over the years, there has been significant confusion and debate about the CNC role, and how these professionals contribute to improved service delivery (
      • Baldwin R.
      • Duffield C.M.
      • Fry M.
      • Roche M.
      • Stasa H.
      • Solman A.
      The role and functions of Clinical Nurse Consultants, an Australian advanced practice role: A descriptive exploratory cohort study.
      ,
      • Fry M.
      • Duffield C.
      • Baldwin R.
      • Roche M.
      • Stasa H.
      • Solman A.
      Development of a tool to describe the role of the clinical nurse consultant in Australia.
      ,
      • Wilkes L.
      • Cummings J.
      • McKay N.
      Developing a culture to facilitate research capacity building for Clinical Nurse Consultants in Generalist Paediatric Practice.
      ). There are three grades of CNC in NSW. While job description varies between grades, and corresponding remuneration, there has often been arbitrary application of grade to positions informed in many cases more by budgetary constraints as opposed to rational service planning across NSW. This is one component of the confusion referred to above (
      • Chiarella M.
      • Hardford E.
      • Lau C.
      Report on the evaluation of Nurse/Midwife Practitioner and Clinical Nurse/Midwife Consultant Roles.
      ). The three grades are embedded in the industrial award and are paid at different rates ranging from CNC one at the lowest end to CNC three at the highest end. The focus of the grade varies from unit based expectation for a CNC level one to a state level focus for CNC level three. The different levels should require different academic preparation, but at present in NSW formal qualifications are only listed as desirable elements at the time of recruitment as opposed to mandatory.
      In attempting to identify the unique elements of CNC practice, and the ‘value add’ (
      • Mundinger M.O.
      • Cook S.S.
      • Lenz E.R.
      • Piacentini K.
      • Auerhahn C.
      • Smith J.
      Assuring quality and access in advanced practice nursing: A challenge to nurse educators.
      ,
      • Mundinger M.O.
      • Kane R.L.
      • Lenz E.R.
      • Totten A.M.
      • Tsai W.Y.
      • Cleary P.D.
      Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial.
      ) of these positions, researchers have often relied upon what is termed the “Strong Model” of advanced practice (
      • Ackerman M.H.
      • Norsen L.
      • Martin B.
      • Wiedrich J.
      • Kitzman H.J.
      Development of a model of advanced practice.
      ,
      • Mick D.J.
      • Ackerman M.H.
      Advanced Practice Nursing. Advanced Practice Nursing role delineation in acute and critical care: Application of the Strong Model of Advanced Practice.
      ). The Strong Model was developed by Ackerman and co-workers in the mid-1990s, in an attempt to characterize the unique nature of the acute care nurse practitioner role in the United States (
      • Ackerman M.H.
      • Norsen L.
      • Martin B.
      • Wiedrich J.
      • Kitzman H.J.
      Development of a model of advanced practice.
      ). The model defines five areas of practice which together comprise the advanced nursing role, namely direct comprehensive clinical care (patient-focused activities); support of systems (which include professional contributions to improve nursing practice within the health care institution); education (of staff, clients, carers, and members of the public); research (including the incorporation of findings from evidence-based practice to improve patient care); and professional leadership (which may include publication of findings beyond the immediate practice setting) (
      • Ackerman M.H.
      • Norsen L.
      • Martin B.
      • Wiedrich J.
      • Kitzman H.J.
      Development of a model of advanced practice.
      ). The five components of the Strong Model may be referred to as the “domains” or “pillars” of advanced practice (
      • Barton T.
      • Bevan L.
      • Mooney G.
      Advanced nursing two: A governance framework for advanced nursing.
      ,
      • NSW Health
      Clinical Nurse Consultants – Domains and functions.
      ). Common “conceptual strands” cutting across each domain, namely empowerment; collaboration; and scholarship were also identified.
      Since publication, the Strong Model, or models very similar to this, have been widely employed by nursing researchers. It has been used to characterize a number of different advanced nursing roles, beyond Nurse Practitioners, such as the role of the Clinical Nurse Specialist or Clinical Nurse Consultant (
      • Bahadori A.
      • Fitzpatrick J.J.
      Level of autonomy of primary care nurse practitioners.
      ,
      • Chang A.M.
      • Gardner G.E.
      • Duffield C.
      • Ramis M.-A.
      A Delphi study to validate an Advanced Practice Nursing tool.
      ,
      • Maloney M.A.
      • Volpe J.
      The inpatient Advanced Practice Nursing roles in a Canadian Pediatric Oncology Unit.
      ,
      • Stewart J.G.
      • McNulty R.
      • Griffin M.T.Q.
      • Fitzpatrick J.J.
      Psychological empowerment and structural empowerment among nurse practitioners.
      ). Additionally, the model has been applied to characterize advanced nursing roles beyond the original American context, in places such as the United Kingdom and Australia, and in specialties other than acute care, such as psychiatry and endocrinology (
      • Bahadori A.
      • Fitzpatrick J.J.
      Level of autonomy of primary care nurse practitioners.
      ,
      • Harwood L.
      • Wilson B.
      • Heidenheim A.P.
      • Lindsay R.M.
      The advanced practice nurse-nephrologist care model: Effect on patient outcomes and hemodialysis unit team satisfaction.
      ,
      • Ridley J.
      • Harwood L.
      • Lawrence-Murphy J.A.
      • Locking-Cusolito H.
      • Wilson B.
      How five advanced practice nurses in nephrology spend their time.
      ).
      Internationally, aspects of the Strong Model have been used by policy makers and health service planners in creating position descriptions for advanced nursing roles. For example, in both Wales and Scotland, advanced practice is conceptualized around four “pillars”, namely clinical, education, research, and management/leadership. With the exception of systems support, these reflect the pillars of the Strong Model (
      • National leadership and innovation agency for healthcare
      Advanced practice the portfolio.
      ,
      • NHS Scotland
      Advanced Nursing Practice toolkit.
      ). The current NSW CNC position description also appears to have been based on the Strong Model and its pillars, although this is not explicitly acknowledged in the documentation (
      • NSW Health
      Clinical Nurse Consultants – Domains and functions.
      ). In this position description, the domains of clinical service and consultancy; leadership; research; education; and planning and management, are listed as being central to the CNC role, and bear clear similarities to the five pillars of the Strong Model (
      • NSW Health
      Clinical Nurse Consultants – Domains and functions.
      ).
      However, at this stage, the question arises as to whether the Strong Model does in fact provide an accurate conceptualization of the CNC role and other Australian advanced nursing positions. As explained previously, the model was originally developed as a means of conceptualizing the role of an acute care nurse practitioner in the United States, a role which differs from that of the NSW CNC in important ways. Second, the Strong Model was developed in the mid-1990s, almost 20 years previously, and as Lowe and colleagues correctly suggested, advanced practice nursing roles are not static (
      • Lowe G.
      • Plummer V.
      • O’Brien A.P.
      • Boyd L.
      Time to clarify – The value of advanced practice nursing roles in health care.
      ). Rather, as the health care system changes, such roles tend to evolve, and consequently, a model of practice which was appropriate years ago may not be appropriate now, and may require updating to better reflect contemporary practice.
      A number of Australian researchers have investigated CNC practice, however, there are several weaknesses associated with these studies. First, apart from one study by Chiarella and colleagues, which examined CNC roles across NSW (
      • Chiarella M.
      • Hardford E.
      • Lau C.
      Report on the evaluation of Nurse/Midwife Practitioner and Clinical Nurse/Midwife Consultant Roles.
      ), the research has tended to be small in scale, and concentrate on single sites or health services. For example, Dawson and Benson examined the CNC role in Wentworth Area Health Service, where a total of 13 CNCs were employed (
      • Dawson J.A.
      • Benson S.
      Clinical nurse consultants: Defining the role.
      ), whilst McIntyre and colleagues’ more recent paper looked at ward nurses’ attitudes to intensive care unit CNCs at a single health service (
      • McIntyre T.
      • Taylor C.
      • Eastwood G.M.
      • Jones D.
      • Baldwin I.
      • Bellomo R.
      A survey of ward nurses attitudes to the Intensive Care Nurse Consultant service in a teaching hospital.
      ). Similarly, Santiano and co-authors’ paper on the work of after-hours CNCs at a metropolitan hospital focused on only two participants (
      • Santiano N.
      • Young L.
      • Baramy L.
      • McDonnell S.
      • Page K.
      • Cabrera R.
      • et al.
      How do CNCs construct their after hours support role in a Major Metropolitan Hospital.
      ). Whilst small scale studies provide a useful insight into practice in particular health services and specialties, more extensive research is required in order to gain a comprehensive picture of CNC practice.
      A second weakness with the pre-existing research on CNCs is that some researchers have formulated their research methodologies on the assumption that the Strong Model offers an accurate depiction of advanced practice nursing roles. For example, in their examination of different ‘types’ of CNC roles within the public hospital system, Baldwin and colleagues investigated how individual CNC practice varied across the “five pillars”. Similarly a study examined the differences between CNC grades, using the Strong Model framework (
      • Baldwin R.
      • Duffield C.M.
      • Fry M.
      • Roche M.
      • Stasa H.
      • Solman A.
      The role and functions of Clinical Nurse Consultants, an Australian advanced practice role: A descriptive exploratory cohort study.
      ,
      • Gardner G.
      • Chang A.M.
      • Duffield C.
      • Doubrovsky A.
      Delineating the practice profile of advanced practice nursing: A cross-sectional survey using the modified strong model of advanced practice.
      ). However, it is important to note that these studies fail to consider the possibility that the Strong Model may not offer the most accurate conceptualization of advanced practice roles. Rather, they have proceeded on the foundation that the model is compatible, and then attempted to fit the CNC roles around the pre-existing “pillars of practice.”
      A third weakness in the pre-existing studies surrounding CNC practice is the lack of research on autonomy of practice. Under the NSW Health guidelines, the CNC position is considered to be an advanced nursing role (
      • NSW Health
      Clinical Nurse Consultants – Domains and functions.
      ,
      • NSW Health
      Public Health System Nurses’ and Midwives’ (State) Award 2011.
      ) and, as has been noted, one of the key distinguishing features of advanced nursing roles is the level of autonomy and clinical decision making afforded to their incumbents (
      • Elsom S.
      • Happell B.
      • Manias E.
      The Clinical Nurse Specialist and Nurse Practitioner roles: Room for both or take your pick?.
      ,
      • MacDonald J.-A.
      • Herbert R.
      • Thibeault C.
      Advanced practice nursing: Unification through a common identity.
      ,
      • NHS Scotland
      Advanced Nursing Practice toolkit.
      ). However, apart from recent research led by Duffield and team, which looked at the variability between CNC positions in areas such as decision-making and teamwork (
      • Baldwin R.
      • Duffield C.M.
      • Fry M.
      • Roche M.
      • Stasa H.
      • Solman A.
      The role and functions of Clinical Nurse Consultants, an Australian advanced practice role: A descriptive exploratory cohort study.
      ), the few existing studies of NSW CNC practice have not tended to examine autonomy of practice or how this is manifested in the daily activities of the CNC (
      • Chiarella M.
      • Hardford E.
      • Lau C.
      Report on the evaluation of Nurse/Midwife Practitioner and Clinical Nurse/Midwife Consultant Roles.
      ,
      • Fry M.
      • Duffield C.
      • Baldwin R.
      • Roche M.
      • Stasa H.
      • Solman A.
      Development of a tool to describe the role of the clinical nurse consultant in Australia.
      ,
      • O’Baugh J.
      • Wilkes L.M.
      • Vaughan K.
      • O’Donohue R.
      The role and scope of the clinical nurse consultant in Wentworth area health service, New South Wales, Australia.
      ). This is an important omission, because if the CNC role is described as being “autonomous”, it is vital for policy makers and health service managers to know how this autonomy is manifested in the workplace, and for nurse educators to ensure that current training programs are designed to foster this attribute in future CNCs.
      Internationally the impetus to create such advanced practice positions within the RN scope has included the ideal of creating a career pathway, as expressed in NSW, but also modernization of services (
      • Franks H.
      • Howarth M.
      Daring to be different: A qualitative study exploring the education needs of the nurse consultant.
      ). Modernization referred to designing positions that enable the full expression of scope of practice, moving beyond traditional constraints of community perception and traditional practice. This notion of modernization is in keeping with notion of flexible boundaries and innovation in the exploration of possible futures currently being explored by Health Workforce Australia (
      • McCarty M.
      • Fenech B.
      Towards best practice in national health workforce planning.
      ).
      The present study aims to overcome these identified weaknesses, by examining contemporary CNC practice free of any prior theoretical commitment to the Strong Model, and to identify the key features, or unique value add of the CNC role as lived. This identification will facilitate more specific tailoring of design of education programs to prepare for the role. It will also provide an understanding that contributes to scenario-based modeling of possible futures for the nursing workforce.

      2. Aim

      To identify the key features or unique value add of the CNC role as lived (free of theoretical commitment to the Strong Model).

      3. Methodology

      The scholarly tradition of Hermeneutic Phenomenology was used to explore the experience as lived of being a CNC in regional (North Coast of NSW) and metropolitan (Sydney NSW) locations. Five focus groups were conducted with a total of 37 CNCs (18 metropolitan, 19 regional). Each group was guided by a facilitator and co-facilitator from the research team. Like all phenomenology there is no cook book style recipe of method that can be employed, but rather quality scholarship arises from adherence to the chosen philosophical tradition (
      • Van Manen M.
      The phenomenology of pedagogic observation.
      ). Demonstration of scholarship and how the project ‘hangs together’ conceptually (
      • Davey N.
      Unquiet understanding: Gadamer's philosophical hermeneutics.
      ) allows the passing of the “so-what” test of significance (
      • Sandelowski M.
      To be of use: Enhancing the utility of qualitative research.
      ). This study used focus groups to allow the researchers to fuse horizons (
      • Gadamer H.
      On the scope and function of hermeneutical reflection.
      ) with CNCs in a group conversation related to the nature of the role. In keeping with hermeneutics (as opposed to transcendental phenomenology) this fusion involves a conscious effort to acknowledge the subjectivity of both the participants and researchers as meaning is found in the contact between people, as opposed to a misguided quest to construct a perfect ‘subject less’ interaction (in which all prejudices can be identified and bracketed) between completely understood motives and the consciously performed action of research to aimed at identifying universal essence (
      • Gadamer H.
      On the scope and function of hermeneutical reflection.
      ,
      • Finlay L.
      Outing the researcher: The provenance, process and the practice of reflexivity.
      ). The group environment conducive to moving in a circular process from concrete to abstraction and back again while checking resonance with CNCs from different contexts. Participating CNCs responded to a general emailed invitation to participate in the study. Inclusion criteria were employment as a CNC in NSW. The conversation was not idle chatter but a dialog focused on the phenomena of which both participants and researchers had agreed to focus and shared a sense of relevance (
      • Bernstein R.
      Beyond objectivism and relativism: Science hermeneutics and praxis. Philadelphia.
      ). The researchers began with the general invitation to discuss the experience of practicing as a CNC and had an interview guide that could be used to prompt, to reground the conversations as needed and to encourage a consistent approach to directing the discussion (see Table 1). The invitation in a phenomenological study may be all the structure that is required (
      • Osborne J.
      Some similarities and differences among phenomenological and other methods of psychological qualitative research?.
      ). The prompts were available if the conversation stalled or needed redirecting. In the phenomenological spirit of moving beyond subjective interpretations and drilling to ‘the thing itself’ (
      • Heidegger M.
      Being and time.
      ), participants were prompted to give examples from their practice. The interviews were audio recoded and rendered to text through professional transcription. It is acknowledged that the act of gathering and interpreting data are not separate events as each is related to the other (
      • Kvale S.
      Ten standard objections to qualitative research interviews.
      ,
      • Sandelowski M.
      Qualitative analysis: What it is and how to begin.
      ). Each audio recording was placed in an online repository as close as possible to the event and the research team were able to listen to recordings and become immersed in the data, even before receiving the transcripts. In a circular process between the team and the audio recordings, and then the transcribed data, the data was organized into themes. Evidence in the form of participant quotes that supported the themes or suggested further refinement was gathered. The team conducted an initial thematic analysis individually, then after reading and rereading the transcripts, conversed frequently via teleconference and email until consensus was reached. Themes earned a place in the published construction through fit to the data, and faithfulness to the data (
      • Sandelowski M.
      Qualitative analysis: What it is and how to begin.
      ). The published, although not final telling, was a construction arrived at that provides a conceptual map consisting of the predominate story lines or themes (
      • LeCompte M.
      Analyzing qualitative data.
      ). Any understanding is shaped by a conviction that there is always more to a phenomenon than can be said about it; the historical continuity implies that meaning cannot be finalized and no interpretation is exhaustive (
      • Davey N.
      Unquiet understanding: Gadamer's philosophical hermeneutics.
      ). However, a new telling was arrived at through the circular process of moving back and forward between smaller parts of data and the whole; the parts being the individual participant quotes and lines of discussion – and the whole, being the larger culture of advanced nursing practice. This does allow in Heideggerian terms, a ‘clearing in the woods’ (
      • Heidegger M.
      Being and time.
      ), where light is shed on the experience of ‘being’ related to the value-add of CNCs in the nursing landscape.
      Table 1Focus group prompts.
      Prompts for CNC focus groups
      1.To begin, can you provide a brief description of your typical day as a CNC? How do you perceive your role?
      2.What proportion of your role is clinical care?
      3.What motivated you to apply for a CNC position?
      4.CNCs are often described as advanced nurses, meaning nurses who possess expertise or specialization beyond that of Registered Nurses. How does your practice differ from RN practice? In what ways is CNC practice similar to RN practice?
      5.Some researchers have suggested that CNC practice is centered around four key pillars, namely clinical care, research, management and education. Do you believe these accurately capture the important aspects of your practice? If not, what else would you add and how would you describe it?
      6.In your opinion, how does the work of CNCs impact on outcomes for patients or clients (particularly around holism and continuity of care)? Could you give some examples?
      7.In your opinion, how does the work of CNCs impact on staff outcomes? Again, can you give some examples?
      8.In your opinion, how does the work of CNCs impact on outcomes for the healthcare service? Can you provide some examples to illustrate?
      9.What factors enable you to fulfill your CNC role?
      10.Do you experience any barriers to implementing the CNC role? What are these?
      The study was approved by the institutional ethics committees of Southern Cross University, the University of Sydney and Northern NSW Local Health District.

      4. Findings

      Demographic data was collected from all focus groups. This data is presented in Table 2.
      Table 2Demographic data for metropolitan and regional CNCs.
      MetropolitanRegionalTotal
      Gender
       Male1 (6%)4 (21%)5 (14%)
       Female17 (94%)15 (79%)32 (86%)
      Age
       35–449 (50%)2 (11%)11 (30%)
       45–543 (17%)5 (26%)8 (22%)
       55–645 (28%)12 (63%)17 (46%)
       65+1 (6%)0 (0%)1 (3%)
      Mean years RN (range)25.5 (12–42)32.5 (16–41)29.1 (12–42)
      Mean years CNC (range)9.1 (1–24)12.8 (1–28)11.0 (1–28)
      CNC grade
       CNC 11 (6%)3 (16%)4 (11%)
       CNC 212 (67%)10 (53%)22 (59%)
       CNC 35 (28%)6 (32%)11 (30%)
      Highest education level
       Hospital Cert1 (6%)0 (0%)1 (3%)
       Nursing Dip0 (0%)1 (5%)1 (3%)
       Bachelor0 (0%)4 (21%)4 (11%)
       Grad/PG Cert3 (17%)4 (21%)7 (19%)
       Grad Dip2 (12%)1 (5%)3 (8%)
       Master10 (56%)8 (42%)18 (49%)
       PhD1 (6%)0 (0%)1 (3%)
       Not specified1 (6%)1 (5%)2 (5%)
      Due to rounding, some totals do not add to 100%.
      The lived experience of the CNC role was varied, but characterized by the ‘head-up’ nature of this role that distinguished if from that of the other nurse and health clinicians. A consistent and almost unanimous theme that pervaded the conversation was that of flexibility, which was possible because the role was not dominated by having allocated patients. “I’m not counted in the numbers”. This distinguished the CNCs from other clinically focused roles and was interpreted as autonomy. “From my perspective the clinician on the floor, they’re focused on the patient in front of them. They don’t have time to see anything else that's around there, or even policy”. Within the limits of the health service structures (such as meeting schedules) the participants described being in charge of their own diaries (schedules) and as a result, had the flexibility to plan their own work and set priorities. “If you looked at someone who is clinically based, who took a patient load every day versus a CNC who doesn’t, then I would say that the clinically-based patient load person tends to focus on achieving things for a shift versus the CNC who has a very collateral vision that sets up plans for futures and moves us forward as a service”. The metaphor of the ability to get the head up from the immediate demands of allocated patient work and look into the future had good fit with the data. In this respect, the CNC role was described as unique; no other professional disciplines have such a role. Other roles within nursing and across disciplines were seen to tend to be demarcated based on clinical care, education or management and were restricted to practice dominated by those portfolios. The flexibility in the consultant role afforded the “glue” like role of crossing boundaries and acting as a “conduit” for communication within nursing and inter professionally. The flexibility and longer term big picture vision of the CNC role enabled clinically focused system work with a focus on remediation and rescue. Those CNCs with a consistent patient load discussed flexibility in scheduling both patients and clinics. The CNC role had both change agent and trouble shooter features across professional boundaries.

      4.1 Crossing boundaries

      “I’d describe the role as sort of being like a conduit, a conduit for each of the services within the district, to link everyone”. While inter professional communication is common it was described as being particularly focused on individual patient episodes. The conversations enabled by the conduit-like nature of the CNC role were broader in focus, and whilst remaining clinically focused, were related to systems of care. Having the flexibility to move through the system, “you have influence at various levels, so manage up, down, sideways and you can act quickly because you have the knowledge within the system”. This influence was built through dialog and the development of trust. The ‘head up’ nature of the role allowed not only questioning of efficiency and effectiveness of care and systems of care, but also brought together stakeholders across disciplines in a systematic exploration of issues lead by the CNC. The CNC was not only a conduit for interaction within the system but was also involved in the introduction and translation of information, including new policy and procedures to the system from state, national and international working groups. The conduit is kept patent through ongoing strategic and collaborative dialog. “It is about collaboration. Whether it's the nursing manger, or the CNSs or the RNs or medicine, allied health, it is about communicating and being collaborative”. Another way of describing the conduit function was, “it's more being a focus person or liaison”.

      4.2 System remediation

      “I keep coming back to the whole service thing, thinking about how the service has to change and modify and even if that's the way the service is delivered or the change in product or all those sorts of things”. Running “quality” programs was consistently referred to as part of system work. This ranged from regular audits to evaluations triggered by specific identified events. Most work had a quality and evaluative framework. While some participants discussed research as part of their regular routine, the majority discussed research as an added extra that was time consuming and detracted from “the patient focus”. Many participants spoke of not feeling adequately prepared to conduct independent research, but being confident in the conduct of audit and quality review. The system work had a heavy focus on patient safety, but also included elements of efficiency such as patient flow and resource utilization. “I guess it's all that resource management and trying to make sure the technology that we purchase is appropriate and not just toys for the boys”. The participants had a strong sense of saving lives and monies. There was some system work looked at as being less productive and this too was part of the role. “It almost feels like there's a lot of arse covering, like tick the box, it's like for accreditation, tick, tick, tick, tick, in essence what does that mean?”

      4.3 System rescue

      System rescue included notions of troubleshooting and ‘just-in-time’ service development. “When they get into hot water (Nursing Unit Managers and educators) and they are like, this is out of my depth, I’m not comfortable, I need you to come and do a debrief or talk about how we are going to manage this, I can reorganise my day and come up and do that”. This troubleshooting has clear links to particular patients or groups of patients. “Well yesterday a patient wasn’t able to be turned onto his belly. He wasn’t able to ventilate so they called me over to help with that, to troubleshoot what was going on and what was wrong. It's a matter of just getting him back onto his back and to oxygenate him. It can be that sort of thing”. At other times the flexibility to do environmental scans allows early identification of potential problems. This can be anywhere within an admission. “It's a good example, the discharge one; when they arrange home oxygen and say they’ll send the person home to wait for oxygen. You have to really argue with the doctors to keep a patient in hospital until the home oxygen is in the home because they’d be happy to actually send them home, wait until Monday morning”. Problems can be actual or potential, those yet to occur. “I also pick up problems and I actually lead it. Yeah, I pick up and flag it and then I’ll take it on board”. Those working in the community also identified their role in the recognition of problems and early intervention to avoid negative health outcomes. “Recognition of things prior to them happening to prevent admission I suppose”.
      The work in the role was prioritized on the basis of impact on patients. “It's about keeping a clinical focus on the patients and being an advocate for clinical care and getting good outcomes for all of our patients, or clients or people”. While not unanimous when discussing what best prepares someone for the CNC role, many participants identified personal attributes. Few participants identified formal educational preparation specifically for the role. The personal traits raised were passion, drive, leadership abilities, and confidence in speaking up and injecting ideas on how to improve care. Clinical experience was also highly valued. “I mean you seriously need a clinical expert doing these jobs”. This was combined with a need to be flexible and the ability to engage people to “get buy-in”. Those with strong research experience nominated research as useful preparation for the role, and others, particularly some participants with a masters degree, identified that skills in working with and developing systems have been, or would be, most useful.
      Consistent with the value placed on flexibility to allow optimal performance of the role, limitations to role performance were related to factors that impinged on flexibility. “So for example our Director of Nursing has never done any further study, doesn’t believe in any of it, won’t allow us to do things like research and things like that would make a difference. It's very hard to get things off the ground when it's not endorsed at that level”. The concept of “micro-management” was also identified as a severe limiter. Another common limitation was colleague's lack of understanding of the CNC role. “People haven’t seen all the stuff that goes up and all the heartache that goes up before that. No one asks our staff specialists if they’re not on the ward for a week, what they are doing. They don’t have to justify themselves”. The work was described as iceberg-like, and not immediately visible, particularly to clinical colleagues. Further to invisibility was that, “we don’t articulate, we don’t sell, we were never equipped with that kind of toolkit, and you don’t feel you want to put yourself out there all the time”.

      5. Discussion

      This study utilized hermeneutic phenomenology to identify important features of CNC practice and this provides a beginning articulation of the value-add of the advanced practice within the RN scope role.
      There were aspects of the Strong Model of Advanced Practice (
      • Ackerman M.H.
      • Norsen L.
      • Martin B.
      • Wiedrich J.
      • Kitzman H.J.
      Development of a model of advanced practice.
      ) that were apparent in the participant narratives and we collected clear examples of advanced practice in clinical care, support of systems, education, research and professional leadership. However, the organization of these domains into separate pillars misses the unique ‘value-add’ of the CNC that comes through the inter connectivity of the pillars in the clinically focused work – the ability to have a ‘head-up’ view of health systems resulting in a broad geographical impact and an ability to cross traditional multidisciplinary boundaries in health delivery. The interconnectivity of the pillars in consultancy was identified by
      • Humpthreys A.
      • Richardson J.
      • Stenhouse E.
      • Watkins M.
      Assessing the impact of nurse and allied health professional consultants: Developing an activity diary.
      . The current study extended these findings through the identified expression of the interconnectivity through the ‘head up’ view as expressed in systems work.
      This ‘head-up’ view is congruent with early conceptualizations of the role as a nurse who fulfills a cross-hospital, cross-area or regional role (
      • Dickenson M.
      An unsentimental union.
      ). The CNCs’ clinical experience, combined with active involvement in local, state, national or international committees and active immersion in a multidisciplinary team enabled by the flexibility to organize their work allowed effectiveness in systems remediation and systems rescue. It was this ‘systems work’ that was most strongly articulated as the factor that separated CNCs from other nursing roles.
      This was facilitated by the depth of their clinical experience, the flexibility of their work schedules and the advanced level of clinical judgment that led to identification of risk and advanced problem solving. With regard to being recognized as having, and applying, a depth of clinical experience this finding is in line with the findings of the
      • Jannings W.
      • Underwood E.
      • Almer M.
      • Luxford B.
      How useful is the expert practitioner role of the clinical nurse consultant to the generalist community nurse?.
      Australian study of community nurses (n = 125), in which it was reported that the most common reasons for accessing CNCs was for such expert clinical knowledge and problem solving.
      Systems work was founded on a focus of the patient experience and this priority of clinical care for CNCs is well recognized (
      • Baldwin R.
      • Duffield C.M.
      • Fry M.
      • Roche M.
      • Stasa H.
      • Solman A.
      The role and functions of Clinical Nurse Consultants, an Australian advanced practice role: A descriptive exploratory cohort study.
      ,
      • Chiarella M.
      • Hardford E.
      • Lau C.
      Report on the evaluation of Nurse/Midwife Practitioner and Clinical Nurse/Midwife Consultant Roles.
      ). Clinical care was a priority for our sample because of their belief in the primacy of patient well-being, their specialist skill set that filled previously unaddressed therapeutic opportunities and because patient-focused activities provided possibilities for mentorship and incidental teaching. The ‘head-up’ orientation meant that the CNC clinical care was expressed in broad and creative ways that promoted earlier discharge, could reduce complications and facilitated multidisciplinary care models, as opposed to a focus on a single or allocated group of patients. The vision was longer term, rather than discrete episodes of care. The importance of this kind of senior nurse support of systems in reducing adverse outcomes has been recognized in past research (
      • Duffield C.
      • Roche M.
      • O’Brien-Pallas L.
      • Diers D.
      • Aisbett C.
      • King M.
      Glueing it together: Nurses, their work environment and patient safety.
      ).
      System remediation occurred through quality activities and strategic thinking that could impact on patient flow, resource utilization and patient safety. Systems rescue was exhibited through a progressive and pre-emptive nursing perspective applied to complex clinical problems, and just-in-time service development. System rescue is consistent with the two case studies presented of CNCs by
      • Fairley D.
      • Closs S.
      Evaluation of a nurse consultant's clinical activities and the search for patient outcomes in critical care.
      in which troubleshooting and maintaining standards of care through identifying problems overlooked by other clinicians were described.
      Our findings contrast with those of
      • Bloomer M.
      • Cross W.
      An exploration of the role and scope of the clinical nurse consultant in a metropolitan health service.
      in their focus group study of 15 CNCs in which they identified that CNCs did not perceive that leadership was a strong focus of their work. The novelty of the current research is that it operationalizes abstract terminology such as leadership. It does so through a description of the application of leadership integrated in the lived experience of CNC work, and would perhaps make it easier for CNCs to recognize in practice, and may explain the difference in findings. The CNCs in the latter study perhaps more strongly perceiving the clinical focus, as discussed above, and not recognizing the leadership involved as an integrated part of working within this focus.
      Similarly research as a discrete activity was not common in our sample, but rather expressed through knowledge brokering. In line with the findings of
      • Gerrish K.
      • McDonnell A.
      • Nolan M.
      • Guillaume L.
      • Kirshbaum M.
      • Tod A.
      The role of advanced practice nurses in knowledge brokering as a means of promoting evidence-based practice among clinical nurses.
      research was expressed as a translational activity. The systems work encapsulated aspects of this domain.
      This new conceptualization of CNC roles has implications for postgraduate education to optimally prepare nurses for this multi-dimensional role. As we have identified the predominant value-add of the CNC as the ‘head-up’ factor, educational activities that promote critical thinking and risk identification could build on the existing skills born of clinical experience. Teaching leadership, educational theory and research as embedded components of integrated systems work could promote learning and avoid the inevitable abstraction of these concepts when considered as separate domains. Curricula structured on critical reflection on practice at the system level, would allow the meaningful integration of learning and promote translation to the practice world of CNCs.
      Whilst leadership qualities may be intrinsic to many people seeking CNC roles, these attributes need conscious refinement through education and reflective practice to be optimized. Skills in assertiveness and negotiation to influence practice are examples of valuable assets that can be developed in postgraduate curricula. For example, the corporate world has long recognized the value of executive coaching to facilitate reflective practice and health facilities have also utilized this approach for health managers (
      • Grant A.
      • Curtayne L.
      • Burton G.
      Executive coaching enhances goal attainment, resilience and workplace well-being: A randomized controlled study.
      ,
      • Karsten M.
      • Baggot D.
      Professional coaching as an effective strategy to retaining frontline managers.
      ,
      • Kowalski K.
      • Casper C.
      The Coaching Process. An effective tool for Professional Development.
      ,
      • McNally K.
      • Lukens R.
      Leadership development: An external–internal coaching partnership.
      ,
      • Yu N.
      • Collins C.G.
      • Cavanagh M.
      • White K.
      • Fairbrother G.
      Positive coaching with frontline managers. Enhancing their effectiveness and understanding why.
      ). With access to core components of executive coaching, when combined with formal education as part of a targeted master's program, CNCs could more easily facilitate important aspects of change management and stakeholder buy-in for what has been identified as a highly strategic role.

      6. Limitations of the study

      Whilst this study has taken a solid sample of CNCs from a number of health districts and across rural, regional and urban settings, the Clinical Nurse Consultant role is expressed differently across Australian states, and the job title does not exist in many international settings. This may limit the interpretation of the findings beyond CNC roles. However as a model of advanced nursing practice in the RN scope, the role undoubtedly resonates with other expressions and titles for similar roles to which the recommendations for educational preparation may equally apply.

      7. Conclusion

      This study has illuminated the potential benefit of extending and refining the ‘pillar’ framework of articulating CNC and APRN practice, in describing the ‘head-up’ nature of the CNC role. The broad geographical and multidisciplinary impact of CNCs described in our findings allows us to identify the important areas for postgraduate preparation in keeping with our new understandings. Further research is needed to ascertain the application of these findings across CNC roles generally and to conduct research on related patient outcomes and the economic impact of these outcomes, both of which are noticeably absent in the literature. Both the head-up nature of the CNC work and systems work would appear to generate outcomes that could be explicitly measured. This is of significance in terms of quality and safety, as well as economic impact at a time when scarcity is ubiquitous in health service budgets, and warrants investigation.

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