A deconstruction and reconstruction of advanced nurse specialisation and education

Th"e purpose of this study was to present 1hc issues and the paradoxes surrounding advanced nurse spccialisution (ANS) and education, This study was conducted in two parts. Part A examined the prospective experiences 1Jf 13 registered nurses (RNs) who were advancing in an area of specialisation: they were working in a specialist area or practice nnd studying in II course specific lo their specialisation. Two rounds of interviews were completed over six-month intervals. Part B examined the data gathered from a focus group interview and follow-up feedback from IO nurse executives as stakeholders. The intersubjectivc data from this group of nurses expanded on the political, economic, and social complexities surrounding the same phenomenon of interest. A methodological framework of intentional phenomenology(Crotty, 1996, 1998; Husserl, 1960, 1973; Moustakas, 1994) and critical phenomenology (Crotty, 1998) was used. Such an interpretive approach enabled exploration of the issues from a multiple perspective. The triangulation of data sets obtained from Part A and Part B captured the meanings and understanding of the phenomena experienced by nurses involved in ANS ' and educlltion. Overall, the deconstruction of the interviews in Part A and Part B enabled a reconstruction of the multiple realities of ANS and education. The "analyzing approach" (van Man en, 1990) was used for the purposes of dt.ta analysis. The data sets were stored, retrieved and analysed with the use of The Ethnograph computer software program. The findings in Part A identified the nature of ANS and education by RNs who were experiencing ANS. The core theme of'movlng toward ANS and education' showed the noematic textural quality of the phenomenon. This included the nature of the competing forces that the RNs faced. This rtquired the RNs to sci personal goals, to sustain a level oftolerance related to change in the work place, and to negotiate with stakeholders, options that were conducive to their practice and study. The RNs told of the rewards and limited rewards of being an advancing specialist, when they succeeded in becoming a credible practitioner and of being multiskilled and versatile as specialists. They maintained an ideology about advanced practice that was achieved by ensuring best practice, or by doing nursing research, or both. Five sub-themes emerged metaphorically as the way through the labyrinth, These themes provided the noetic slructural characteristics about the phenomenon. The first sub-theme described how the RNs had the rreedom to choose ANS and education. ,, This included the way that they reasoned about the choices they had. They took reflexive action, problem-solved, and, compared and rationalised organisational activities in the face of the nursing shortage to enable them lo advance. The second sub-theme related to their knowing through expericntlal learning and advancing. As consumers of education, the RNs were described in tcnns oft he cost associated with their advancement, which was offset by the education gained, and the enlightenment felt. They identified with the transportability of their prior knowledge as an advancing RN, the need for nurse crcdentia\ling, and responded favourably to the use of technology. However, they were disappointed by RNs, other than current advanced specialists, who failed to share knowledge with nursing colleagues in general. The third sub-theme outlined how the RNs wanted to maintain their interdependence of practice as advancing specialists. They were enterprising and wanted to connect with other specialists, particularly those within their professional nursing organisations. In so doing, it was important for them to maintain a sense of persona\ integrity. Therefore, they were mutually responsive to colleagues about nursing care issues. However, they expected to be acknowledged by colleagues as well as family members for their advancement as specialists in return. The fourth sub-theme described their need to be profiling, requiring them to be able to visualise and situate thcmsch·cs as advancing specialists. That is, they persevered with their studi1:s and practice and created opportunities for their likely advancement. Furthcnnore, they felt a n~d to develop a nursing profile that was self, as well as publicly oriented. The fonner was achk~ed by being self-praising of their current advancement; the latter, by focusing on the need for the community and colleagues to view nursing as a legitimate and worthwhile profession, rather than being undervalued in spite of the workload that nurses and the atlvancing sp.icialists had. The fifth sub-theme described how vulnerable the RNs felt but at the same time, liberated because of their progressive self-assurance and influen~e over others because of their advancing p~aclice. They enjoyed the challenges that they faced, were open about their ambitions, and able to move on once they had reached a plateau relevant to their practice. At this stage, they continued in advanced practice because they had discovered a pathway that best suited them. This was realised as meeting the crossroads. Part B findings emerged from the stakeholders as three intersubjcctivc but discrete themes. The first emerged 11s the d-thale about the stakeholder and employer concerns regarding the phenomenon orintcrcst. From their point of view, the advanced specialist wns ofcnonnous benefit to them and the profession. However, the stakeholders as employers, were concerned about the recruitment, retainment, and opportunity for promotion of RNs as advanced specialists, The second theme emerged as the solutions that describe the desired pathways for ANS. Tlic stakeholders desired a pathway that enabled them to facilitate advancing RNs during their practice and studies, and one that th(l profession would support. Nursing should take an integrate approach to ANS and education. It was optimal that joint specialist programs bctwP.cn all health care facilities and education providers including university schools of nursing, be pursued in order to maintain ANS that could provide advanced care lo an increasingly complex population that expected an acceptable standard of care. In order to meet the increasing demand for advanced specialist RNs, it was necessary to provide a specialist clinical program in the hospital setting in which the RN worked. The stakeholders indicated that RNs who wanted to advance further into master or doctoral programs should be able to gain advanced standing for their hospital based clinical program into a nursing school within the university setting. Finally, based on the stakeholders' reflections and shared experiences about the phenomenon of interest, a philosophy of nurse education that is able to uphold the increasing value of specialist practice for RNs was considered necessary. The dilemmas that each of the stakeholders had . themselves faced as . advancing specialists, rcsl•ltcd in a rewarding experience along with career advancement for nine of the 10 nurse executives who participated in the study. Overall, moving toward ANS and education is a continually dynamic process in which the bericfits to the majority of participants in this study were attainable. However, the recruitment and retainment of advancing specialists remains uncertain because life of RNs today is less stable than it was. There is no one pathway for advancing specialists to take that is based on a linear progression. Globalisation had created greater diversity in society, whereby the majority of the RNs and stakeholders embraced the diversity while a few did net because of the turmoil of contemporary competitive life. This could leave many RNs feeling disenfranchised by change and more specifically by the nexus :c between commodificd health care and education. '