Recognising the differences in the nurse consultant role across context: a study protocol

BackgroundThe advanced practice role of the Nurse Consultant is unique in its capacity to provide clinical leadership across a range of contexts. However, the Nurse Consultant role has been plagued with confusion due to lack of clarity over function and appropriateness for purpose within health organisations across contexts. Changing health service delivery models are driving the emergence of new nursing roles, further clouding the waters related to role positioning and purpose. There is an urgent need for evidence of impact and demonstration of how Nurse Consultants contribute to health care outcomes. This study aims to gain a clearer understanding of the Nurse Consultant role and its impact in metropolitan and rural New South Wales (NSW) Australia.DesignThe proposed study employs a sequential mixed method design, underpinned by Realistic Evaluation, to explore how Nurse Consultants contribute to organisational outcomes. The ‘context – mechanism – outcome’ approach of realistic evaluation provides a sound framework to examine the complex, diverse and multifaceted nature of the Nurse Consultant’s role.MethodParticipants will be stakeholders, recruited across a large Local Health District in NSW, comprising rural and metropolitan services. A modified and previously validated survey will be used providing information related to role characteristics, patterns and differences across health context. Focus groups with Nurse Consultant’s explore issues highlighted in the survey data. Focus groups with other clinicians, policy makers and managers will help to achieve understanding of how the role is viewed and enacted across a range of groups and contexts.DiscussionLack of role clarity is highlighted extensively in international and Australian studies examining the role of the Nurse Consultant. Previous studies failed to adequately examine the role in the context of integrated and complex health services or to examine the role in detail. Such examination is critical in order to understand the significance of the role and to ascertain how Nurse Consultants can be most effective as members of the health care team. This is the first Australian study to include extensive stakeholder perspectives in order to understand the relational and integrated nature and impact of the role across metropolitan and rural context.

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title: Time to clarify--the value of advanced practice nursing roles in health care.
abstract: This article presents a discussion of the importance of providing meaningful advanced practice nursing role definition and clarity to improve international standards of nursing titles and scopes of practice.



A plethora of international literature exists discussing advanced practice nursing roles and their contribution to healthcare delivery in various countries. However, lack of consistency around title, role definition and scope of practice remains.



CINAHL and Medline databases were searched using 'nurse practitioner', 'nurse practitioner role', 'nurse practitioner practice', 'nurse practitioner in public health', 'advanced practice nursing roles' and 'development of new nursing roles' with articles limited to years 1995-2010. Citations used in those articles were also explored. All cited articles were in the English language.



This article supports the need to strengthen the Nurse Practitioner role in health care and professional clarity is identified as a strategy to enhance this. Themes around role clarity, professional identity, ability to enhance healthcare provision and inter-professional issues are examined. The need to more clearly articulate advanced nursing roles in light of the evolution of the Nurse Practitioner role is highlighted. Much work has already occurred in this domain and a means of adapting and broadening these developments for a wider, more global audience whilst maintaining local context is discussed.



Although evidence exists that advanced practice nursing roles are increasing internationally, uncertainty around role clarity remains. This is problematic because the valuable contribution of nursing roles is lost, if the ability to clearly express their function does not exist.

title: Advanced nursing practice: a global perspective.
abstract: To review the titles, roles and scope of practice of Advanced Practice Nurses internationally.



There is a worldwide shortage of nurses but there is also an increased demand for nurses with enhanced skills who can manage a more diverse, complex and acutely ill patient population than ever before. As a result, a variety of nurses in advanced practice positions has evolved around the world. The differences in nomenclature have led to confusion over the roles, scope of practice and professional boundaries of nurses in an international context.



CINAHL, Medline, and the Cochrane database of Systematic Reviews were searched from 1987 to 2008. Information was also obtained through government health and professional organisation websites. All information in the literature regarding current and past status, and nomenclature of advanced practice nursing was considered relevant.



There are many names for Advanced Practice Nurses, and although many of these roles are similar in their function, they can often have different titles.



Advanced Practice Nurses are critical for the future, provide cost-effective care and are highly regarded by patients/clients. They will be a constant and permanent feature of future health care provision. However, clarification regarding their classification and regulation is necessary in some countries.

title: Role development and effective practice in specialist and advanced practice roles in acute hospital settings: systematic review and meta-synthesis.
abstract: This paper reports a study whose aim was to identify and synthesize qualitative research studies reporting barriers or facilitators to role development and/or effective practice in specialist and advanced nursing roles in acute hospital settings.



The number of clinical nurse specialist, nurse practitioner, advanced nurse practitioner and consultant nurse roles has grown substantially in recent years. Research has shown that nurses working in innovative roles encounter a range of barriers and facilitators to effective practice.



Systematic literature searches were undertaken, and relevant studies identified using specific inclusion and exclusion criteria. The selected studies were appraised, and their findings synthesized using Ritchie and Spencer's 'Framework' approach.



Fourteen relevant studies were identified, mostly from the UK. They described a range of barriers and facilitators affecting specialist and advanced nursing practice. These related to the practitioner's personal characteristics and previous experience, professional and educational issues, managerial and organizational issues, relationships with other health care professionals, and resources. The factors most widely identified as important were relationships with other key personnel, and role definitions and expectations.



Relationships with other staff groups and role ambiguity are the most important factors which hinder or facilitate the implementation of specialist and advanced nursing roles. These factors seem interlinked, and the associated problems do not appear to resolve spontaneously when staff become familiar with the new roles. In order to reduce role ambiguity and the consequent likelihood of negative responses we recommend that, when specialist and advanced nursing roles are introduced, clear role definitions and objectives are developed and communicated to relevant staff groups; these definitions and objectives should be updated as necessary.

title: Making nursing work: breaking through the role confusion of advanced practice nursing.
abstract: This paper reports a study to develop a research-informed model of the service parameters and an analysis framework for advanced practice nursing roles.



Changing patterns of health care are forcing service planners to examine new service delivery models. Apparent is the call for nursing service that incorporates expanded levels of autonomy, skill and decision-making. A number of nursing roles conform to this description under the generic title of advanced practice nurse. However, there is confusion in the health service community internationally about nomenclature, role and scope for advanced practice nursing roles. An emerging priority in response to recent developments in the nurse practitioner role is to establish service parameters for advanced practice nursing and to differentiate operationally between advanced practice and practitioner nursing roles.



We conducted an interpretive, qualitative examination of the practice of a random sample of nine advanced practice nurses working in three acute care hospitals in south east Queensland, Australia in 2006. Data collection involved individual in-depth interviews, which were deductively analysed and tested against published advanced practice nursing models.



The data most comprehensively supported the Strong Model of Advanced Practice as representing the practice experiences of the research participants. This model supports definition of the service parameters and the design of an operational framework for implementation and evaluation of advanced practice nursing roles.



The findings differentiate advanced practice nurse and nurse practitioner roles, and offer an operational framework to identify, establish and evaluate advanced and extended nursing positions. Subject to further validation, this outcome can provide operational information for implementing innovative nursing roles appropriate to consumer needs and specific health service models.

title: A Delphi study to validate an advanced practice nursing tool.
abstract: This paper is a report of a study conducted to validate an instrument for measuring advanced practice nursing role delineation in an international contemporary health service context using the Delphi technique.



Although most countries now have clear definitions and competency standards for nurse practitioners, no such clarity exists for many advanced practice nurse roles, leaving healthcare providers uncertain whether their service needs can or should be met by an advanced practice nurse or a nurse practitioner. The validation of a tool depicting advanced practice nursing is essential for the appropriate deployment of advanced practice nurses. This paper is the second in a three-phase study to develop an operational framework for assigning advanced practice nursing roles.



An expert panel was established to review the activities in the Strong Model of Advanced Practice Role Delineation tool. Using the Delphi technique, data were collected via an on-line survey through a series of iterative rounds in 2008. Feedback and statistical summaries of responses were distributed to the panel until the 75% consensus cut-off was obtained.



After three rounds and modification of five activities, consensus was obtained for validation of the content of this tool.



The Strong Model of Advanced Practice Role Delineation tool is valid for depicting the dimensions of practice of the advanced practice role in an international contemporary health service context thereby having the potential to optimize the utilization of the advanced practice nursing workforce.

title: Deriving Consensus on the Characteristics of Advanced Practice Nursing: Meta-summary of More Than 2 Decades of Research
abstract: Over recent decades, there has been considerable research and debate about essential features of advanced nursing practice and differences among various categories of advanced practice nurses. This study aimed to derive an integrative description of the defining characteristics of advanced practice nursing through a meta-summary of the existing literature. A three-phase approach involved (a) systematic review of the literature to identify the specific activities characterized as advanced practice nursing, (b) qualitative meta-summary of practice characteristics extracted from manuscripts meeting inclusion criteria; and (c) statistical analysis of domains across advanced practice categories and country in which the study was completed. A descriptive framework was distilled using qualitative and quantitative results. Fifty manuscripts met inclusion criteria and were retained for analysis. Seven domains of advanced nursing practice were identified: (a) autonomous or nurse-led extended clinical practice; (b) improving systems of care; (c) developing the practice of others; (d) developing/delivering educational programs/activities; (e) nursing research/scholarship; (f) leadership external to the organization; and (g) administering programs, budgets, and personnel. Domains were similar across categories of advanced nursing practice; the domain of developing/delivering educational programs/activities was more common in Australia than in the United States or United Kingdom. Similarity at the domain level was sufficient to suggest that advanced practice role categories are less distinct than often argued. There is merit in adopting a more integrated and consistent interpretation of advanced practice nursing.

title: Advanced nursing roles: A systematic review
abstract: In this systematic literature review, we analyzed and synthesized the literature on one specialized advance practice nursing role in three countries for the purpose of describing and comparing these roles, as well as discussing whether an international consensus of the advance practice nursing definition is possible. A systematic search on CINAHL and PubMed Medline was conducted in 2011 to search the literature on the nurse consultant in the UK, the clinical nurse specialist in the USA, and the clinical nurse consultant in Australia. The studies (n = 42) were analyzed and combined using qualitative content analysis method. The roles of the nurse consultant, clinical nurse specialist, and clinical nurse consultant were similar. The variation in the roles appears to derive from organizational or individual choices, not the country in question. The study process comprised a synthesized representation of one specialized advance practice nursing role. More work is needed to further define the concept of the advance practice nursing, as well as its implementation on other cultures beyond this review. Based on this review, an international consensus regarding the definition of advance practice nursing and its subroles is possible.

title: Advanced practice nursing: a concept analysis.
abstract: A variety of terms are used to describe advanced practice nursing roles internationally. This has resulted in confusion in terminology around these roles. The aim of this concept analysis was to clarify what is meant by advanced practice nursing internationally, what attributes signify advanced practice nursing and what are its antecedents, consequences, references and related terms. Rodgers's evolutionary method of concept analysis was used. Data sources included Medline, CINAHL, Applied Social Sciences Index and Abstracts (ASSIA), Cochrane Library, Science Direct, SCOPUS, Web of Science, Dissertation Abstracts and DARE as well as relevant nursing texts and professional organization websites. The analysis reveals that there are many different articulations of the advanced practice nursing role outlined in the literature. This variety in terminology hinders developments in advanced practice nursing roles. Consensus on advanced practice nursing definitions, terminology, educational requirements and regulatory approaches is integral to the implementation of the advanced practice nursing role internationally.

title: A critical engagement with the concept of advancing nursing practice.
abstract: This paper aims to elucidate the concept of advancing nursing practice by engaging critically with developments in policy in the UK and ongoing debates in the international literature.



Advancing practice to the outer edges of nursing's scope of practice is a challenge for the profession both in the UK and elsewhere. However, defining what advancing nursing practice is and what it might become remains problematic.



Critical analysis of published papers and policy documents pertaining to the concept of advancing nursing practice.



Advancing nursing practice as a concept offers enormous potential for nurses and has been the subject of numerous debates over the last 25 years. Previous history of advanced practice offers no imperative practice and informs us little about the future roles of advanced nurse practitioners.



Current understanding about the role of advanced nurse practitioner and the nature of advanced practice remains unclear. Measuring the impact and outcome of the complex advanced practice nursing roles remains a challenge.



While it is difficult to articulate succinctly what constitutes advancing nursing practice, defining the activities nurses engage in, the skills and competencies involved and the qualities and attributes required help reduce the ambiguities of the role.

title: A conceptual framework for advanced practice: an action research project operationalizing an advanced practitioner/consultant nurse role.
abstract: A preliminary conceptual framework for an advanced practice/consultant nurse role is presented which links the role to its context and outcomes. The conceptual framework was developed in the process of analysing data from a 3-year action research study involving the operationalization of an advanced practice/consultant nurse role in a Nursing Development Unit. The skills and knowledge base of consultancy, underpinned by a strong nursing foundation, augmented by strong leadership and combined with the educator and researcher functions, are presented as the attributes of the advanced practitioner/consultant nurse. The facilitation of a transformational culture is highlighted as central to the skills and processes used within the role. Implications for the preparation and accreditation of the advanced practitioner/consultant nurse are highlighted.

title: Nursing staffing, nursing workload, the work environment and patient outcomes.
abstract: Nurse staffing (fewer RNs), increased workload, and unstable nursing unit environments were linked to negative patient outcomes including falls and medication errors on medical/surgical units in a mixed method study combining longitudinal data (5 years) and primary data collection.

title: The role and functions of Clinical Nurse Consultants, an Australian advanced practice role: a descriptive exploratory cohort study.
abstract: The NSW Health Policy Directive (NSW Department of Health, 2000) lists clinical service and consultancy; clinical leadership; research; education; clinical services planning and management as the five domains of practice for nurses appointed as Clinical Nurse Consultants (CNCs), an Australian advanced practice nurse (APN) role. However, there is no clear definition of what is meant by advanced practice in the Australian nursing context. Nowhere is this more evident than in differentiating between the roles of Clinical Nurse Consultants (CNCs) and Nurse Practitioners (NP) in NSW. To date, limited empirical research has been done to characterise or delineate CNC role activity and responsibility.



To investigate (i) the nature of CNC roles, activities and responsibilities, (ii) differentiate between CNCs by their work patterns and activities, and (iii) empirically conceptualize and differentiate ways CNCs practice in terms of an APN typology.



The study sample was 56 CNCs at one tertiary level public hospital in Australia.



A descriptive exploratory cohort study was conducted to explore CNC role characteristics and patterns of activity. Data were triangulated using an online survey, a follow-up survey, and semi-structured interviews. The data were analysed using descriptive statistics to examine differences between CNC work patterns and role activities. The survey data and the individual reports were thematically analysed to investigate for difference across the population of CNCs.



Interpretation of survey and interview data led to an analyst-developed CNC typology of four CNC categories based on the work patterns and activities of Sole Practitioner, Clinic Coordinator, Clinical Team Coordinator and Clinical Leader. The typology was based on the themes interprofessional, role focus, clinical focus and setting as these themes distinguished and differentiated CNC roles.



The study provides evidence of great diversity and prioritization within CNC roles. The CNC typology identified in this study is similar to the categorisation of the roles of APNs reported by other researchers. With further testing, the CNC typology could be useful to service managers and policy makers in making decision on the category of CNC required for a position and may also be able to be applied to other APN roles.

title: Sustaining innovation in the health care workforce: A case study of community nurse consultant posts in England
abstract: BackgroundRecruiting, retaining and meeting increasing demand for experienced, qualified nurses is an issue of concern for all health care systems. The UK has been creating clinical career structures for nurses that include innovative posts known as nurse consultants. While the numbers overall appear to have grown over the last eleven years, there is evidence that in some specialities and regions the numbers are decreasing. This paper considers the factors that sustain or curtail workforce innovations through the case example of a cohort of nurse consultants established in one community health service in England.MethodsA mixed method case study evaluation was undertaken over three years, using interviews, observations, documentary analysis and questionnaires. The final element of data collection was obtained three years later. Data was anonymised, analysed using a framework method and then integrated using a narrative synthesis.ResultsTen nurse consultant posts were created over a period of two years (2002-2004). Within two years only five posts remained and within five years (2009) only two part time posts, with the original appointees, remained. When the nurse consultants left their posts, these were not replaced. In exploring the interaction between the innovation (the nurse consultant posts), the adoptees (the senior staff in the organisation) and the context (the immediate service colleagues, the service organisation and commissioners as well as the broader NHS policy context) three key factors were identified as influential in the demise of the posts. These were: a) the extent to which there was support for individual nurses rather than the post, b) the extent to which there was an unambiguous and uncontested clinical service requirement for a nurse consultant and c) the extent to which finances for the post were judged as being used to best effect in a service setting.ConclusionsThis case study example demonstrates how tantalisingly close the nurse consultant initiative came to achieving a clinical career pathway for nurses in community services but more work was required to normalise clinician and managers' beliefs in the relevance and need for the role. Those looking to embed these types of nursing workforce innovations should pay due regard to these issues.

title: Development of a tool to describe the role of the clinical nurse consultant in Australia.
abstract: To develop a tool for defining and measuring the role characteristics and responsibilities of an advanced practice nursing role in Australia.



Internationally, there is considerable confusion about the precise role responsibilities of advanced practice nursing positions. In Australia, the clinical nurse consultant is an advanced practice role with five nominated domains of practice. However, there are no tools for measuring the performance of clinical nurse consultants against the listed domains.



Participants were 56 clinical nurse consultants at a tertiary public hospital. The existing literature, an online survey, and position descriptions were used to generate the a priori themes for the initial template. Semi-structured interviews were conducted (in 2010) to test the template characteristics. The template underwent multiple iterations in its development.



A 50-item tool was devised, which consisted of five domains with a ten-point hierarchical scale within each domain. In preliminary testing, the revised template was found to provide greater clarity regarding roles and grades than the original position descriptions.



Further testing and refinement of the modified rating scale is needed, but it offers the possibility of a new tool that can be used by health service managers to determine the grade of a clinical nurse consultant position and for evaluating role performance.


 TO CLINICAL PRACTICE
This preliminary study suggests that the tool provides a useful means of measuring advanced nursing practice and responsibilities across different domains and levels of appointment. The tool may be able to be adapted for use with other advanced practice nursing roles both within Australia and internationally.

title: Evaluation of a nurse consultant's clinical activities and the search for patient outcomes in critical care.
abstract: To describe the actual clinical activities undertaken by a critical care nurse consultant in an eight-bedded adult surgical high dependency unit within a large NHS Teaching Hospitals NHS Trust.



In the United Kingdom, the first critical care nurse consultants were approved in 2000 following the Department of Health's (1999) revised career structure for nurses. Expert practice is a core function of the role although the nature of expert practice in the context of critical care is unclear. Expert practice is often deemed to be a feature of advanced practice and although a number of studies have investigated this in context of critical care, there is little insight into the nature of advanced practitioners' clinical practice and how it might influence patient outcome.



A diary was used by a critical care nurse consultant to record activity during scheduled clinical sessions. Data were collected for four months: 39 sessions were evaluated. Qualitative data were content analysed and coded into categories. Clinical activities were coded, categorized and analysed using SPSS 11.0 for windows (SPSS Inc., Chicago, IL, USA).



Clinical activities included direct care activities, clinical leadership, education and training. Two main themes emerged from the qualitative data and were categorized as clinical reasoning and clinical instruction. Clinical activities arising from clinical reasoning and clinical instruction were aimed at minimizing risk and the provision of quality care. In doing this, one of the outcomes was the detection and resolution of untoward clinical occurrences.



The level of achievement--or end point--of clinical activities was that the patient was established in 'a state free from risk or harm that optimises rehabilitation'. 'A state free from risk or harm that optimizes rehabilitation' might be one outcome reflecting the needs of individual critically ill patients that is sensitive to individual nursing contribution.


 TO CLINICAL PRACTICE
There is increasing pressure on health-care professionals to identify and measure their individual impact on the outcome of patients. This study adds further insight into the complexities associated with evaluating the influence of individual contribution on patient outcome, especially when it is characterized by complex processes involving clinical judgement and decision-making.

title: The development of a framework for evaluating the impact of nurse consultant roles in the UK.
abstract: To develop a framework to evaluate the impact of nurse consultants on patient, professional and organizational outcomes and identify associated indicators of impact.



Since nurse consultants were introduced into the UK in 2000, there has been growing interest in demonstrating their impact, although robust evidence of impact is lacking. Existing frameworks for evaluating the impact of advanced practice roles do not cover the four dimensions of the nurse consultant role sufficiently.



Multiple case study.



Individual case studies of six nurse consultants in England were undertaken between December 2009-October 2010. Each case study involved interviews with the nurse consultant, healthcare staff, managers, patients and carers. Interviews explored participants' perceptions of the impact of the nurse consultant and indicators of actual and/or potential impact. Data were analysed using framework approach.



Three domains of impact of nurse consultant roles were identified: clinical significance, professional significance and organizational significance. Each domain included three to four indicators of impact. All nurse consultants showed some evidence of impact in all three domains although the primary focus varied across the different nurse consultants. Due to the wide diversity in nurse consultant roles there was little commonality in the specific indicators of impact across all nurse consultants.



The framework for capturing the impact of nurse consultants could be used by researchers and by nurse consultants to demonstrate their impact. Further research is required to assess the suitability of the framework for capturing the impact of other advanced practice roles.

title: Being an effective nurse consultant in the English National Health Service: what does it take? A study of consultants specializing in safeguarding.
abstract: This study established key attributes and perceived strengths, weaknesses, opportunities and threats (SWOT) of nurse consultants specializing in safeguarding children.



The nurse consultant role in England spans four domains--clinical, leadership, education and research--and was intended to enable senior nurses to remain in clinical practice.



ata identifying the time spent by the nurse consultants in the four domains was collated and a thematic content analysis of the SWOT of the role was ascertained from semi-structured interviews with nurse consultants (n = 4) and stakeholders (n = 6).



Strengths and opportunities in clinical (consultancy), leadership and educational functions were identified but some weaknesses and threats in terms of nurse consultant's contributions to research were also identified. The role was neither wholly strategic nor clinical. Role ambiguity meant that they were not always valued by managers, making the role potentially expendable.



Nurse consultants are pivotal within health-care organizations because they span clinical practice and leadership enabling them to support managers in strategic planning, commissioning and implementation of policy.



Nurse consultants can support strategic practice development and influence quality and effectiveness service-wide. To succeed they must be understood, supported and nurtured by managers.

title: Evaluating the perceived role of the nurse consultant through the lived experience of healthcare professionals.
abstract: This study aimed to evaluate the perceived impact of the nurse consultant through the lived experience of the staff.



Ambiguities exist about the nature, function and value of the nurse consultant role to the individual, nursing and the UK National Health Service.



A descriptive qualitative research design was developed to evaluate the perceived impact of the nurse consultant through the lived experience of staff by the use of a 360-degree semi-structured interview framework. Interviews were undertaken with executive, senior managers, medical, nursing and allied healthcare professional colleagues. The study was based on three nurse consultants working at a University Hospital in the North East of England. A collaborative purposive sampling technique was used involving 10 participants to provide detailed, objective and relevant information associated with the nurse consultant role.



Thirty semi-structured interviews were undertaken. A thematic analysis using Bowling's approach to deciphering interview data revealed nine primary categories. With the exception of the personal qualities, the nurse consultant brings to the role. A series of generalist themes emerged associated with how the role can be enhanced in the future by involving, informing and engaging staff and by developing a phased approach to implementing and evaluating the role.



The findings indicate that the continued success of the nurse consultant role is associated with developing a more structured approach to implementation and evaluation within the employing organizations.


 TO CLINICAL PRACTICE
Awareness of the nurse consultant should be raised through communication, clarification of expectations by engaging and supporting the staff in the acceptance of the role. Organizationally there should be a more phased approach to establishing, implementing and evaluating the nurse consultant.

title: Nurse consultants: their characteristics and achievements.
abstract: This paper reports one aspect of a larger study of nursing research strategies in one English region, focusing particularly on nurse consultants' characteristics and achievements in the role.



Nurse consultant posts have only been established in the United Kingdom since 1999 and, although much comment has appeared in the professional literature, there is very little research-based evidence of how the roles are developing. The role is intended to integrate four domains: expert practice; professional leadership and consultancy; education, training and development; and practice and service development.



A cross-sectional design, using a convenience sample, was adopted.



Ten nurse consultants working in a variety of settings and specialties participated in in-depth, tape-recorded interviews. The data were analysed using the Framework approach.



Four themes were identified from the data: characteristics of the postholder, role achievement, support systems and National Health Service influences. The first two themes are discussed in this paper and the data show that the nurse consultants varied in terms of their academic background and previous experience. Not all had the recommended minimum of Master's degree level preparation and some had limited research experience. These background characteristics seemed to influence the degree to which they were able to achieve the four domains of the role, with those with lower qualifications and from a mental health background appearing to struggle most.



New appointments to these roles should only be made when candidates possess the recommended levels of educational preparation and professional experience of change management. It is also important that there is clarity about the scope of the role, which should not include management responsibilities. On-going research is essential to evaluate how the roles develop for postholders, the extent to which they fulfil policymakers' expectations and what difference they make to patient care from a patient perspective.


 TO CLINICAL PRACTICE
The findings show that holders of such posts need to have appropriate previous knowledge, skills and personal characteristics, as these seem to influence their ability to integrate the four domains of the role and thus achieve the requirements of the post.

title: Evaluation of the impact of nurse consultant roles in the United Kingdom: a mixed method systematic literature review.
abstract: This paper reports a mixed methods systematic review examining the impact of nurse consultant roles in adult healthcare settings, with a view to identifying indicators for demonstrating their impact on patient and professional outcomes.



Nurse consultants were introduced in England in 2000 with the intention to achieve better outcomes for patients by improving quality and services. Previous studies have investigated the impact of nurse consultants, but attempts to amalgamate this evidence have been methodologically limited. Since these reviews were published, the importance of demonstrating the contribution of nurse consultants has prompted new research. A robust review of the evidence is now required.



A broad search strategy was adapted for eight databases. Grey literature was sought from various sources.



Quantitative and qualitative studies were included. Study quality was assessed using appropriate instruments. Cross-study synthesis combined the quantitative and qualitative findings in relation to the dimensions of impact identified. Measures of impact were mapped against a framework for assessing clinical and professional outcomes.



Thirty-six studies were included. The findings suggest a largely positive influence of nurse consultants on a range of clinical and professional outcomes, which map onto the proposed framework of impact. However, there was very little robust evidence and the methodological quality of studies was often weak.



Further robust research is required to explore nurse consultants' impact on patient and professional outcomes. The proposed framework for assessing impact could be used to guide future research and assist nurse consultants assess their impact.

title: Impact of the role of nurse, midwife and health visitor consultant.
abstract: This paper describes the findings from one aspect of an evaluation study of the role of the nurse, midwife and health visitor consultant and the consultants' perceived impact of their role on services and patient care.



The nurse, midwife and health visitor consultant role was established in 2000 in England to improve patient care, strengthen leadership and provide a clinical career opportunity for nurses, midwives and health visitors. An evaluative study was commissioned to report on the role 4 years after the new consultant posts were first established.



A multimethod evaluation was undertaken in 2002-2003 combining focus groups, telephone interviews and a comprehensive questionnaire survey of all the consultants in England. Four hundred and nineteen consultants responded to the questionnaire, 22 volunteered for the focus groups and 32 participated in the interviews.



Nearly half (44%) the consultants who responded to the survey reported having a substantial impact on their service and 55% reported having some positive impact. High reported impact increased to 71% for those who had been in post for 2 years or longer. Consultants felt that they had been most successful in providing better support to staff, but only 10% said that they had a major impact on reducing unnecessary expenditure within the service. Factors associated with high levels of reported impact included engagement in a wide range of activities, perceived competence in the role and strong medical support. Those reporting most impact also reported the greatest dissatisfaction with salary.



As consultants become more established in their posts, they are able to identify improvements in practice, service reconfiguration and educational advantages for staff. Our findings suggest that the true influence of these posts will become clearer over time as the impact of consultants on long-term organizational change becomes more apparent.

title: Advanced practice nurse outcomes 1990-2008: a systematic review.
abstract: Advanced practice registered nurses have assumed an increasing role as providers in the health care system, particularly for underserved populations. The aim of this systematic review was to answer the following question: Compared to other providers (physicians or teams without APRNs) are APRN patient outcomes of care similar? This systematic review of published literature between 1990 and 2008 on care provided by APRNs indicates patient outcomes of care provided by nurse practitioners and certified nurse midwives in collaboration with physicians are similar to and in some ways better than care provided by physicians alone for the populations and in the settings included. Use of clinical nurse specialists in acute care settings can reduce length of stay and cost of care for hospitalized patients. These results extend what is known about APRN outcomes from previous reviews by assessing all types of APRNs over a span of 18 years, using a systematic process with intentionally broad inclusion of outcomes, patient populations, and settings. The results indicate APRNs provide effective and high-quality patient care, have an important role in improving the quality of patient care in the United States, and could help to address concerns about whether care provided by APRNs can safely augment the physician supply to support reform efforts aimed at expanding access to care.

title: An exploration of the role and scope of the clinical nurse consultant (CNC) in a metropolitan health service.
abstract: Clinical nurse consultants have been a part of the nursing workforce for some time however a lack of clarity regarding this role has led to significant variations in health service expectations, workloads and scope for the Clinical nurse consultants working within this metropolitan health service.



The aim of this study was to explore the role of the CNC as it is perceived by them, in the context of this health service.



A qualitative approach was used for this study. Following ethics approval a single audio-taped focus group was undertaken to gather data. Guiding questions were used to elicit responses from the group, moderated by the co-investigators. The focus group was transcribed verbatim. Each researcher independently analysed the narrative data, using coding and clustering the data to develop primary and sub-themes.



Whilst each participant experiences their role individually, there were four themes derived from comments expressed by the participants: 'Diversity and conflict', 'Leaders but powerless', 'Support systems' and 'The portfolio holder role'.



The role of the Clinical nurse consultant is complex and diverse. The variability in the role suggests that organisational consensus of the role, scope and purpose of the CNC position has not been actualised, resulting in a lack of support systems, and an underutilisation of the Clinical nurse consultants as leaders, where they can challenge existing practice and guide future directions in care delivery.

title: Rural and remote public health in Australia: building on our strengths.
abstract: The governments of Australia have agreed that ‘People in rural, regional and remote Australia will be as healthy as other Australians . . .’ To eliminate current health inequalities between metropolitan and rural Australia, we need to enhance disease prevention and health promotion efforts based on a better understanding of the nature of rural–urban inequalities. We also need to recognise that a deficit view of the bush is neither helpful nor justified. Future effort should acknowledge rural and remote area advantages and build on the strength of rural and remote public health infrastructure, ingenuity and practice.

title: The lure of the bush: do rural placements influence student nurses to seek employment in rural settings?
abstract: The aim of this study was to investigate whether rural clinical placements for student nurses at a rural university in New South Wales influence their decision to join the rural and remote Registered Nurse workforce. The study utilised a convenience sample of final year Bachelor of Nursing students at a rural university campus, and consisted of two stages of data collection. Stage One employed a pre- and post-clinical placement survey design that elicited both demographic and qualitative data. Stage Two consisted of individual interviews with a sample of final year nursing students while they were on a rural clinical placement. The findings highlight the factors that influence final year students' decisions to seek employment in rural healthcare facilities. These findings will be of interest to nurse academics concerned with ensuring that undergraduate nursing curricula relate to rural nursing practice in Australia and to those involved in recruitment of new graduate RN's to rural nursing practice.

title: Disentangling the Effects of CEO Turnover and Succession on Organizational Capabilities: A Social Network Perspective
abstract: Prior reviews of the CEO turnover and succession literature suggest that empirical findings on organizational implications continue to be equivocal. In this paper, we develop a conceptual framework for examining the impact of CEO turnover and succession on organizational capabilities. Using the social network perspective as a theoretical lens, we identify conditions in which CEO turnover is expected to influence organizational exploration and exploitation capabilities. We also identify contingencies under which CEO succession will moderate the impact of CEO turnover on organizational capabilities. Our framework provides a useful lens through which to view the consequences of CEO turnover and succession and sheds some light on the equivocal findings to date.

title: Bridging the Qualitative-Quantitative Divide: Guidelines for Conducting Mixed Methods Research in Information Systems
abstract: Mixed methods research is an approach that combines quantitative and qualitative research methods in the same research inquiry. Such work can help develop rich insights into various phenomena of interest that cannot be fully understood using only a quantitative or a qualitative method. Notwithstanding the benefits and repeated calls for such work, there is a dearth of mixed methods research in information systems. Building on the literature on recent methodological advances in mixed methods research, we develop a set of guidelines for conducting mixed methods research in IS. We particularly elaborate on three important aspects of conducting mixed methods research: (1) appropriateness of a mixed methods approach; (2) development of meta-inferences (i.e., substantive theory) from mixed methods research; and (3) assessment of the quality of meta-inferences (i.e., validation of mixed methods research). The applicability of these guidelines is illustrated using two published IS papers that used mixed methods.

title: A realistic evaluation: the case of protocol-based care
abstract: Background'Protocol based care' was envisioned by policy makers as a mechanism for delivering on the service improvement agenda in England. Realistic evaluation is an increasingly popular approach, but few published examples exist, particularly in implementation research. To fill this gap, within this paper we describe the application of a realistic evaluation approach to the study of protocol-based care, whilst sharing findings of relevance about standardising care through the use of protocols, guidelines, and pathways.MethodsSituated between positivism and relativism, realistic evaluation is concerned with the identification of underlying causal mechanisms, how they work, and under what conditions. Fundamentally it focuses attention on finding out what works, for whom, how, and in what circumstances.ResultsIn this research, we were interested in understanding the relationships between the type and nature of particular approaches to protocol-based care (mechanisms), within different clinical settings (context), and what impacts this resulted in (outcomes). An evidence review using the principles of realist synthesis resulted in a number of propositions, i.e., context, mechanism, and outcome threads (CMOs). These propositions were then 'tested' through multiple case studies, using multiple methods including non-participant observation, interviews, and document analysis through an iterative analysis process. The initial propositions (conjectured CMOs) only partially corresponded to the findings that emerged during analysis. From the iterative analysis process of scrutinising mechanisms, context, and outcomes we were able to draw out some theoretically generalisable features about what works, for whom, how, and what circumstances in relation to the use of standardised care approaches (refined CMOs).ConclusionsAs one of the first studies to apply realistic evaluation in implementation research, it was a good fit, particularly given the growing emphasis on understanding how context influences evidence-based practice. The strengths and limitations of the approach are considered, including how to operationalise it and some of the challenges. This approach provided a useful interpretive framework with which to make sense of the multiple factors that were simultaneously at play and being observed through various data sources, and for developing explanatory theory about using standardised care approaches in practice.

title: Advanced practice nursing roles: development, implementation and evaluation.
abstract: The aim of this paper is to discuss six issues influencing the introduction of advanced practice nursing (APN) roles: confusion about APN terminology, failure to define clearly the roles and goals, role emphasis on physician replacement/support, underutilization of all APN role domains, failure to address environmental factors that undermine the roles, and limited use of evidence-based approaches to guide their development, implementation and evaluation.



Health care restructuring in many countries has led to substantial increases in the different types and number of APN roles. The extent to which these roles truly reflect advanced nursing practice is often unclear. The misuse of APN terminology, inconsistent titling and educational preparation, and misguided interpretations regarding the purpose of these roles pose barriers to realizing their full potential and impact on health. Role conflict, role overload, and variable stakeholder acceptance are frequently reported problems associated with the introduction of APN roles.



Challenges associated with the introduction of APN roles suggests that greater attention to and consistent use of the terms of the terms advanced nursing practice, advancement and advanced practice nursing is required. Advanced nursing practice refers to the work or what nurses do in the role and is important for defining the specific nature and goals for introducing new APN roles. The concept of advancement further defines the multi-dimensional scope and mandate of advanced nursing practice and distinguishes differences from other types of nursing roles. Advanced practice nursing refers to the whole field, involving a variety of such roles and the environments in which they exist. Many barriers to realizing the full potential of these roles could be avoided through better planning and efforts to address environmental factors, structures, and resources that are necessary for advanced nursing practice to take place.



Recommendations for the future introduction of APN roles can be drawn from this paper. These include the need for a collaborative, systematic and evidence-based process designed to provide data to support the need and goals for a clearly defined APN role, support a nursing orientation to advanced practice, promote full utilization of all the role domains, create environments that support role development, and provide ongoing evaluation of these roles related to predetermined goals.

title: A framework for the introduction and evaluation of advanced practice nursing roles.
abstract: This paper describes a participatory, evidence-based, patient-focused process for advanced practice nursing (APN) role development, implementation, and evaluation (PEPPA framework).



Despite the growing demand for advanced practice nurses, there are limited data to guide the successful implementation and optimal utilization of these roles. The participatory, evidence-based, patient-focused process, for guiding the development, implementation, and evaluation of advanced practice nursing (PEPPA) framework is an adaptation of two existing frameworks and is designed to overcome role implementation barriers through knowledge and understanding of APN roles and environments. The principles of participatory action research directed the construction of the new framework.



The process for implementing and evaluating APN roles is as complex and dynamic as the roles themselves. The PEPPA framework is shaped by the underlying principles and values consistent with APN, namely, a focus on addressing patient health needs through the delivery of coordinated care and collaborative relationships among health care providers and systems. Engaging environmental stakeholders as participants in the process provides opportunity to identify the need and shared goals for a clearly defined APN role. The process promotes increased understanding of APN roles and optimal use of the broad range of APN knowledge, skills, and expertise in all role domains and scope of practice. The steps for planning and implementation are designed to create environments to support APN role development and long-term integration within health care systems. The goal-directed and outcome-based process also provides the basis for prospective ongoing evaluation and improvement of both the role and delivery of health care services.

title: Nurse consultants: organizational influences on role achievement.
abstract: This paper reports on organizational influences on nurse consultant post holders. The influence of individual characteristics has been the subject of another paper.



Nurse consultant posts were set up in the United Kingdom from the late 1990s onwards and, therefore, there has been little opportunity to report on evaluations of these innovative initiatives.



A cross-sectional design, using a convenience sample, was adopted.



Ten nurse consultants working in a variety of settings and specialties participated in in-depth, tape-recorded interviews. The data were analysed using the Framework approach.



Support systems were important influences on nurse consultants' role achievement levels. These took the form of internal trust networks, nurse consultant forums and links with higher education institutions. Post holders both gave and received support and acted to empower other nurses. Thus, relationships were vital to successful role integration. The culture and structures of the National Health System were also a powerful influence in terms of local and national modernization policies, and participants had to be careful in their choice of strategies to deal with the traditional medically dominated culture.



The new nurse consultant role is challenging and innovative, but a major area of contention is how much post holders are expected to take on work previously done by doctors rather than developing their nursing role. Organizational support and commitment are needed if nurse consultants are to maximize the benefits of this innovation.


 TO CLINICAL PRACTICE
The findings show that new nursing roles are not always easily accepted in multidisciplinary settings and that holders of such post need to have the appropriate previous knowledge, skills and personal characteristics, as well as the ability to negotiate their way through organizational influences.

title: Collaboration and local networks for rural and remote primary mental healthcare in South Australia.
abstract: This paper draws on a consultation with 200 stakeholders about a mental health plan in the most remote region of South Australia to discuss primary mental healthcare improvement strategies. In rural and remote environments, a lack of services means that it is more difficult to deal with a mental illness or provide assistance for circumstantial life problems. The authors' consultations revealed difficulties with service access, acceptability and teamwork. They also found that the availability of local human service workers leads to their use as first-level mental health contacts, but these workers are neither skilled nor supported for this. These difficulties will require attention to the boundaries between different service providers which can otherwise create inflexibility and service gaps. The regional mental health plan that is being rolled out will develop collaboration through regional interagency task groups, networking groups for local human service workers and the position of a regional mental health coordinator in order to overcome these difficulties and to operationalise service partnerships.

title: The Use of Partial Least Squares Structural Equation Modeling in Strategic Management Research: A Review of Past Practices and Recommendations for Future Applications
abstract: Every discipline needs to frequently review the use of multivariate analysis methods to ensure rigorous research and publications. Even though partial least squares structural equation modeling (PLS-SEM) is frequently used for studies in strategic management, this kind of assessment has only been conducted by Hulland (1999) for four studies and a limited number of criteria. This article analyzes the use of PLS-SEM in thirty-seven studies that have been published in eight leading management journals for dozens of relevant criteria, including reasons for using PLS-SEM, data characteristics, model characteristics, model evaluation and reporting. Our results reveal several problematic aspects of PLS-SEM use in strategic management research, but also substantiate some improvement over time. We find that researchers still often do not fully make use of the method's capabilities, sometimes even misapplying it. Our review of PLS-SEM applications and recommendations on how to improve the use of the method are important to disseminate rigorous research and publication practices in the strategic management discipline.

title: Qualitative Research: Rigour and qualitative research
abstract: Various strategies are available within qualitative research to protect against bias and enhance the reliability of findings. This paper gives examples of the principal approaches and summarises them into a methodological checklist to help readers of reports of qualitative projects to assess the quality of the research.

In the health field--with its strong tradition of biomedical research using conventional, quantitative, and often experimental methods--qualitative research is often criticised for lacking scientific rigour. To label an approach “unscientific” is peculiarly damning in an era when scientific knowledge is generally regarded as the highest form of knowing. The most commonly heard criticisms are, firstly, that qualitative research is merely an assembly of anecdote and personal impressions, strongly subject to researcher bias; secondly, it is argued that qualiative research lacks reproducibility--the research is so personal to the researcher that there is no guarantee that a different researcher would not come to radically different conclusions; and, finally, qualitative research is criticised for lacking generalisability. It is said that qualitative methods tend to generate large amounts of detailed information about a small number of settings.

The pervasive assumption underlying all these criticisms is that quantitative and qualitative approaches are fundamentally different in their ability to ensure the validity and reliability of their findings. This distinction, however, is more one of degree than of type. The problem of the relation of a piece of research to some presumed underlying “truth” applies to the conduct of any form of social research. “One of the greatest methodological fallacies of the last half century in social research is the belief that science is a particular set of techniques; it is, rather, a state of mind, or attitude, and the organisational conditions which allow that attitude to be expressed.”1 In quantitative data analysis it is possible to generate statistical …