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Thoracic surgery as a nursing specialty : perceptions of senior nurses and surgeons of specialist nursing… Wilson, Angela Marie 2015

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	  	  	  	  	   THORACIC	  SURGERY	  AS	  A	  NURSING	  SPECIALTY:	  	  PERCEPTIONS	  OF	  SENIOR	  NURSES	  AND	  SURGEONS	  OF	  SPECIALIST	  NURSING	  PRACTICE	  	  	  	  	  	  by	  	   	  	  	  ANGELA	  MARIE	  WILSON	  B.S.N.,	  Kwantlen	  Polytechnic	  University,	  2008	  	   	  	  	  A	  THESIS	  SUBMITTED	  IN	  PARTIAL	  FULFILLMENT	  OF	  THE	  REQUIREMENTS	  FOR	  THE	  DEGREE	  OF	  	  	  MASTER	  OF	  SCIENCE	  IN	  NURSING	  	  	  	  in	  	  	  	  THE	  FACULTY	  OF	  GRADUATE	  AND	  POSTDOCTORAL	  STUDIES	  THE	  UNIVERSITY	  OF	  BRITISH	  COLUMBIA	  	  (Vancouver)	  	  	  	  	  	   August	  2015	  ©	  Angela	  Marie	  Wilson	  	   ii	  ABSTRACT	  	  With	  the	  continual	  advances	  in	  medical	  technology	  and	  specialized	  procedures,	  surgical	  patients	  have	  increasingly	  complex	  and	  specific	  needs.	  The	  questions	  that	  surfaces	  are:	  1)	  Do	  surgical	  nurses	  now	  require	  advanced	  knowledge	  and	  skills	  to	  meet	  the	  needs	  of	  the	  thoracic	  surgery	  patient	  population?	  2)	  And	  if	  so,	  do	  nurses	  and	  surgeons	  perceive	  value	  in	  recognizing	  thoracic	  surgery	  as	  a	  specialty	  for	  nurses?	  	  	  In	  this	  study,	  the	  perceptions	  of	  senior	  thoracic	  nurses	  and	  surgeons	  regarding	  nursing	  specialization	  were	  examined.	  	  Nurses’	  and	  surgeons’	  perceptions	  of	  what	  characterize	  a	  nursing	  specialty,	  if	  and	  why	  they	  consider	  thoracic	  surgery	  a	  nursing	  specialty,	  and	  what	  they	  identify	  as	  the	  outcomes	  and	  value	  of	  nursing	  specialization	  and	  related	  outcomes	  were	  also	  explored.	  	  An	  inductive	  approach	  was	  used,	  with	  data	  collected	  through	  a	  quantitative	  web-­‐based	  questionnaire,	  using	  the	  18-­‐item	  Perceived	  Value	  of	  Certification	  Tool	  ©	  (PVCT)	  as	  well	  as	  specific	  additional	  Likert	  scale	  and	  multiple-­‐choice	  questions	  related	  to	  thoracic	  surgery.	  	  Study	  findings	  revealed	  that	  thoracic	  nurses	  and	  surgeons	  value	  nurse	  certification	  for	  similar	  intrinsic	  and	  extrinsic	  reasons	  as	  nurses	  in	  other	  specialties	  and	  in	  other	  countries,	  identifying	  several	  intrinsic	  rewards,	  such	  as	  “enhances	  feelings	  of	  personal	  accomplishment,”	  “provided	  a	  professional	  challenge,”	  and	  “validates	  specialized	  knowledge,”	  as	  motivators	  for	  certification.	  	  Findings	  from	  this	  study	  also	  suggest	  that	  nurses	  and	  surgeons	  perceive	  that	  additional	  nursing	  education	  related	  to	  knowledge	  and	  skills	  is	  required	  to	  meet	  the	  care	  needs	  of	  the	  	   iii	  thoracic	  surgery	  patient	  population,	  and	  improve	  the	  overall	  nursing	  care	  provided.	  Additionally,	  study	  results	  also	  suggested	  that	  nurses	  and	  surgeons	  believe	  that	  nursing	  specialty	  recognition	  may	  promote	  better	  patient	  outcomes.	  Finally,	  study	  findings	  demonstrated	  that	  thoracic	  nurses	  and	  surgeons	  believe	  that	  thoracic	  surgery	  should	  be	  formally	  recognized	  as	  a	  certified	  nursing	  specialty.	  	   	  	   iv	  PREFACE	  	  This	  research	  is	  based	  on	  the	  work	  conducted	  in	  the	  University	  of	  British	  Columbia’s	  School	  of	  Nursing	  by	  myself,	  Angela	  Marie	  Wilson.	  I	  was	  responsible	  for	  conducting,	  collecting,	  and	  analyzing	  the	  research	  data	  under	  the	  supervision	  of	  my	  thesis	  committee.	  The	  names	  of	  committee	  members	  as	  follows:	  Dr.	  Bernie	  Garrett,	  Dr.	  Victoria	  Bungay,	  &	  Sarah	  Derman.	  The	  following	  Health	  Authority	  collaborators	  distributed	  the	  survey	  invitations,	  consent	  information,	  and	  the	  online	  survey	  link	  to	  participants:	  Priscilla	  Messier	  (Vancouver	  Coastal	  Health),	  Melanie	  Skidmore	  (Fraser	  Health),	  Lindsay	  Wheelock	  (Island	  Health),	  and	  Paula	  Cyra	  (Interior	  Health).	  	  Harmonized	  ethics	  approval	  was	  obtained	  from	  UBC	  Behavioral	  Research	  Ethics	  as	  the	  Board	  of	  Record	  for	  Vancouver	  Coastal	  Health	  Authority,	  Fraser	  Health	  Authority,	  Island	  Health	  Authority,	  and	  Interior	  Health	  Authority.	  Certificate	  number:	  H14-­‐02015.	  	   v	  TABLE	  OF	  CONTENTS	  	  ABSTRACT	  ..................................................................................................................................	  ii	  PREFACE	  ....................................................................................................................................	  iv	  TABLE	  OF	  CONTENTS	  .............................................................................................................	  v	  LIST	  OF	  TABLES	  ....................................................................................................................	  viii	  LIST	  OF	  FIGURES	  .....................................................................................................................	  ix	  CHAPTER	  1:	  INTRODUCTION	  OF	  PROBLEM	  ....................................................................	  1	  Introduction	  ........................................................................................................................................	  1	  Background	  of	  Problem	  ..................................................................................................................	  3	  Problem	  Statement	  ...........................................................................................................................	  5	  Purpose	  .................................................................................................................................................	  5	  Research	  Questions	  ..........................................................................................................................	  6	  Significance	  of	  Study	  ........................................................................................................................	  6	  Organization	  of	  Thesis	  .....................................................................................................................	  6	  Terminology	  ........................................................................................................................................	  7	  CHAPTER	  2:	  LITERATURE	  REVIEW	  ....................................................................................	  8	  Introduction	  ........................................................................................................................................	  8	  Historical	  Development	  of	  Nursing	  Specialties	  .......................................................................	  9	  Nursing	  Specialty	  Certification	  in	  Canada	  ..............................................................................	  11	  Definition	  of	  a	  Nursing	  Specialty:	  Thoracic	  Surgery?	  ........................................................	  12	  Value	  of	  Specialty	  Certification	  in	  Nursing	  ............................................................................	  17	  Barriers	  to	  Specialty	  Certification	  ............................................................................................	  21	  Conclusion	  ........................................................................................................................................	  23	  CHAPTER	  3:	  METHODS	  .......................................................................................................	  25	  Study	  Design	  and	  Setting	  .............................................................................................................	  25	  Sample	  Selection	  &	  Recruitment	  ...............................................................................................	  26	  Procedures	  and	  Data	  Collection	  ................................................................................................	  29	  Data	  Analysis	  ...................................................................................................................................	  31	  Ethical	  Considerations	  ..................................................................................................................	  32	  	   vi	  Limitations	  of	  Study	  Design	  ........................................................................................................	  33	  Summary	  ...........................................................................................................................................	  34	  CHAPTER	  4:	  RESEARCH	  FINDINGS	  ..................................................................................	  35	  Sample	  Characteristics	  .................................................................................................................	  35	  Perceived	  Value	  of	  Certification	  ................................................................................................	  36	  Perceptions	  of	  Thoracic	  Surgery	  ...............................................................................................	  39	  Advanced	  Knowledge	  Related	  to	  Thoracic	  Surgery	  ......................................................................	  39	  Advanced	  Skills	  Related	  to	  Thoracic	  Surgery	  ...................................................................................	  43	  Education	  Requirements	  ...........................................................................................................................	  45	  Patient	  Outcomes	  ..........................................................................................................................................	  47	  Thoracic	  Surgery	  as	  a	  Nursing	  Specialty	  ............................................................................................	  48	  Summary	  of	  Findings	  ....................................................................................................................	  50	  CHAPTER	  5:	  DISCUSSION	  ....................................................................................................	  52	  Perceived	  Value	  of	  Certification	  ................................................................................................	  52	  Perceptions	  of	  Thoracic	  Surgery	  ...............................................................................................	  54	  Advanced	  Knowledge	  and	  Skills	  ............................................................................................................	  54	  Education,	  Patient	  Outcomes,	  and	  Specialty	  Recognition	  ...........................................................	  56	  Limitations	  .......................................................................................................................................	  58	  Summary	  ...........................................................................................................................................	  59	  CHAPTER	  6:	  CONCLUSIONS	  AND	  IMPLICATIONS	  ........................................................	  61	  Summary	  ...........................................................................................................................................	  61	  Conclusions	  ......................................................................................................................................	  61	  Perceptions	  of	  the	  Value	  of	  Specialist	  Certification	  .......................................................................	  62	  Level	  of	  Knowledge	  Required	  of	  Thoracic	  Nurses	  .........................................................................	  62	  Thoracic	  Certification	  .................................................................................................................................	  63	  Outcomes	  .........................................................................................................................................................	  63	  Implications	  .....................................................................................................................................	  64	  REFERENCES	  ...........................................................................................................................	  66	  APPENDIX	  A	  ............................................................................................................................	  74	  APPENDIX	  B	  ............................................................................................................................	  77	  APPENDIX	  C	  ............................................................................................................................	  80	  	   vii	  APPENDIX	  D	  ............................................................................................................................	  81	  APPENDIX	  E	  ............................................................................................................................	  87	  	  	   viii	  LIST	  OF	  TABLES	  	  	  Table	  1	  Demographic	  profile	  of	  respondents	  ...................................................................................	  36	  Table	  2	  PVCT	  item	  response	  statistics	  ................................................................................................	  38	  Table	  3	  Perceptions	  of	  advanced	  nursing	  knowledge	  related	  to	  thoracics,	  by	  role	  ........	  42	  Table	  4	  Perceptions	  of	  advanced	  nursing	  skills	  related	  to	  thoracic	  surgery,	  by	  role	  .....	  45	  Table	  5	  Additional	  education	  related	  to	  nursing	  knowledge	  and	  skills	  is	  required	  to	  meet	  the	  care	  needs	  of	  the	  thoracic	  surgery	  patient	  population	  ..................................	  46	  Table	  6	  Nursing	  specialty	  recognition	  promotes	  better	  patient	  outcomes	  ........................	  47	  Table	  7	  Thoracic	  surgery	  should	  be	  formally	  recognized	  as	  a	  certified	  nursing	  specialty	  ....................................................................................................................................................................	  49	  	  	  	  	   ix	  LIST	  OF	  FIGURES	  	  Figure	  1	  PVCT	  item	  response	  statistics	  ...............................................................................................	  39	  Figure	  2	  Perception	  of	  additional	  education	  requirements	  for	  thoracic	  nurses,	  response	  breakdown	  by	  role	  .............................................................................................................................	  46	  Figure	  3	  Nursing	  specialty	  recognition	  promotes	  better	  patient	  outcomes,	  response	  breakdown	  by	  role	  .............................................................................................................................	  48	  Figure	  4	  Thoracic	  surgery	  should	  be	  formally	  recognized	  as	  a	  certified	  nursing	  specialty,	  response	  breakdown	  by	  role	  .....................................................................................	  49	  	  	  	  	  	  	  	   1	  CHAPTER	  1:	  INTRODUCTION	  OF	  PROBLEM	  	  Introduction	  	  	   Specialty	  practice	  is	  recognized	  across	  many	  health	  care	  professions	  such	  as	  nurses,	  physicians	  and	  surgeons,	  and	  allied	  health	  professionals.	  In	  Canada,	  a	  health	  profession’s	  national	  regulatory	  body	  is	  responsible	  for	  credentialing	  and	  promoting	  professional	  development.	  The	  best-­‐known	  example	  is	  probably	  in	  medicine,	  where	  the	  Royal	  College	  of	  Physicians	  and	  Surgeons	  of	  Canada,	  currently	  oversees	  the	  requirements	  for	  specialty	  education	  in	  70	  areas	  of	  medical	  practice.	  Within	  this	  framework,	  a	  specialty	  is	  defined	  as,	  “an	  area	  of	  medicine	  with	  a	  more	  focused	  or	  advanced	  scope	  that	  builds	  upon	  broad-­‐based	  knowledge”	  (Royal	  College	  of	  Physicians	  and	  Surgeons	  of	  Canada,	  2014,	  Subspecialties,	  para.	  1).	  As	  an	  example,	  thoracic	  surgery	  represents	  a	  specialty	  within	  the	  practice	  of	  surgery	  that	  is	  concerned	  with	  diseases	  of	  the	  organs	  in	  the	  chest,	  including	  the	  chest	  wall,	  mediastinum,	  lungs,	  trachea,	  pleura,	  esophagus,	  stomach,	  and	  diaphragm	  (Royal	  College	  of	  Physicians	  and	  Surgeons	  of	  Canada,	  2010).	  A	  thoracic	  surgeon	  is	  a	  graduate	  of	  medical	  school	  who	  completes	  a	  residency	  in	  general	  or	  cardiac	  surgery,	  followed	  by	  a	  two-­‐year	  thoracic	  surgery	  program	  accredited	  by	  the	  Royal	  College	  of	  Physicians	  and	  Surgeon,	  after	  which,	  he	  or	  she	  writes	  a	  certification	  examination	  (Royal	  College	  of	  Physicians	  and	  Surgeons	  of	  Canada,	  2013).	  	  Thoracic	  surgeons	  practice	  with	  expert	  clinical	  knowledge	  and	  skills	  appropriate	  to	  thoracic	  surgery,	  which	  includes	  the	  foundational	  principles	  and	  	   2	  practice	  of	  surgery,	  as	  well	  more	  specific	  knowledge	  related	  to	  the	  anatomy,	  physiology,	  and	  diseases	  of	  the	  chest.	  These	  complex	  surgeries	  include	  thoracoscopy	  and	  mediastinoscopy,	  and	  chest	  wall,	  pulmonary,	  tracheal,	  esophageal,	  and	  gastric	  resections	  for	  various	  conditions	  and	  diseases,	  including	  cancers	  (Royal	  College	  of	  Physicians	  and	  Surgeons	  of	  Canada,	  2010).	  A	  study	  completed	  by	  Kuo,	  Chang,	  and	  Wright	  (2001)	  in	  South	  Carolina	  hospitals,	  suggested	  that	  mortality	  was	  significantly	  lower	  for	  patients	  who	  underwent	  lung	  resection	  for	  cancer	  by	  a	  thoracic	  surgeon	  rather	  than	  a	  general	  surgeon.	  This	  leads	  one	  to	  wonder,	  if	  the	  populations	  undergoing	  these	  very	  particular	  surgical	  procedures	  benefit	  from	  specialized	  and	  expert	  surgeons,	  are	  they	  not	  complex	  patients	  who	  would	  in	  turn	  require	  and	  benefit	  from	  more	  focused	  and	  specialized	  surgical	  nursing	  care	  pre	  and	  post-­‐operatively?	  Further	  questions	  also	  arise,	  such	  as:	  do	  nurses	  perceive	  thoracic	  surgery	  to	  be	  a	  specialized	  area	  of	  practice	  with	  specific	  knowledge	  and	  skill	  requirements?	  And,	  do	  surgeons	  themselves	  feel	  that	  their	  patient	  population	  requires	  specialized	  nursing	  care?	  While	  there	  are	  many	  nurses	  who	  work	  in	  thoracic	  surgery	  centers	  across	  Canada	  providing	  care	  that	  may	  be	  different	  from	  basic	  surgical	  nursing	  or	  entry-­‐to-­‐practice	  standards,	  unlike	  the	  medical	  profession,	  thoracic	  surgery	  is	  not	  currently	  recognized	  by	  the	  Canadian	  Nurses	  Association	  (CNA)	  as	  a	  “certified”	  nursing	  specialty.	  The	  American	  Board	  of	  Nursing	  Specialties	  (ABNS)	  defines	  nursing	  specialty	  certification	  as	  the	  “formal	  recognition	  of	  specialized	  knowledge,	  skills,	  and	  experience	  demonstrated	  by	  the	  achievement	  of	  standards	  identified	  by	  a	  nursing	  specialty	  to	  promote	  optimal	  health	  outcomes”	  (2005,	  p.	  1).	  The	  CNA	  	   3	  currently	  offers	  such	  certification	  in	  20	  specialties	  of	  nursing	  practice,	  including	  areas	  such	  as	  cardiovascular	  nursing,	  critical	  care	  nursing,	  orthopedic	  nursing,	  perioperative	  nursing,	  peri-­‐anesthesia	  nursing,	  and	  medical-­‐surgical	  nursing	  (CNA,	  2014a).	  The	  increasing	  complexity	  of	  patients	  and	  their	  needs	  are	  continually	  creating	  new	  challenges	  for	  the	  nursing	  profession.	  Thus,	  in	  order	  to	  meet	  the	  needs	  of	  these	  complex	  patient	  populations,	  should	  the	  identification	  and	  development	  of	  nursing	  specialties	  be	  supported?	  Research	  in	  other	  areas	  of	  nursing	  suggests	  that	  specialty	  areas	  of	  nursing	  practice	  such	  as	  thoracic	  surgery	  may	  benefit	  from	  recognition,	  suggesting	  that	  certification	  not	  only	  signifies	  specialized	  knowledge,	  professional	  credibility	  and	  commitment	  (Allen,	  2010),	  but	  may	  also	  be	  associated	  with	  patient	  satisfaction,	  better	  patient	  outcomes,	  and	  improved	  quality	  of	  care	  (Kendall-­‐Gallagher,	  Aiken,	  Sloane,	  and	  Cimiotti,	  2011).	  Background	  of	  Problem	  	  Nursing	  is	  a	  profession	  with	  a	  broad	  variation	  in	  knowledge	  and	  scope	  of	  practice.	  The	  CNA	  emphasizes	  that	  the	  ability	  of	  individual	  nurses	  to	  work	  to	  their	  full	  scope	  of	  practice	  is	  influenced	  by	  the	  settings	  in	  which	  they	  practice,	  the	  requirements	  of	  the	  employer,	  and	  the	  needs	  of	  their	  patients.	  There	  are	  many	  settings	  where	  additional	  education	  and	  training	  is	  required	  to	  care	  for	  specific	  patient	  populations,	  for	  example	  cardiac	  nursing,	  critical	  care	  nursing,	  and	  renal	  nursing	  (Dunn	  et	  al.,	  2000).	  While	  often	  difficult	  to	  characterize,	  nursing	  scope	  of	  practice	  is	  important	  as	  it,	  “is	  the	  base	  from	  which	  governing	  bodies	  prepare	  standards	  of	  practice,	  educational	  institutions	  prepare	  curricula,	  and	  employers	  	   4	  prepare	  job	  descriptions”	  (CNA,	  2014b).	  Registered	  nurses	  are	  accountable	  for	  providing	  competent	  nursing	  care,	  which	  involves	  on-­‐going	  professional	  development	  to	  ensure	  the	  maintenance	  and	  enhancement	  of	  the	  knowledge,	  skills,	  attitude	  and	  judgment	  required	  to	  meet	  the	  needs	  of	  patients	  in	  an	  evolving	  health-­‐care	  system	  (CNA,	  2014b).	  This	  process	  often	  includes	  continuing	  education	  programs	  and	  specialty	  certification.	  While	  continuing	  education	  for	  nurses	  promotes	  ongoing	  safe,	  ethical	  and	  competent	  practice,	  it	  also	  offers	  nurses	  opportunities	  to	  pursue	  and	  achieve	  professional	  growth	  throughout	  their	  careers	  (CNA,	  2014b).	  Specialty	  certification	  is	  growing	  in	  popularity,	  and	  there	  have	  been	  many	  studies	  showing	  the	  benefits	  and	  value	  of	  nursing	  specialization	  and	  certification.	  In	  2003,	  the	  American	  Board	  of	  Nursing	  Specialties	  Research	  Committee	  completed	  a	  study	  that	  sought	  to	  validate	  nurses’	  perceptions,	  values	  and	  behaviors	  related	  to	  specialty	  certification,	  using	  a	  web-­‐based	  survey	  that	  included	  the	  18-­‐item	  Perceived	  Value	  of	  Certification	  Tool	  ©	  (PVCT).	  Among	  the	  top	  perceived	  values,	  they	  found	  that	  specialty	  certification	  is	  perceived	  to	  enhance	  feelings	  of	  personal	  accomplishment,	  provide	  personal	  satisfaction	  and	  a	  professional	  challenge,	  enhance	  professional	  credibility,	  and	  provide	  evidence	  of	  professional	  commitment	  (American	  Board	  of	  Nursing	  Specialties,	  2006).	  	  In	  an	  article	  about	  specialization	  in	  nursing,	  Peplau	  (2003)	  argues	  that	  initially,	  the	  planning	  of	  specialization	  “is	  determined	  by	  avant-­‐garde	  workers	  in	  a	  particular	  field	  who	  see	  or	  sense	  a	  great	  need	  to	  move—in	  depth—in	  a	  particular	  direction”	  (p.	  4).	  While	  there	  is	  much	  evidence	  to	  support	  the	  benefit	  of	  nursing	  	   5	  specialization,	  in	  the	  process	  of	  initiating	  a	  nursing	  certification	  examination	  in	  Canada,	  and	  thus	  recognizing	  a	  new	  specialty,	  the	  demand	  first	  has	  to	  come	  from	  a	  national	  nursing	  group	  in	  submitting	  a	  proposal	  to	  the	  CNA.	  The	  intent	  of	  this	  proposal	  is	  to	  demonstrate	  the	  uniqueness	  of	  the	  practice	  through	  outlining	  nursing	  standards,	  role	  descriptions,	  and	  a	  body	  of	  literature,	  education	  and	  research	  (L.	  Vachon,	  personal	  communication,	  January	  5,	  2015).	  Consequently,	  does	  potential	  for	  this	  type	  of	  movement	  exist	  in	  the	  population	  of	  nurses	  working	  in	  thoracic	  surgery?	  Problem	  Statement	  	  With	  the	  continual	  advances	  in	  medical	  technology	  and	  specialized	  procedures,	  surgical	  patients	  have	  increasingly	  complex	  and	  specific	  needs.	  The	  question	  then	  arises;	  do	  surgical	  nurses	  now	  require	  advanced	  knowledge	  and	  skills	  to	  meet	  the	  needs	  of	  this	  specific	  patient	  population	  in	  the	  specialty	  of	  thoracic	  surgery?	  And	  if	  so,	  do	  nurses	  and	  surgeons	  perceive	  value	  in	  recognizing	  thoracic	  surgery	  as	  a	  specialty	  for	  nurses?	  	  	  Purpose	  	  The	  purpose	  for	  this	  study	  was	  to	  examine	  the	  perceptions	  of	  senior	  thoracic	  nurses	  and	  surgeons	  regarding	  nursing	  specialization.	  It	  explored	  what	  they	  perceive	  characterizes	  a	  nursing	  specialty,	  if	  they	  consider	  thoracic	  surgery	  as	  a	  nursing	  specialty,	  and	  what	  they	  identify	  as	  the	  outcomes	  and	  value	  of	  nursing	  specialization,	  both	  for	  nurses,	  and	  the	  thoracic	  surgery	  patient	  population.	  	   6	  Research	  Questions	  	  The	  specific	  research	  questions	  that	  were	  addressed	  were:	  	  (a) How	  do	  experienced	  thoracic	  nurses	  and	  surgeons	  perceive	  nursing	  specialization/certification?	  	  (b) Do	  nurses	  and	  surgeons	  perceive	  nursing	  to	  require	  an	  advanced	  level	  of	  knowledge	  and	  skills	  to	  meet	  the	  needs	  of	  the	  thoracic	  surgery	  patient	  population?	  (c) Do	  nurses	  and	  surgeons	  feel	  that	  thoracic	  surgery	  should	  be	  formally	  recognized	  as	  a	  nursing	  specialty?	  Significance	  of	  Study	  	  Exploration	  of	  these	  questions	  may	  reveal	  potential	  benefits	  of	  nursing	  specialty	  recognition	  to	  both	  nurses	  and	  patients,	  such	  as	  satisfaction,	  an	  increase	  in	  quality	  care,	  and	  lower	  rates	  of	  patient	  complications	  (Ferdon,	  2009;	  Kendall-­‐Gallagher,	  Aiken,	  Sloane,	  &	  Cimiotti,	  2011).	  Results	  of	  this	  study	  may	  also	  have	  an	  impact	  for	  other	  surgical	  specialties	  and	  patient	  populations,	  by	  highlighting	  nursing	  specialties	  that	  move	  beyond	  the	  traditional	  “medical-­‐surgical”	  nursing	  label.	  Organization	  of	  Thesis	  This	  thesis	  is	  compromised	  of	  six	  chapters.	  In	  chapter	  one,	  the	  introduction,	  background	  of	  problem,	  the	  problem	  statement,	  purpose,	  research	  question,	  and	  significance	  of	  the	  study	  have	  been	  addressed.	  Chapter	  two	  will	  consist	  of	  the	  literature	  review	  for	  the	  identified	  problem.	  Chapter	  three	  will	  address	  the	  	   7	  methodology	  that	  the	  research	  study	  follows	  and	  will	  explain	  the	  study	  design,	  sampling,	  data	  collection	  procedures,	  data	  analysis,	  ethical	  considerations,	  and	  study	  limitations.	  Chapter	  four	  will	  be	  comprised	  of	  the	  study	  findings.	  Chapter	  five	  discusses	  these	  findings,	  considers	  explanations	  for	  them,	  and	  relates	  the	  findings	  to	  existing	  literature.	  Lastly,	  chapter	  six	  will	  be	  the	  summary	  of	  the	  research,	  future	  implications	  and	  conclusions.	  Terminology	  Certification:	  The	  formal	  recognition	  of	  specialized	  knowledge,	  skills,	  and	  experience	  demonstrated	  by	  the	  achievement	  of	  standards	  identified	  by	  a	  nursing	  specialty	  to	  promote	  optimal	  health	  outcomes	  (American	  Board	  of	  Nursing	  Specialties,	  2005).	  Specialization:	  Specialization	  is	  a	  concentrated	  area	  of	  expert	  clinical	  practice	  with	  focused	  knowledge	  and	  competencies.	  The	  specialty	  area	  may	  be	  broadly	  or	  narrowly	  defined,	  well	  established	  or	  emerging	  (Fulton,	  2005).	  Specialty:	  A	  branch	  of	  medicine	  or	  nursing	  in	  which	  the	  professional	  is	  specifically	  qualified	  to	  practice	  by	  attending	  an	  advanced	  program	  of	  study,	  passing	  an	  examination	  given	  by	  an	  organization	  of	  the	  members	  of	  the	  specialty,	  or	  gaining	  experience	  by	  extensive	  practice	  in	  the	  specialty	  (Boss,	  1989,	  p.	  213).	  Thoracic	  Surgery:	  A	  specialty	  within	  the	  practice	  of	  surgery	  that	  is	  concerned	  with	  diseases	  of	  the	  organs	  in	  the	  chest,	  including	  the	  chest	  wall,	  mediastinum,	  lungs,	  trachea,	  pleura,	  esophagus,	  stomach,	  and	  diaphragm	  (Royal	  College	  of	  Physicians	  and	  Surgeons	  of	  Canada,	  2010).	  	   8	  CHAPTER	  2:	  LITERATURE	  REVIEW	  Introduction	  	   In	  this	  chapter,	  the	  historical	  development	  of	  nursing	  specialties,	  the	  current	  definitions	  of	  specialty	  nursing	  with	  consideration	  to	  thoracic	  surgery,	  and	  certification	  from	  the	  perspectives	  of	  nursing	  regulatory	  bodies	  will	  be	  presented.	  The	  value	  of	  specialty	  certification	  will	  be	  then	  be	  discussed,	  as	  there	  is	  extensive	  research	  and	  literature	  identifying	  the	  benefits	  of	  nursing	  certification.	  Lastly,	  opposing	  viewpoints	  will	  be	  examined,	  although	  there	  is	  a	  lack	  of	  literature	  within	  the	  field	  of	  nursing	  regarding	  specialization.	  A	  literature	  review	  was	  conducted,	  with	  the	  search	  limited	  to	  articles	  written	  in	  English	  during	  the	  time	  period	  of	  2000–2014,	  using	  the	  combination	  of	  key	  words	  and	  phrases	  as	  follows:	  “nursing	  certification”,	  “specialty	  nursing”,	  “nurse	  specialization”,	  “nurse	  perception”,	  “nursing	  specialty	  development”,	  “thoracic	  surgery”,	  and	  “surgical	  nursing”.	  Two	  older	  key	  articles,	  arising	  in	  this	  literature,	  one	  from	  1989,	  and	  another	  from	  1945,	  were	  also	  found	  to	  have	  particular	  relevance	  to	  the	  historical	  development	  of	  nursing	  specialties.	  The	  database	  search	  engines	  used	  to	  do	  the	  literature	  review	  included:	  Cumulative	  Index	  of	  Nursing	  Allied	  Literature	  (CINHAL),	  Science	  Direct,	  OvidSP,	  ProQuest,	  and	  Pub	  Med.	  Numerous	  relevant	  articles	  and	  research	  studies	  where	  discovered,	  examined,	  and	  are	  presented	  in	  this	  review	  of	  literature.	  	   9	  Historical	  Development	  of	  Nursing	  Specialties	  From	  the	  late	  1800s	  to	  1900,	  “private	  duty	  nursing”,	  might	  have	  been	  thought	  of	  as	  the	  first	  nursing	  specialty,	  with	  nurses	  providing	  dedicated,	  full-­‐time	  care	  in	  a	  patient’s	  home	  (Boss,	  1989).	  Military	  nursing	  may	  have	  been	  the	  next	  more	  evident	  specialty	  to	  emerge,	  and	  was	  arguably	  one	  of	  the	  most	  impactful.	  	  Through	  the	  early	  and	  mid	  1900s,	  war	  and	  conflict	  introduced	  patients	  with	  far	  more	  complex	  health	  problems	  than	  previously	  seen,	  and	  advanced	  both	  medical	  and	  nursing	  knowledge	  and	  skill	  related	  to	  trauma	  care	  (Boss,	  1989).	  The	  late	  1900s	  subsequently	  brought	  advancements	  in	  technology	  that	  placed	  increased	  demand	  on	  nursing	  to	  learn	  and	  manage	  new	  skills	  and	  tools	  (Boss,	  1989).	  In	  Canada,	  in	  1980,	  the	  Canadian	  Nurses	  Association	  began	  exploring	  the	  growing	  interest	  of	  nurses	  in	  the	  development	  of	  specialty	  certification,	  and	  in	  doing	  so,	  discovered	  that	  many	  Canadian	  nurses	  were	  seeking	  certification	  in	  the	  United	  States.	  Following	  the	  annual	  meeting	  of	  that	  year,	  the	  CNA	  board	  was	  directed	  to	  look	  at	  the	  possibility	  of	  developing	  examinations	  for	  certification	  in	  major	  nursing	  specialties,	  such	  as	  critical	  care,	  perioperative,	  and	  emergency	  nursing.	  In	  October	  of	  1986,	  the	  CNA	  certification	  program	  was	  approved,	  following	  several	  years	  of	  consultations	  with	  national	  nursing	  groups,	  and	  in	  1991,	  the	  CNA	  certified	  its	  first	  group	  of	  nurses	  in	  the	  specialty	  of	  neuroscience	  nursing	  (CNA,	  2014a).	  Since	  then,	  more	  than	  18,000	  nurses	  have	  been	  certified	  across	  20	  different	  formally	  recognized	  specialties	  (CNA,	  2014c).	  Although	  Canada	  is	  moving	  forward	  with	  specialty	  development,	  it	  still	  remains	  behind	  other	  countries	  such	  as	  the	  United	  	   10	  States,	  which	  has	  28	  organizations	  offering	  144	  different	  credentials	  (American	  Board	  of	  Nursing	  Specialties,	  2014).	  Development	  of	  specialty	  certification	  programs	  starts	  with	  a	  passionate	  group	  of	  nurses	  working	  in	  a	  particular	  niche,	  who	  may	  identify	  the	  benefits	  of	  having	  a	  recognized,	  defined	  area	  of	  practice.	  For	  example,	  in	  2005,	  members	  of	  the	  American	  Society	  for	  Metabolic	  and	  Bariatric	  Surgery	  (ASMBS)	  voiced	  an	  interest	  in	  developing	  a	  specialty	  certification	  program	  for	  nurses	  caring	  for	  morbidly	  obese	  and	  bariatric	  surgical	  patients	  (Berger	  et	  al.,	  2010).	  The	  first	  step	  was	  to	  undertake	  a	  practice	  analysis	  study	  in	  order	  to	  identify	  and	  outline	  the	  knowledge	  and	  skills	  of	  the	  nurse	  working	  with	  morbidly	  obese	  and	  bariatric	  surgical	  patients.	  This	  study	  was	  performed	  using	  several	  methods,	  including	  interviews,	  focus	  groups,	  subject-­‐matter	  expert	  meetings,	  and	  a	  survey	  of	  nurses	  practicing	  within	  in	  the	  specialty.	  The	  group	  then	  created	  an	  initial	  draft	  of	  the	  domains	  (or	  major	  areas)	  of	  practice,	  skills	  performed,	  and	  knowledge	  required	  in	  the	  bariatric	  nursing	  specialty.	  The	  information	  gathered	  in	  this	  practice	  analysis	  formed	  the	  foundation	  for	  the	  development	  of	  the	  certification	  examination	  for	  the	  specialty	  of	  bariatric	  nursing,	  for	  which	  the	  first	  examination	  was	  administered	  in	  June	  2007	  (Berger	  et	  al.).	  Canadian	  nurses	  face	  similar	  challenges	  in	  obtaining	  certifications,	  especially	  since	  there	  are	  relatively	  few	  options	  in	  Canada.	  For	  example,	  until	  2006,	  certification	  in	  rehabilitation	  nursing	  was	  not	  available	  in	  Canada,	  thus	  many	  nurses	  were	  seeking	  certification	  in	  the	  United	  States	  (Leclerc,	  Holdway,	  Kettyle,	  Ball,	  &	  Keith,	  2004).	  	  Writing	  an	  American	  examination	  presented	  challenges	  of	  its	  own	  to	  these	  Canadian	  nurses,	  who	  not	  only	  were	  required	  to	  pay	  lofty	  exam	  fees,	  but	  also	  	   11	  study	  and	  prepare	  for	  an	  exam	  that	  is	  based	  on	  American	  course	  content	  and	  American	  health	  legislation,	  which	  may	  not	  be	  relevant	  for	  Canadian	  nurses.	  To	  overcome	  this	  issue,	  a	  group	  of	  rehabilitation	  nurses	  from	  Ottawa	  formed	  a	  collaborative	  partnership	  called	  the	  Rehabilitation	  Nursing	  Network.	  Their	  primary	  objectives	  were	  to	  support	  and	  encourage	  nurses	  in	  the	  certification	  process;	  provide	  continuing	  education	  opportunities;	  and	  combine	  efforts	  to	  achieve	  Canadian	  rehabilitation	  certification.	  They	  conducted	  a	  study	  to	  examine	  nurses'	  perceptions	  regarding	  the	  impact	  of	  rehabilitation	  certification	  on	  professional	  practice,	  which	  helped	  to	  drive	  the	  development	  of	  a	  certification	  examination	  and	  formal	  recognition	  for	  their	  specialty	  area	  (Leclerc	  et	  al.).	  Nursing	  Specialty	  Certification	  in	  Canada	  In	  order	  to	  become	  certified	  in	  one	  of	  the	  20	  currently	  CNA	  recognized	  specialties	  in	  Canada,	  the	  CNA	  outlines	  eligibility	  criteria.	  The	  applicant:	  1. Must	  be	  a	  registered	  nurse	  with	  current	  Canadian	  registration,	  and	  	  2. Must	  have	  worked	  a	  minimum	  of	  3,	  900	  hours	  in	  their	  nursing	  specialty	  area	  over	  the	  past	  five	  years	  (one	  full-­‐time	  year	  is	  equivalent	  to	  1950	  hours).	  This	  experience	  must	  be	  verified	  by	  a	  supervisor	  in	  the	  applicant’s	  specialty	  area	  of	  practice.	  	  3. Must	  pass	  a	  CNA	  recognized	  specialty	  certification	  examination.	  (CNA,	  2015a).	  The	  certification	  examination	  is	  developed	  by	  expert	  representatives	  from	  the	  specialty’s	  national	  association,	  in	  collaboration	  with	  CNA	  approved	  testing	  	   12	  consultants	  who	  ensure	  the	  exams	  are	  valid	  and	  reliable.	  Exam	  content	  typically	  consists	  of	  the	  aptitudes	  of	  a	  fully	  competent	  practicing	  specialty	  nurse	  with	  at	  least	  two	  years	  of	  experience.	  Multiple-­‐choice	  questions	  are	  aimed	  at	  three	  levels	  of	  cognitive	  ability:	  knowledge/comprehension,	  application,	  and	  critical	  thinking	  (CNA,	  2014d).	  Therefore,	  it	  is	  expected	  that	  the	  specialty	  nurse	  with	  at	  least	  two	  years	  of	  experience	  will	  have	  a	  certain	  knowledge	  base	  and	  understanding	  of	  the	  principles	  of	  the	  given	  specialty,	  be	  able	  to	  apply	  this	  knowledge	  in	  the	  care	  of	  clients,	  and	  make	  decisions	  based	  on	  the	  interpretation	  of	  data	  to	  support	  the	  needs	  of	  clients	  (CNA,	  2014d).	  Definition	  of	  a	  Nursing	  Specialty:	  Thoracic	  Surgery?	  One	  of	  the	  challenges	  in	  defining	  nursing	  specialization	  is	  recognizing	  that	  there	  are	  likely	  far	  more	  specialties	  in	  practice	  than	  those	  formally	  identified.	  The	  CNA	  recognizes	  20	  certified	  nursing	  specialties,	  but	  also	  acknowledges	  a	  network	  of	  44	  national	  associations	  in	  various	  specialized	  areas	  of	  nursing.	  The	  nursing	  specialties	  in	  this	  network	  “range	  widely	  from	  aboriginal	  health	  nurses	  to	  operating	  room	  nurses	  to	  occupational	  health	  nurses	  to	  legal	  nurse	  consultants”	  (CNA,	  2014e).	  	  Within	  health	  disciplines,	  a	  specialty	  can	  be	  described	  as:	  A	  branch	  of	  medicine	  or	  nursing	  in	  which	  the	  professional	  is	  specifically	  qualified	  to	  practice	  by	  attending	  an	  advanced	  program	  of	  study,	  passing	  an	  examination	  given	  by	  an	  organization	  of	  the	  members	  of	  the	  specialty,	  or	  gaining	  experience	  by	  extensive	  practice	  in	  the	  specialty.	  (Boss,	  1989,	  p.	  213)	  	  	   13	  Therefore,	  a	  specialist	  nurse	  is	  an	  expert	  in	  his	  or	  her	  field,	  and	  possesses	  specialized	  skills,	  knowledge,	  and	  clinical	  judgment.	  Boss	  (1989),	  asserts	  that	  specialty	  nursing	  is	  characterized	  by	  two	  elements:	  the	  first	  being	  the	  needs	  of	  a	  particular	  patient	  population,	  and	  second,	  the	  clinical	  expertise	  (specialized	  knowledge	  and	  skill)	  necessary	  to	  meet	  those	  needs.	  While	  one	  could	  assume	  that	  certification	  is	  the	  “formal”	  recognition	  of	  a	  nursing	  specialty,	  these	  definitions	  offer	  a	  more	  realistic	  interpretation	  and	  highlight	  the	  idea	  that	  specialties	  are	  a	  result	  of	  complex	  patient	  populations	  requiring	  an	  enhanced	  level	  of	  nursing	  care.	  So	  the	  question	  that	  surfaces	  is,	  does	  thoracic	  surgery	  fit	  as	  a	  nursing	  specialty?	  An	  article	  from	  the	  American	  Journal	  of	  Nursing,	  published	  back	  in	  1945,	  suggests	  that	  thoracic	  surgery	  may	  have	  been	  a	  nursing	  specialty	  even	  70	  years	  ago:	  Thoracic	  surgery	  requires	  specialized	  training,	  and	  the	  surgical	  nurse	  on	  the	  team	  must	  not	  only	  be	  an	  experienced	  surgical	  nurse	  but	  in	  addition	  must	  have	  a	  detailed	  knowledge	  of	  the	  technical	  features	  of	  this	  specialty…	  the	  ability	  to	  think	  quickly	  and	  to	  act	  deftly	  and	  accurately	  may	  spell	  the	  difference	  between	  success	  and	  disaster	  to	  the	  patient.	  (Brooks,	  1945,	  p.	  275)	  Like	  other	  surgical	  specialties,	  the	  outcomes	  of	  thoracic	  surgery	  depend	  to	  a	  large	  degree	  on	  good	  post-­‐operative	  care.	  Specific	  complications	  can	  occur	  very	  rapidly,	  and	  if	  not	  identified	  and	  treated	  immediately,	  contribute	  to	  significant	  morbidity	  and	  mortality	  (Myatt,	  2006).	  Surgical	  complications	  of	  lung	  resection,	  for	  example,	  included	  pneumothorax,	  pulmonary	  collapse,	  and	  accidental	  puncture,	  damage,	  or	  contamination	  of	  the	  surgical	  site,	  with	  pulmonary	  complications	  including	  new-­‐onset	  pulmonary	  insufficiency	  and	  respiratory	  arrest	  (Bach	  et	  al.,	  	   14	  2001).	  Atrial	  fibrillation	  is	  a	  common	  complication	  after	  major	  noncardiac	  thoracic	  surgery	  and	  is	  associated	  with	  increases	  in	  the	  morbidity	  and	  length	  of	  hospital	  stay	  associated	  with	  these	  procedures	  (Passman	  et	  al.,	  2005).	  Swisher	  et	  al.	  (2000)	  also	  highlights	  that	  the	  esophagectomy	  is	  also	  one	  of	  the	  most	  complex	  surgical	  procedures	  performed	  and	  therefore	  has	  the	  potential	  for	  high	  morbidity	  and	  mortality	  rates.	  Given	  the	  potential	  for	  complications	  in	  the	  thoracic	  patient	  population,	  there	  is	  a	  fair	  amount	  of	  research	  to	  suggest	  that	  specialized	  surgical	  centers	  demonstrate	  lower	  morbidity	  and	  mortality.	  A	  common	  explanation	  for	  this	  trend	  is	  that	  physicians	  and	  nurses	  become	  more	  effective	  in	  providing	  care	  by	  gaining	  experience	  and	  expertise	  as	  volumes	  increase	  (Farley	  &	  Ozminskowski,	  1992).	  In	  a	  study	  by	  Kuo,	  Chang,	  and	  Wright	  (2001)	  it	  was	  found	  that	  patients	  undergoing	  surgery	  for	  lung	  resection	  in	  hospitals	  performing	  a	  high	  volume	  of	  these	  procedures	  were	  associated	  with	  a	  2-­‐day	  decrease	  in	  median	  length	  of	  stay	  (p	  <	  0.001)	  and	  a	  3.7-­‐fold	  decrease	  in	  hospital	  mortality	  (9.2%	  vs	  2.5%;	  p	  <	  0.001)	  compared	  to	  lower	  volume	  hospitals.	  A	  similar	  study	  by	  Swisher	  et	  al.	  (2000)	  found	  that	  hospitals	  performing	  a	  high	  volume	  of	  esophagectomies	  versus	  hospitals	  with	  a	  low	  volume,	  showed	  a	  tendency	  toward	  decreased	  complications	  (55%	  versus	  68%,	  p	  =	  .06),	  and	  decreased	  length	  of	  stay	  (14.7	  days	  versus	  17.7	  days,	  p	  =	  .006).	  One	  theory	  used	  to	  explain	  these	  differences	  is	  the	  obvious	  ‘practice	  makes	  perfect’	  concept.	  This	  theory	  proposes	  that	  surgeons	  performing	  a	  particular	  procedure	  on	  a	  regular	  basis	  become	  more	  proficient	  in	  that	  procedure,	  a	  concept	  that	  is	  demonstrated	  in	  a	  systematic	  review	  of	  22	  studies	  consisting	  of	  172,	  173	  patient	  	   15	  outcomes.	  Specialist	  surgeons	  had	  significantly	  better	  overall	  outcomes	  than	  general	  surgeons	  performing	  the	  same	  procedure,	  with	  a	  lower	  mortality	  rate	  in	  92	  percent	  of	  studies,	  a	  shorter	  hospital	  stay	  all	  studies,	  and	  fewer	  complication	  rates	  in	  14	  of	  17	  studies	  (Chowdhury,	  Dagash,	  &	  Pierro,	  2007).	  So	  while	  this	  evidence	  exists	  to	  show	  that	  mortality	  rates	  are	  reduced	  for	  specific	  surgeons	  who	  perform	  more	  of	  these	  specialized	  procedures,	  another	  component	  is	  the	  improved	  perioperative	  care	  that	  comes	  with	  the	  experience	  of	  the	  team.	  	  The	  study	  by	  Kuo,	  Chang,	  and	  Wright	  (2001)	  suggested	  that	  in	  addition	  to	  the	  experience	  of	  individual	  surgeons,	  surgical	  specialization	  has	  been	  demonstrated	  to	  improve	  surgical	  outcomes	  because	  both	  quality	  and	  outcomes	  are	  also	  influenced	  by	  the	  knowledge,	  skill,	  and	  experience	  of	  the	  whole	  surgical	  team.	  Hospitals	  performing	  a	  high	  volumes	  of	  specific	  surgical	  procedures	  such	  as	  lung	  resections,	  provides	  an	  opportunity	  for	  a	  small	  number	  of	  surgeons,	  anesthesiologists,	  intensivists,	  and	  nursing	  staff	  to	  gain	  expertise	  through	  experience	  in	  both	  performing	  and	  managing	  this	  specific	  complex	  operation.	  This	  increased	  experience	  can	  result	  in	  early	  detection	  and	  standardized	  treatment	  of	  complications	  (Kuo,	  Chang,	  &	  Wright).	  According	  to	  a	  survey	  by	  the	  Canadian	  Association	  of	  Thoracic	  Surgeons,	  almost	  all	  major	  thoracic	  centers	  in	  Canada	  (83%)	  have	  a	  geographic	  thoracic	  unit	  with	  patients	  centralized	  in	  a	  ward	  with	  dedicated	  nursing	  and	  physiotherapists	  (Darling	  et	  al.,	  2004).	  One	  might	  wonder	  if	  surgeons	  then	  expect	  and	  appreciate	  the	  additional	  specialized	  knowledge	  and	  skill	  of	  thoracic	  nurses,	  and	  to	  what	  extent	  they	  also	  perceive	  thoracic	  surgery	  to	  be	  a	  nursing	  specialty	  not	  unlike	  their	  own.	  	   16	  While	  thoracic	  surgery	  has	  known	  implications	  to	  cardiac	  and	  lung	  function,	  nurses	  must	  also	  consider	  its	  effects	  on	  pain,	  activity,	  nutrition,	  and	  lifestyle.	  Managing	  pain	  after	  thoracic	  surgery	  can	  be	  challenging	  due	  to	  the	  nature	  of	  the	  surgical	  procedures,	  as	  the	  muscles	  of	  the	  chest	  wall	  are	  separated	  and	  intercostal	  nerves	  are	  often	  damaged	  (Cox,	  Cousins,	  Smith,	  Marwick,	  &	  Gullberg,	  2007).	  Thoracic	  epidural	  analgesia	  for	  thoracic	  surgery	  is	  often	  considered	  ideal,	  in	  addition	  to	  a	  multimodal	  approach	  of	  opioids,	  acetaminophen,	  NSAIDs,	  and	  gabapentin	  (Davies	  &	  Rozario,	  2014).	  Thoracic	  nurses	  require	  the	  appropriate	  knowledge	  and	  skill	  to	  effectively	  manage	  pain	  in	  the	  postoperative	  period.	  In	  turn,	  good	  pain	  control	  post-­‐operatively	  is	  key	  to	  promoting	  deep	  breathing	  and	  coughing,	  as	  well	  as	  mobilization,	  both	  important	  for	  the	  thoracic	  surgery	  patient	  in	  order	  to	  promote	  lung	  expansion,	  expel	  secretions,	  and	  prevent	  pneumonia	  (Magereson	  &	  Riley,	  2008).	  Postoperative	  pneumonia	  resulting	  in	  respiratory	  failure	  continues	  to	  be	  a	  leading	  cause	  of	  mortality,	  morbidity,	  and	  prolonged	  hospital	  stay	  after	  thoracic	  surgery	  (Allan,	  Donahue,	  &	  Garrity,	  2009).	  A	  patient's	  ability	  to	  clear	  pulmonary	  secretions	  following	  thoracic	  surgery	  is	  a	  key	  indicator	  in	  a	  thoracic	  patient’s	  postoperative	  recovery.	  	  The	  thoracic	  nurse’s	  role	  in	  the	  postoperative	  prevention	  of	  pneumonia	  is	  crucial,	  and	  includes	  encouragement	  of	  frequent	  deep	  breathing	  and	  coughing	  exercises,	  incentive	  spirometry,	  and	  ensuring	  ambulation	  at	  least	  3	  times	  a	  day	  in	  the	  first	  48	  hours	  (Allan,	  Donahue,	  &	  Garrity).	  Maintaining	  fluid	  balance	  in	  the	  thoracic	  patient	  is	  also	  critical	  to	  preventing	  fluid	  overload	  and	  pulmonary	  edema	  post-­‐operatively	  (Myatt).	  Nursing	  skills	  specific	  to	  the	  thoracic	  surgery	  patient	  population	  may	  include	  exceptional	  	   17	  skill	  in	  the	  auscultation	  of	  chest	  sounds,	  the	  interpretation	  of	  cardiac	  rhythms	  and	  interventions,	  and	  the	  assessment	  and	  care	  of	  chest	  tubes	  and	  drainage	  devices.	  	  Pre	  and	  post-­‐operative	  patient	  education	  is	  important	  with	  the	  thoracic	  surgery	  population,	  as	  the	  surgery	  or	  the	  disease	  process	  itself	  may	  have	  implications	  to	  lifestyle	  such	  as	  activity	  restrictions,	  smoking	  cessation,	  and	  nutritional	  considerations.	  Thoracic	  patients	  commonly	  have	  experienced	  weight	  loss	  due	  to	  disease	  progression,	  and	  require	  advanced	  nutritional	  support	  and	  education	  (Magereson	  &	  Riley).	  Thoracic	  surgery	  encompasses	  a	  diverse	  range	  of	  procedures	  for	  a	  variety	  of	  conditions	  that	  have	  a	  enormous	  impact	  on	  the	  life	  of	  a	  patient,	  and	  in	  developing	  knowledge	  and	  skills	  in	  management	  of	  these	  conditions,	  the	  nurse	  plays	  a	  vital	  role	  in	  the	  treatment	  and	  care	  of	  the	  thoracic	  surgical	  patient	  (Myatt,	  2006).	  Value	  of	  Specialty	  Certification	  in	  Nursing	  	  Although	  licensure	  and	  registration	  are	  granted	  for	  meeting	  minimum	  professional	  requirements,	  certification	  denotes	  a	  more	  advanced	  level	  of	  knowledge	  and	  practice	  (Byrne,	  Valentine,	  &	  Carter,	  2004).	  The	  position	  of	  the	  Canadian	  Nurses	  Association	  is	  that	  nursing	  certification	  is	  a	  “tangible	  distinction”	  that	  verifies	  knowledge	  and	  skill	  levels	  in	  a	  specialty,	  and	  that	  this	  credential	  indicates	  to	  patients,	  employers,	  and	  the	  public,	  that	  you	  are	  qualified,	  competent,	  and	  current	  in	  a	  specialty	  area	  of	  nursing	  practice.	  	  The	  CNA	  asserts	  that	  by	  preparing	  for	  the	  rigorous	  certification	  exam,	  a	  specialty	  nurse	  ensures	  their	  specialized	  knowledge	  and	  skill	  level	  is	  current	  and	  comprehensive,	  and	  that	  by	  	   18	  renewing	  the	  certification	  every	  five	  years,	  continuous	  learning	  and	  competence	  is	  maintained	  (CNA,	  2014f).	  Nurses'	  attitudes	  and	  perceptions	  related	  to	  specialty	  certification	  have	  been	  studied	  for	  many	  years.	  In	  2003,	  the	  U.S.	  based	  Competency	  and	  Credentialing	  Institute	  (CCI),	  who	  represent	  certified	  perioperative	  nurses,	  stated	  that	  certification	  was	  valued	  because	  it	  “validated	  specialized	  knowledge,	  indicated	  professional	  growth,	  indicated	  attainment	  of	  a	  practice	  standard,	  provided	  evidence	  of	  professional	  commitment,	  provided	  a	  professional	  challenge,	  and	  enhances	  professional	  credibility”	  (Allen,	  2010,	  p.	  28).	  In	  their	  research	  around	  specialty	  certification,	  CCI	  developed	  the	  Perceived	  Value	  of	  Certification	  Tool	  ®	  (PVCT).	  Using	  this	  tool,	  the	  value	  of	  certification	  is	  demonstrated	  through	  intrinsic	  and	  extrinsic	  rewards.	  Intrinsic	  rewards	  are	  personal	  incentives	  which	  include	  accountability,	  clinical	  competence,	  confidence	  in	  clinical	  abilities,	  and	  professional	  growth,	  where	  as	  extrinsic	  rewards	  consist	  of	  external	  motivators	  such	  as	  consumer	  confidence,	  employer	  recognition,	  nursing	  peer	  recognition,	  and	  recognition	  from	  other	  health	  care	  professionals	  (Byrne,	  Valentine,	  &	  Cater,	  2004).	  	  This	  type	  of	  research	  has	  been	  replicated	  across	  many	  different	  nursing	  specialties	  over	  the	  last	  12	  years,	  as	  well	  as	  by	  the	  American	  Board	  of	  Nursing	  Specialties	  (ABNS)	  with	  similar	  results	  (Allen,	  2010).	  A	  2011	  study	  by	  Straka	  et	  al.	  (2014)	  involving	  the	  pediatric	  nursing	  population,	  demonstrated	  that	  nursing	  certification	  promotes	  professional	  growth,	  a	  level	  of	  clinical	  competence,	  and	  professional	  credibility.	  Results	  of	  this	  study	  revealed	  that	  the	  perceived	  value	  of	  certification,	  professional	  development,	  and	  level	  of	  clinical	  competence	  are	  higher	  	   19	  among	  certified	  pediatric	  nurses.	  By	  expanding	  the	  use	  of	  the	  PVCT	  to	  include	  a	  study	  sample	  of	  20	  different	  nursing	  specialties,	  Niebuhr	  &	  Biel	  (2007)	  determined	  that	  the	  value	  statements	  resonate	  with	  a	  variety	  of	  nurses	  regardless	  of	  specialty	  area,	  work	  role,	  or	  certification	  status.	  In	  terms	  of	  clinical	  knowledge	  and	  competence,	  a	  study	  by	  Coleman,	  Coon,	  Copeland,	  Kennedy,	  and	  McNatt	  (2009)	  compared	  certified	  and	  noncertified	  oncology	  nurses	  in	  their	  knowledge	  of	  symptom	  management	  for	  pain	  and	  chemotherapy	  induced	  nausea	  and	  vomiting,	  patient	  satisfaction,	  and	  nurse	  satisfaction,	  in	  order	  to	  determine	  the	  effect	  of	  certification	  in	  oncology	  nursing	  on	  those	  nursing-­‐sensitive	  outcomes.	  The	  results	  of	  this	  study	  provided	  some	  support	  to	  their	  hypothesis,	  that	  certification	  improves	  patient	  care	  quality,	  as	  the	  positive	  effects	  on	  the	  nurses'	  knowledge	  of	  symptom	  management,	  was	  related	  to	  the	  nurse	  being	  certified	  in	  oncology	  nursing	  and	  attending	  more	  hours	  of	  continuing	  education	  (Coleman	  et	  al.,	  2009).	  Kendall-­‐Gallagher,	  Aiken,	  Sloane,	  and	  Cimiotti	  (2011)	  found	  that	  the	  specialty	  certification	  of	  nurses	  was	  associated	  with	  lower	  mortality	  and	  failure	  to	  rescue	  in	  general	  surgery	  patients.	  Their	  study	  looked	  at	  risk-­‐adjusted	  outcome	  data	  for	  general,	  orthopedic,	  and	  vascular	  surgery	  patients	  (n	  =	  1,283,241)	  in	  652	  hospitals	  in	  California,	  Florida,	  New	  Jersey,	  and	  Pennsylvania,	  and	  linked	  outcomes	  with	  nurse	  survey	  data	  (n	  =	  28,598). The	  researchers	  found	  that	  within	  a	  hospital,	  for	  each	  10%	  increase	  in	  baccalaureate	  and	  certified	  baccalaureate	  staff	  nurses,	  respectively,	  the	  odds	  of	  inpatient	  30-­‐day	  mortality	  and	  failure	  to	  rescue	  decreased	  by	  6%	  and	  2%,	  respectively	  (Kendall-­‐Gallagher	  et	  al.).	  They	  concluded	  that	  specialty	  certification	  is	  	   20	  associated	  with	  better	  patient	  outcomes	  and	  “the	  investment	  in	  baccalaureate-­‐educated	  workforce	  and	  specialty	  certification	  has	  the	  potential	  to	  improve	  the	  quality	  of	  care”	  (Kendall-­‐Gallagher	  et	  al.,	  p.	  188).	  With	  growing	  evidence	  that	  demonstrates	  the	  relationship	  between	  educational	  preparation	  for	  nurses	  and	  patient	  outcomes,	  in	  Canada,	  baccalaureate	  education	  is	  required	  for	  basic	  entry	  to	  practice	  as	  a	  registered	  nurse	  (Canadian	  Association	  of	  Schools	  of	  Nursing,	  2011).	  Pursuing	  specialty	  certification	  beyond	  entry-­‐to-­‐practice	  requirements	  promotes	  continuing	  education	  and	  professional	  development	  (CNA,	  2014f).	  The	  CNA	  further	  describes	  other	  extrinsic	  benefits	  of	  certification	  such	  as	  more	  job	  opportunities,	  as	  some	  employers	  list	  certification	  as	  a	  preferred	  qualification,	  career	  advancement	  and	  increased	  responsibilities,	  and	  formal	  recognition	  in	  the	  workplace	  (CNA,	  2014f).	  Moreover,	  Miller	  and	  Boyle	  (2008)	  suggest	  that	  there	  are	  several	  other	  extrinsic	  advantages	  of	  nursing	  specialization,	  which	  include	  the	  development	  of	  nurse	  experts	  who	  serve	  as	  peer	  supports	  for	  bedside	  nurses,	  help	  educate	  patients,	  and	  bring	  expertise	  to	  quality	  improvement	  activities,	  while	  also	  showing	  improvements	  in	  nurse	  and	  patient	  satisfaction,	  and	  nurse	  retention.	  A	  study	  by	  Ferdon	  (2009)	  supports	  this	  idea,	  demonstrating	  that	  nurses	  value	  specialization	  and	  certification	  through	  findings	  of	  a	  perceived	  increase	  in	  quality	  care,	  personal	  satisfaction,	  accomplishment,	  and	  autonomy. Nurse	  respondents	  in	  this	  study	  “overwhelmingly	  agreed	  at	  93.3%”	  that	  certification	  improves	  patient	  outcomes	  (Ferdon,	  p.	  17).	  	   21	  Barriers	  to	  Specialty	  Certification	  While	  there	  is	  a	  large	  amount	  of	  evidence	  to	  support	  specialization	  through	  certification,	  there	  is	  some	  literature	  to	  suggest	  it	  is	  not	  without	  drawbacks.	  In	  a	  study	  by	  Byrne	  et	  al.	  (2004)	  using	  the	  PVCT,	  the	  most	  frequently	  reported	  barriers	  to	  certification	  for	  nurses	  were	  the	  costs	  related	  to	  taking	  the	  exam	  and	  maintaining	  certification,	  lack	  of	  institutional	  support	  and	  reward,	  lack	  of	  time	  to	  prepare	  for	  the	  exam,	  and	  lack	  of	  study	  resources.	  They	  also	  explored	  nurses	  who	  had	  previously	  been	  certified	  but	  let	  their	  credentials	  lapse,	  and	  found	  the	  following	  reasons	  for	  not	  renewing:	  lack	  of	  recognition,	  lack	  of	  compensation,	  cost	  of	  renewal	  fee,	  lack	  of	  time	  for	  continuing	  education,	  and	  personal	  circumstances.	  In	  a	  study	  with	  1748	  medical/surgical	  nurse	  respondents,	  Haskins,	  Hnatiuk,	  and	  Yoder	  (2011)	  surveyed	  the	  barriers	  to	  certification,	  and	  indicated	  the	  top	  barriers	  were	  cost	  of	  the	  examination,	  discomfort	  with	  the	  test-­‐taking	  process,	  and	  lack	  of	  institutional	  reward.	  Nurses	  who	  were	  certified	  and	  did	  not	  maintain	  their	  certification	  listed	  the	  fee	  for	  renewal	  as	  the	  primary	  cause	  for	  non-­‐renewal,	  with	  leaving	  the	  specialty	  area	  ranked	  second	  among	  barriers.	  The	  lowest	  rated	  barrier	  for	  both	  certification	  and	  recertification	  was	  lack	  of	  access	  to	  continuing	  education.	  Interestingly,	  Haskins,	  Hnatiuk,	  and	  Yoder	  also	  posed	  a	  question	  regarding	  what	  type	  of	  incentives	  provided	  by	  employers	  would	  promote	  certification,	  and	  found	  that	  the	  top	  three	  incentives	  were:	  reimbursement	  for	  exam	  fees,	  listing	  of	  certification	  credentials	  on	  name	  tags	  and/or	  business	  cards,	  and	  advancement	  on	  the	  nursing	  clinical/career	  ladder.	  	   22	  In	  2010,	  there	  were	  287,344	  registered	  nurses	  in	  Canada,	  with	  16,260	  of	  those	  holding	  valid	  CNA	  certification	  in	  a	  specialty	  area	  of	  practice,	  a	  number	  that	  represents	  fewer	  than	  6%	  of	  nurses	  (CNA,	  2012;	  CNA	  2015b).	  This	  highlights	  another	  significant	  barrier	  to	  certification,	  which	  is	  that	  some	  specialties	  just	  don’t	  possess	  it.	  Consider	  one	  of	  the	  most	  publicly	  recognized	  specialties:	  pediatrics.	  This	  is	  a	  specialty	  area	  of	  nursing	  that	  already	  has	  a	  well-­‐defined	  practice,	  existing	  advanced	  education	  programs,	  and	  a	  large	  body	  of	  nursing	  literature	  and	  research.	  Yet	  pediatric	  nursing	  still	  lacks	  national	  recognition	  in	  the	  form	  of	  a	  certification	  examination.	  In	  2012,	  the	  Canadian	  Association	  of	  Pediatric	  Nurses	  held	  a	  meeting	  to	  discuss	  restoring	  the	  group,	  which	  has	  been	  inactive	  since	  2005,	  and	  beginning	  work	  to	  develop	  national	  standards	  of	  pediatric	  nursing	  care,	  as	  well	  as	  advocating	  for	  the	  certification	  of	  pediatric	  nurses	  in	  Canada	  (Bailey,	  2012;	  Pediatric	  Nurses	  Interest	  Group,	  2012).	  One	  of	  the	  challenges	  in	  the	  development	  of	  CNA	  specialty	  certification	  is	  the	  existence	  of	  human	  resources	  to	  support	  exam	  development	  and	  the	  ongoing	  maintenance	  of	  a	  certification	  program	  (L.	  Vachon,	  personal	  communication,	  January	  5,	  2015).	  Other	  drawbacks	  of	  specialization	  are	  suggested	  via	  the	  medical	  profession.	  In	  an	  article	  from	  the	  New	  England	  Journal	  of	  Medicine,	  Cassell	  and	  Reuben	  (2011)	  contend	  that	  while	  new	  specialties	  can	  benefit	  both	  patients	  and	  physicians,	  “a	  proliferation	  of	  specialties	  without	  adequate	  justification	  may	  simply	  confuse	  the	  public	  without	  creating	  a	  social	  good”	  (p.	  1173).	  They	  suggest	  the	  need	  to	  find	  a	  balance	  between	  the	  “potential	  benefits	  of	  recognizing	  more	  specific	  expertise	  with	  the	  detriment	  of	  fragmentation	  of	  the	  profession”	  (p.	  1173).	  Cassell	  and	  Reuben	  	   23	  point	  out	  that	  medical	  students	  often	  develop	  the	  misguided	  idea	  that	  generalist	  fields	  are	  less	  exciting,	  when	  the	  reality	  is	  that	  even	  generalist	  practice	  is	  increasingly	  difficult	  to	  keep	  up	  with,	  given	  the	  breadth	  of	  knowledge	  and	  skill	  required.	  Conclusion	  Nursing	  specialization	  has	  been	  around	  for	  many	  years,	  and	  the	  development	  of	  specialties	  is	  becoming	  more	  common	  with	  the	  increased	  complexity	  of	  patients	  and	  medical	  technology.	  While	  nursing	  licensure	  is	  intended	  to	  ensure	  the	  minimum	  competency	  of	  practicing	  nurses,	  “certification	  demonstrates	  nurses'	  achievement	  of	  a	  high	  level	  of	  competence	  or	  expertise	  in	  a	  particular	  area	  or	  specialty”	  (Haskins,	  Hnatiuk,	  &	  Yoder,	  2011,	  p.	  77).	  	  This	  review	  of	  relevant	  literature	  has	  revealed	  a	  substantial	  body	  of	  evidence	  of	  professional	  recognition	  of	  the	  value	  of	  specialty	  certification,	  that	  identifies	  advantages	  of	  increased	  accountability,	  clinical	  competence,	  confidence	  in	  clinical	  abilities,	  professional	  growth,	  consumer	  confidence,	  employer	  recognition,	  nursing	  peer	  recognition,	  and	  recognition	  from	  other	  health	  care	  professionals	  (Allen,	  2010;	  Byrne,	  Valentine,	  &	  Cater,	  2004;	  Niebuhr	  &	  Biel,	  2007).	  Specialty	  certification	  may	  also	  be	  associated	  with	  patient	  satisfaction,	  better	  patient	  outcomes,	  and	  improved	  quality	  of	  care	  (Coleman	  et	  al.,	  2009;	  Kendall-­‐Gallagher	  et	  al.,	  2011;	  Miller	  &	  Boyle,	  2008).	  There	  may	  also	  be	  additional	  advantages	  of	  nursing	  specialization,	  such	  as	  the	  development	  of	  nurse	  experts	  to	  support	  and	  educate	  bedside	  nurses	  and	  	   24	  patients,	  and	  bring	  expertise	  to	  quality	  improvement	  activities,	  while	  also	  improving	  nurse	  satisfaction	  and	  retention	  (Miller	  &	  Boyle,	  2008).	  Although	  certification	  is	  frequently	  perceived	  positively,	  barriers	  to	  specialization	  also	  exist	  and	  concerns	  about	  access	  to	  attaining	  specialty	  certification	  status,	  without	  which,	  one	  cannot	  be	  formally	  recognized	  in	  any	  given	  specialty.	  Specialties	  lacking	  formal	  recognition	  in	  the	  form	  of	  a	  certification	  examination	  also	  present	  a	  significant	  barrier.	  Literature	  also	  revealed	  some	  possible	  negative	  attitudes	  towards	  specialization,	  particularly	  in	  the	  medical	  profession.	  Whereas	  certification	  is	  the	  “formal”	  recognition	  of	  a	  nursing	  specialty,	  given	  the	  idea	  that	  specialties	  are	  produced	  out	  of	  the	  needs	  of	  specific	  patient	  populations	  and	  their	  required	  level	  of	  nursing	  care,	  thoracic	  surgery	  may	  be	  a	  good	  contender	  for	  fitting	  with	  descriptions	  of	  a	  nursing	  specialty.	  Much	  of	  the	  literature	  explored	  does	  not	  account	  for	  how	  nurses	  perceive	  these	  non-­‐formally	  recognized	  specialties.	  	  Chapter	  three	  will	  be	  about	  the	  methodological	  approach	  and	  methods	  of	  analysis	  used	  to	  undertake	  this	  study	  and	  understand	  the	  perceptions	  of	  specialty	  certification,	  as	  well	  as	  thoracic	  surgery	  as	  a	  nursing	  specialty.	  	  	  	   25	  CHAPTER	  3:	  METHODS	  	   The	  research	  questions	  for	  this	  study	  included:	  	  (a) How	  do	  experienced	  thoracic	  nurses	  and	  surgeons	  perceive	  nursing	  specialization/certification?	  	  (b) Do	  nurses	  and	  surgeons	  perceive	  nursing	  to	  require	  an	  advanced	  level	  of	  knowledge	  and	  skills	  to	  meet	  the	  needs	  of	  the	  thoracic	  surgery	  patient	  population?	  (c) Do	  nurses	  and	  surgeons	  feel	  that	  thoracic	  surgery	  should	  be	  formally	  recognized	  as	  a	  nursing	  specialty?	  The	  methodology	  for	  the	  study	  is	  described	  in	  this	  chapter,	  including	  design,	  sampling,	  data	  collection,	  analysis,	  ethical	  considerations	  and	  limitations	  of	  the	  study.	  Study	  Design	  and	  Setting	  To	  address	  the	  research	  question	  and	  objectives,	  I	  selected	  a	  methodology	  that	  I	  believed	  would	  elicit	  the	  most	  authentic	  answers.	  A	  quantitative	  approach	  was	  used	  in	  this	  study,	  with	  data	  collected	  through	  a	  web-­‐based	  survey	  that	  included	  both	  Likert-­‐scale	  and	  multiple-­‐choice	  questions.	  	  Apart	  from	  low	  cost,	  the	  use	  of	  a	  web-­‐based	  survey	  approach	  ensured	  the	  survey	  was	  self-­‐paced	  and	  anonymous	  to	  encourage	  accurate	  and	  honest	  answers.	  Ha	  et	  al.	  (2015)	  suggest	  that	  if	  the	  researcher	  wants	  a	  survey	  to	  be	  self-­‐paced	  by	  the	  respondent,	  then	  self-­‐administered	  paper	  surveys,	  mail	  or	  online	  surveys	  are	  the	  best	  choices,	  while	  telephone	  or	  face-­‐to-­‐face	  interviews	  with	  the	  presence	  of	  an	  	   26	  interviewer	  are	  more	  effective	  in	  controlling	  the	  flow	  of	  response	  as	  well	  as	  questions	  that	  need	  further	  explanation	  and	  probing.	  Additionally,	  telephone	  and	  face-­‐to-­‐face	  surveys	  are	  more	  likely	  to	  elicit	  socially	  acceptable	  answers,	  while	  privacy	  of	  mail	  and	  online	  surveys	  has	  been	  repeatedly	  shown	  to	  reduce	  socially	  desirable	  answers	  and	  increase	  more	  accurate	  answers	  (Ha	  et	  al.).	  The	  first	  half	  of	  the	  survey	  utilized	  the	  Perceived	  Value	  of	  Certification	  Tool	  ©	  (PVCT)	  to	  explore	  perceptions	  of	  the	  value	  of	  nurse	  certification.	  Additional	  multiple-­‐choice	  questions	  were	  added	  after	  the	  PVCT,	  and	  collected	  demographic	  information,	  as	  well	  as	  examined	  if	  advanced	  knowledge	  and	  skills	  are	  required	  of	  thoracic	  nurses,	  and	  in-­‐turn,	  if	  they	  felt	  thoracic	  surgery	  should	  be	  recognized	  as	  a	  nursing	  specialty.	  These	  questions	  were	  developed	  based	  on	  the	  research	  questions:	  Do	  nurses	  and	  surgeons	  perceive	  nursing	  to	  require	  an	  advanced	  level	  of	  knowledge	  and	  skills	  to	  meet	  the	  needs	  of	  the	  thoracic	  surgery	  patient	  population?	  And	  also,	  do	  nurses	  and	  surgeons	  feel	  that	  thoracic	  surgery	  should	  be	  formally	  recognized	  as	  a	  nursing	  specialty?	  The	  multiple-­‐response	  answers	  were	  developed	  from	  a	  combination	  of	  medical-­‐surgical	  nursing	  texts,	  thoracic	  surgery	  literature,	  and	  the	  researcher’s	  personal	  experience	  of	  the	  specialty.	  Sample	  Selection	  &	  Recruitment	  	  The	  researcher	  aimed	  to	  target	  experienced	  thoracic	  nurses	  and	  surgeons	  from	  several	  major	  thoracic	  surgery	  centers	  in	  British	  Columbia	  such	  as	  Surrey	  Memorial	  Hospital	  (SMH),	  Vancouver	  General	  Hospital	  (VGH),	  Kelowna	  General	  Hospital	  (KGH)	  and	  Victoria	  Royal	  Jubilee	  Hospital	  (RJH)	  who	  could	  speak	  to	  the	  	   27	  phenomena	  of	  concern.	  As	  each	  site	  employs	  a	  slightly	  different	  thoracic	  surgery	  care	  model	  (for	  example,	  closed	  units	  admitting	  only	  respiratory	  and/or	  thoracic	  surgery	  patients	  versus	  thoracic	  beds	  within	  a	  general	  surgical	  unit,	  as	  well	  as	  varied	  staff	  mixes)	  the	  inclusion	  of	  several	  sites	  was	  designed	  to	  contribute	  to	  a	  good	  representation	  of	  the	  thoracic	  surgery	  staff	  concerned	  with	  this	  specialty.	  This	  study	  aimed	  to	  produce	  a	  minimum	  sample	  size	  of	  30	  survey	  respondents.	  Given	  the	  narrow	  focus	  of	  the	  research,	  it	  was	  thought	  that	  30	  responses	  would	  be	  the	  minimum	  number	  to	  ensure	  sufficient	  representation	  of	  the	  target	  thoracic	  surgery	  workforce.	  This	  sample	  was	  attained	  through	  targeted	  non-­‐probability	  convenience	  sampling	  (Polit	  and	  Beck,	  2012).	  Convenience	  sampling	  was	  used	  as	  it	  fits	  with	  the	  chosen	  study	  design,	  relies	  on	  volunteers	  and	  worked	  well	  with	  participants	  who	  needed	  to	  be	  “recruited	  from	  a	  particular	  clinical	  setting	  or	  organization”	  (Polit	  &	  Beck,	  p.	  516).	  This	  method	  worked	  well	  given	  the	  limited	  time	  and	  resources	  for	  this	  study,	  especially	  with	  this	  work	  being	  exploratory	  only	  in	  nature,	  and	  the	  desired	  sample	  population	  being	  multi-­‐site	  and	  province-­‐wide.	  	  	   The	  Clinical	  Nurse	  Educator	  (CNE)	  at	  each	  thoracic	  surgery	  center	  was	  asked	  to	  distribute	  the	  study	  invitation	  (Appendix	  A),	  consent	  information	  (Appendix	  B),	  and	  survey	  link	  to	  thoracic	  staff	  via	  institutional	  email.	  A	  small	  recruitment	  poster	  (Appendix	  C)	  was	  created	  and	  provided	  to	  the	  CNEs	  for	  survey	  advertising.	  The	  poster	  addressed	  the	  target	  population	  of	  RNs,	  nurse	  leaders,	  and	  surgeons,	  provided	  a	  brief	  description	  of	  the	  study,	  highlighted	  the	  opportunity	  for	  a	  prize	  draw,	  as	  well	  as	  outlined	  the	  inclusion	  and	  exclusion	  criteria.	  	  	  	   28	  All	  participants	  had	  the	  option	  of	  entering	  a	  prize	  draw	  as	  incentive	  to	  participate.	  Any	  participant	  who	  withdrew	  or	  was	  excluded	  from	  the	  research	  still	  had	  their	  name	  included	  in	  the	  prize	  draw.	  Care	  was	  taken	  such	  that	  entering	  the	  draw	  did	  not	  compromise	  the	  confidentiality	  of	  the	  participant.	  Any	  email	  address	  provided	  by	  the	  participant	  was	  not	  associated	  with	  their	  survey	  responses,	  and	  was	  used	  only	  for	  the	  purpose	  of	  the	  prize	  draw.	  There	  were	  three	  prize	  draw	  winners,	  each	  of	  whom	  were	  notified	  and	  delivered	  a	  $25	  Starbucks	  Gift	  Card	  via	  email.	  The	  inclusion	  criteria	  for	  the	  study	  was	  nurses	  with	  two	  or	  more	  years	  of	  experience	  in	  thoracic	  surgery,	  advanced	  practice	  nurses	  working	  within	  the	  specialty	  area,	  and	  also	  thoracic	  surgeons.	  Benner	  describes	  the	  process	  of	  nursing	  clinical	  judgment	  and	  skill	  development	  using	  different	  levels	  of	  proficiency,	  suggesting	  a	  nurse	  at	  the	  “competent”	  level	  have	  2	  to	  3	  years	  of	  clinical	  experience,	  from	  which	  the	  nurse	  is	  able	  to	  cope	  with	  and	  manage	  many	  of	  the	  more	  challenging	  occurrences	  of	  clinical	  nursing	  practice	  (Valdez,	  2008).	  Hence,	  the	  researcher	  chose	  a	  minimum	  of	  2	  years	  of	  experience	  in	  the	  area.	  Advanced	  Practice	  Nurses	  are	  a	  common	  member	  of	  the	  thoracic	  surgery	  team,	  and	  were	  included	  for	  their	  role	  in	  caring	  for	  the	  thoracic	  surgery	  patient	  population,	  as	  well	  as	  their	  knowledge	  and	  expertise	  of	  the	  subject.	  Thoracic	  surgeons	  were	  included	  in	  this	  study	  in	  order	  to	  gain	  their	  perspectives	  on	  the	  expectations	  of	  nursing	  in	  caring	  for	  the	  thoracic	  patient	  population	  and	  the	  value	  of	  specialization	  for	  thoracic	  nurses.	  As	  thoracic	  surgery	  is	  a	  highly	  specialized	  practice,	  the	  pre	  and	  post-­‐operative	  care	  of	  their	  patients	  is	  just	  as	  specialized.	  Yet	  it	  could	  be	  seen	  as	  entry-­‐level	  nursing	  practice	  by	  surgeons,	  and	  so	  it	  was	  seen	  as	  important	  to	  include	  the	  perceptions	  of	  thoracic	  	   29	  surgeons	  in	  this	  work,	  particularly	  as	  they	  often	  have	  influence	  on	  the	  recruitment	  and	  employment	  of	  nurses	  in	  these	  areas.	  	  Additionally,	  in	  order	  to	  correspond	  with	  CNA	  eligibility	  criteria	  for	  certification,	  exclusion	  criterion	  for	  the	  sample	  included:	  staff	  without	  a	  permanent	  assignment	  in	  the	  thoracic	  surgery	  unit	  or	  area;	  for	  example,	  casually	  employed	  nurses	  who	  work	  on	  multiple	  units	  and	  therefore	  are	  not	  permanent	  thoracic	  surgery	  nurses,	  and	  staff	  with	  less	  than	  two	  years	  of	  experience.	  Given	  the	  varying	  size	  of	  each	  thoracic	  surgery	  center,	  the	  corresponding	  disparity	  in	  staffing	  across	  sites,	  and	  the	  exclusion	  criteria,	  30	  participants	  was	  the	  minimum	  expected	  sample	  size.	  The	  total	  number	  of	  survey	  respondents	  was	  53,	  with	  40	  meeting	  the	  criteria	  for	  inclusion.	  8	  were	  excluded	  due	  to	  casual	  employment	  status,	  and	  5	  excluded	  for	  having	  less	  than	  two	  years	  of	  experience	  in	  thoracic	  surgery.	  Procedures	  and	  Data	  Collection	  	  Data	  collection	  took	  place	  over	  a	  period	  of	  six	  weeks	  through	  a	  web-­‐based	  survey	  using	  the	  Canadian	  FluidSurveys™	  tool.	  A	  link	  to	  the	  anonymous	  online	  survey	  was	  distributed	  to	  staff	  at	  each	  site	  through	  institutional	  email	  by	  the	  department	  CNE.	  	  The	  short-­‐two	  part	  survey	  (Appendix	  D)	  combined	  Likert-­‐scale	  and	  multiple-­‐choice	  type	  questions.	  The	  first	  part	  was	  used	  to	  assess	  the	  participant’s	  perceptions	  of	  nursing	  specialization,	  and	  utilized	  the	  18-­‐item	  Perceived	  Value	  of	  Certification	  Tool	  ©	  (PVCT),	  with	  written	  permission	  from	  the	  Competency	  and	  Credentialing	  Institute	  (Appendix	  E).	  The	  responses	  were	  	   30	  measured	  by	  the	  degree	  to	  which	  the	  respondents	  agree	  or	  disagree	  with	  each	  individual	  statement.	  The	  Likert-­‐type	  response	  scale	  ranges	  from	  strongly	  agree,	  agree,	  disagree,	  strongly	  disagree,	  and	  no	  opinion.	  A	  numerical	  value	  is	  assigned	  to	  each	  Likert-­‐scale	  response,	  and	  the	  assumption	  is	  made	  that	  is	  response	  is	  equidistant	  on	  the	  scale.	  	  The	  PVCT,	  developed	  by	  the	  Competency	  and	  Credentialing	  Institute,	  has	  demonstrated	  excellent	  reliability	  and	  validity	  in	  multiple	  studies.	  In	  a	  recent	  study	  of	  2,323	  certified	  and	  non-­‐certified	  operating	  room	  nurses,	  the	  reliability	  coefficient	  for	  the	  18-­‐survey	  items	  for	  the	  PVCT	  was	  (alpha)	  0.94,	  indicating	  a	  high	  degree	  of	  internal	  consistency	  (reliability)	  among	  the	  items	  (Haskins,	  Hnatiuk,	  &	  Yoder,	  2011).	  Similar	  findings	  have	  also	  been	  noted	  in	  studies	  completed	  by	  the	  American	  Board	  of	  Nursing	  Specialties	  (2006).	  The	  value	  statements	  are	  grouped	  into	  two	  factors:	  intrinsic	  and	  extrinsic	  rewards	  for	  certification.	  Intrinsic	  rewards	  are	  motivators	  internal	  to	  an	  individual	  and	  linked	  to	  personal	  development	  and	  self-­‐concept	  values,	  while	  extrinsic	  rewards	  are	  external	  to	  an	  individual	  and	  defined	  by	  others	  (Niebuhr	  &	  Biel,	  2007).	  The	  second	  portion	  of	  the	  survey	  was	  not	  part	  of	  the	  PVCT,	  and	  collected	  general	  demographic	  information	  (to	  explore	  any	  variations	  within	  the	  sample)	  and	  asked	  several	  multiple-­‐choice	  questions	  about	  the	  knowledge	  and	  skill	  level	  perceived	  necessary	  for	  working	  with	  the	  thoracic	  patient	  population.	  At	  the	  end	  of	  the	  survey,	  participants	  also	  had	  the	  option	  of	  entering	  additional	  comments	  in	  an	  open	  question.	  The	  estimated	  time	  to	  read	  the	  study	  information	  and	  consent,	  as	  well	  as	  complete	  the	  survey	  was	  approximately	  15	  minutes.	  Two	  reminder	  emails	  	   31	  were	  sent	  to	  CNEs	  for	  distribution	  at	  1	  week	  and	  2	  weeks	  after	  the	  initial	  information	  had	  been	  sent.	  Once	  study	  information	  had	  been	  distributed,	  the	  survey	  link	  remained	  open	  for	  a	  period	  of	  six	  weeks	  during	  December	  2014	  to	  January	  2015.	  This	  time	  frame	  gave	  participants	  ample	  time	  to	  review	  the	  purpose	  of	  the	  study	  and	  make	  a	  decision	  about	  participation.	  This	  also	  ensured	  participants	  who	  may	  check	  their	  institutional	  email	  less	  often,	  still	  had	  the	  opportunity	  to	  view	  the	  invitation	  to	  participate.	  Data	  Analysis	  	  After	  closure	  of	  the	  online	  survey,	  data	  was	  downloaded	  and	  participants’	  responses	  were	  coded	  and	  inputted	  into	  computer	  software	  for	  statistical	  analysis,	  the	  Statistical	  Package	  for	  the	  Social	  Sciences	  (SPSS®),	  version	  20.	  The	  data	  was	  analyzed	  using	  descriptive	  statistics	  to	  explore	  for	  trends	  and	  patterns.	  Graphical	  representations	  and	  tables	  were	  created	  using	  Microsoft®	  Excel®	  for	  Mac	  (2011),	  version	  14.1.3,	  and	  SPSS®,	  and	  served	  to	  illustrate	  demographic	  and	  perceptual	  variances,	  as	  well	  as	  the	  distribution	  of	  results,	  such	  as	  years	  of	  experience.	  	  Since	  Likert-­‐type	  scales	  can	  also	  be	  treated	  as	  interval-­‐level	  data,	  for	  the	  PVCT	  questions,	  each	  item	  on	  the	  response	  scale	  was	  assigned	  a	  score,	  with	  strongly	  disagree	  =	  1,	  disagree	  =	  2,	  agree	  =	  3,	  and	  strongly	  agree	  =	  4.	  Since	  “5”	  on	  the	  scale	  represents	  “no	  opinion,”	  it	  could	  not	  be	  considered	  a	  part	  of	  the	  interval	  scale,	  thus	  this	  response	  was	  eliminated	  from	  further	  calculations.	  Since	  the	  percentage	  of	  missing	  data	  was	  minimal	  (less	  than	  2.5%	  of	  overall	  responses),	  those	  subjects	  who	  	   32	  responded	  “no	  opinion”	  (a	  “5”	  on	  the	  response	  scale)	  were	  omitted	  from	  the	  statistical	  analysis	  of	  that	  particular	  question	  only	  in	  order	  to	  keep	  bias	  at	  a	  minimum.	  	  Frequencies	  were	  used	  to	  determine	  how	  many	  participants	  responded	  with	  a	  “1”,	  ”2”,	  ”3”,	  or	  ”4”	  with	  means	  and	  standard	  deviations	  were	  calculated	  for	  participants’	  responses	  to	  the	  18-­‐item	  PVCT	  Likert-­‐type	  questions.	  Responses	  to	  the	  thoracic	  surgery	  specific	  questions	  were	  evaluated	  as	  a	  percent	  agreement	  (nominal	  level)	  for	  each	  statement.	  	  Ethical	  Considerations	  	  Ethical	  approval	  for	  the	  study	  was	  obtained	  from	  the	  UBC	  Behavioral	  Research	  Ethics	  Board,	  as	  the	  Board	  of	  Record	  for	  the	  Ethics	  Boards	  from	  the	  respective	  health	  authorities.	  This	  study	  was	  identified	  as	  minimal	  risk,	  with	  no	  physical,	  psychological,	  emotional,	  or	  social	  risks	  identified.	  Survey	  participation	  was	  voluntary	  and	  participants	  were	  able	  to	  refuse	  or	  end	  their	  participation	  at	  any	  time	  without	  jeopardizing	  any	  relationship	  with	  the	  employing	  institution,	  or	  the	  University	  of	  British	  Columbia.	  The	  surveys	  were	  completed	  anonymously,	  and	  all	  participants	  received	  an	  electronic	  copy	  of	  study	  information	  (Appendix	  A)	  and	  informed	  consent	  (Appendix	  B).	  Completion	  and	  submission	  of	  the	  survey	  was	  taken	  as	  consent	  to	  participate	  in	  the	  study.	  	  Survey	  completion	  was	  anonymous,	  although	  participants	  had	  the	  option	  of	  entering	  their	  email	  address	  if	  they	  wished	  to	  participate	  in	  the	  prize	  draw.	  In	  these	  cases,	  the	  email	  addresses	  were	  not	  associated	  with	  survey	  responses.	  Data	  collected	  via	  FluidSurveys™	  was	  stored	  on	  servers	  located	  at	  UBC	  and	  password	  	   33	  protected.	  Any	  electronic	  files	  were	  password	  protected	  and	  stored	  on	  a	  secure	  computer	  -­‐	  either	  a	  password	  protected	  laptop,	  or	  on	  a	  password	  protected	  computer	  at	  the	  UBC	  School	  of	  Nursing.	  Data	  will	  be	  retained	  on	  a	  secure	  computer	  at	  UBC	  for	  a	  period	  of	  5	  years.	  Details	  of	  study	  confidentiality	  were	  described	  for	  participants	  on	  page	  2	  of	  the	  consent	  information	  (Appendix	  B).	  Limitations	  of	  Study	  Design	  	  There	  were	  several	  limitations	  to	  the	  study	  that	  may	  have	  influenced	  the	  results.	  This	  was	  an	  exploratory,	  non-­‐experimental,	  descriptive	  study,	  with	  the	  small	  sample	  size	  and	  use	  of	  non-­‐probability	  sampling	  representing	  the	  most	  significant	  limitations.	  However,	  because	  participants	  needed	  to	  be	  recruited	  from	  a	  specific	  clinical	  setting,	  convenience	  sampling	  was	  determined	  to	  be	  the	  most	  efficient	  way	  to	  reach	  the	  largest	  number	  of	  potential	  participants.	  In	  attempt	  to	  reduce	  sampling	  bias,	  participants	  were	  recruited	  from	  multiple	  thoracic	  surgery	  sites.	  Unfortunately,	  due	  to	  specific	  inclusion	  criteria,	  the	  sample	  was	  limited	  to	  permanent	  thoracic	  staff,	  and	  several	  casual	  nurse	  responses	  were	  excluded	  from	  the	  data	  set,	  reducing	  the	  overall	  number	  of	  respondents.	  	  When	  implementing	  a	  quantitative	  research	  design,	  use	  of	  a	  non-­‐probability	  sampling	  technique	  limits	  our	  ability	  to	  make	  broader	  generalizations	  from	  our	  results	  (Polit	  and	  Beck,	  2012).	  Another	  specific	  challenge	  of	  using	  surveys	  in	  particular	  as	  a	  data	  collection	  method,	  is	  obtaining	  a	  large	  enough	  sample,	  especially	  when	  good	  representation	  is	  expected	  (Ha,	  2015).	  	  	   34	  Furthermore,	  another	  limitation	  was	  that	  the	  additional	  questions	  concerning	  thoracic	  surgery	  included	  in	  the	  survey	  were	  multiple-­‐choice,	  with	  predetermined	  answers.	  Future	  research	  could	  explore	  physician	  and	  perceptions	  through	  a	  qualitative	  approach,	  using	  more	  open-­‐ended	  questions	  to	  elicit	  further	  answers	  and	  ideas.	  Summary	  	  Chapter	  three	  presented	  an	  overview	  of	  the	  methodologies	  used	  to	  conduct	  this	  quantitative	  research	  study.	  It	  introduced	  how	  data	  was	  collected,	  handled	  and	  analyzed	  and	  additionally,	  how	  confidentiality	  and	  other	  ethical	  considerations	  were	  taken	  into	  account.	  	  That	  data	  that	  was	  generated	  from	  the	  online	  survey	  was	  analyzed	  using	  SPSS®	  software	  and	  is	  presented	  and	  discussed	  in	  chapter	  four.	  	   35	  CHAPTER	  4:	  RESEARCH	  FINDINGS	  	   In	  this	  chapter,	  the	  findings	  from	  this	  research	  are	  presented.	  Graphical	  representations	  and	  tables	  are	  used	  to	  illustrate	  results	  and	  were	  created	  using	  Microsoft®	  Excel®	  for	  Mac	  (2011),	  version	  14.1.3,	  and	  SPSS®.	  Descriptive	  statistics	  were	  used	  to	  examine	  the	  data	  collected	  through	  a	  web-­‐based	  survey.	  Average	  completion	  time	  for	  the	  online	  survey	  was	  5:42	  minutes,	  with	  a	  minimum	  time	  of	  2:02	  and	  maximum	  time	  of	  11:16.	  This	  does	  not	  include	  the	  time	  the	  participant	  spent	  reviewing	  the	  study	  invitation	  and	  consent	  materials.	  The	  total	  number	  of	  survey	  respondents	  was	  53,	  with	  40	  meeting	  the	  criteria	  for	  inclusion.	  Sample	  Characteristics	  Participants	  were	  thoracic	  nurses	  and	  surgeons	  from	  three	  thoracic	  surgery	  centers:	  Surrey	  Memorial	  Hospital	  (70%),	  Vancouver	  General	  Hospital	  (12.5%),	  and	  Victoria	  Royal	  Jubilee	  Hospital	  (17.5%).	  Kelowna	  General	  Hospital	  was	  also	  included	  in	  the	  survey	  invitations.	  However,	  no	  survey	  responses	  were	  completed	  from	  this	  site.	  	   The	  sample	  consisted	  of	  32	  (80%)	  thoracic	  nurses,	  3	  (7.5%)	  thoracic	  surgeons,	  and	  5	  (12.5%)	  nurses	  in	  leadership	  positions	  (Manager,	  Patient	  Care	  Coordinator,	  Clinical	  Nurse	  Educator).	  In	  terms	  of	  gender,	  31	  (77.5	  %)	  respondents	  were	  female,	  and	  9	  (22.5%)	  male.	  33	  respondents	  were	  full	  time	  (82.5%)	  and	  7	  were	  part-­‐time	  (17.5%).	  	  The	  majority	  of	  respondents	  (55%)	  had	  5	  or	  more	  years	  of	  overall	  experience	  in	  their	  profession,	  with	  47.5%	  having	  worked	  5	  or	  more	  of	  those	  years	  in	  a	  thoracic	  	   36	  surgery	  area.	  Table	  1	  illustrates	  the	  characteristics	  of	  the	  sample.	  The	  typical	  respondent	  was	  a	  female	  frontline	  registered	  nurse,	  working	  full	  time.	  	  	  Table	  1	  Demographic	  profile	  of	  respondents	  Characteristics (n=40) Frequency Percentage (%) Primary Work Site Surrey Memorial Hospital Vancouver General Hospital Victoria Royal Jubilee Hospital Current Role Registered Nurse Surgeon Nursing Leadership (Manager, PCCa, CNEb) Gender Male Female Employment Status Full-Time Part-Time Overall Years of Experience 2-3 years 3-5 years Over 5 years Years of Experience with Thoracic Surgery 2-3 years 3-5 years Over 5 years   28 5 7  32 3 5  9 31  33 7  8 10 22  8 13 19    70.0 12.5 17.5  80.0 7.5 12.5  22.5 77.5  82.5 17.5  20.0 25.0 55.0  20.0 32.5 47.5  	  Note. aPatient Care Coordinator (PCC), bClinical Nurse Educator (CNE).  Perceived	  Value	  of	  Certification	  Each	  response	  to	  the	  Perceived	  Value	  of	  Certification	  Tool	  ©	  was	  assigned	  a	  numerical	  value,	  with	  strongly	  disagree	  =	  1,	  disagree	  =	  2,	  agree	  =	  3,	  and	  strongly	  agree	  =	  4.	  These	  values	  were	  analyzed	  as	  interval	  level	  data,	  in	  which	  means	  and	  	   37	  standard	  deviations	  were	  calculated	  (Table	  2).	  Item	  response	  statistics	  are	  also	  represented	  graphically	  in	  Figure	  1.	  The	  statement	  with	  most	  positive	  agreement	  was	  that	  certification	  “enhances	  feelings	  of	  personal	  accomplishment,”	  with	  a	  mean	  score	  of	  3.48,	  suggesting	  respondents	  identified	  most	  with	  this	  intrinsic	  reward	  of	  certification.	  Other	  highly	  agreed	  with	  statements	  indicated	  respondents	  felt	  that	  certification	  “provided	  a	  professional	  challenge”	  (mean	  score	  of	  3.50),	  and	  “validates	  specialized	  knowledge”	  (mean	  score	  of	  3.48).	  	  The	  most	  negatively	  perceived	  statement,	  with	  a	  mean	  score	  of	  2.62,	  (and	  also	  the	  most	  varied	  response:	  SD	  =	  0.924),	  was	  “increases	  salary,”	  suggesting	  that	  most	  respondents	  did	  not	  feel	  that	  certification	  resulted	  in	  an	  increase	  in	  salary.	  	  	  	  	  	  	  	  	  	  	  	  	  	   38	  Table	  2	  PVCT	  item	  response	  statistics	  	  	  	   39	  Figure	  1	  PVCT	  item	  response	  statistics	  	  	  Perceptions	  of	  Thoracic	  Surgery	  Advanced	  Knowledge	  Related	  to	  Thoracic	  Surgery	  Responses	  to	  the	  thoracic	  surgery	  specific	  question	  exploring	  perceptions	  of	  advanced	  knowledge	  required,	  related	  to	  thoracic	  surgery	  were	  analyzed	  as	  a	  percentage	  of	  agreement	  (nominal	  level)	  for	  each	  of	  the	  given	  components,	  and	  results	  are	  represented	  in	  Table	  3.	  	   40	  Participants	  were	  asked	  to	  select	  the	  statements	  that	  they	  perceive	  to	  be	  examples	  of	  advanced	  nursing	  knowledge	  related	  to	  thoracic	  surgery:	  • Knowledge	  of	  lung-­‐associated	  diseases,	  cancers	  and	  their	  stages	  • Knowledge	  of	  esophageal-­‐associated	  diseases,	  cancers	  and	  their	  stages	  • Knowledge	  of	  thoracic	  surgical	  procedures	  (eg.	  lobectomy,	  esophagectomy)	  • Knowledge	  and	  understanding	  of	  potential	  complications	  of	  thoracic	  surgical	  procedures	  and	  when	  to	  intervene	  • Understanding	  of	  the	  implications	  of	  thoracic	  surgeries	  and	  application	  to	  patient	  care	  peri-­‐operatively,	  with	  considerations	  to	  pain	  management,	  activity,	  nutrition,	  and	  lifestyle	  • Ability	  to	  provide	  patient	  teaching	  of	  thoracic	  surgical	  procedures	  and	  their	  implications	  • Anticipation	  of	  the	  needs	  of	  thoracic	  surgery	  patients	  post-­‐discharge	  from	  acute	  care,	  with	  considerations	  to	  pain	  management,	  activity,	  nutrition,	  and	  lifestyle	  • Other:	  _________	  All	  of	  the	  surgeons	  identified	  all	  of	  the	  statements	  as	  advanced	  thoracic	  surgery	  related	  knowledge,	  indicating	  that	  thoracic	  surgeons	  recognize	  and	  value	  the	  additional	  specialist	  knowledge	  that	  is	  required	  of	  thoracic	  nurses.	  However,	  whilst	  the	  majority	  of	  frontline	  registered	  nurses	  also	  reported	  that	  all	  the	  statements	  characterizing	  knowledge	  of	  thoracic	  surgery	  were	  valuable,	  the	  highest	  scoring	  statements	  they	  identified	  were	  those	  relating	  to	  knowledge	  of	  thoracic	  	   41	  surgical	  procedures	  (90.6%),	  and	  of	  the	  potential	  complications	  of	  thoracic	  surgical	  procedures	  and	  when	  to	  intervene	  (93.8%),	  understanding	  of	  the	  implications	  of	  thoracic	  surgeries	  and	  application	  to	  patient	  care	  peri-­‐operatively	  with	  considerations	  to	  pain	  management,	  activity,	  nutrition,	  and	  lifestyle	  (84.4%),	  and	  ability	  to	  provide	  patient	  teaching	  of	  thoracic	  surgical	  procedures	  and	  their	  implications	  (90.6%).	  The	  majority	  (80%)	  of	  nurse	  leaders	  identified	  all	  of	  the	  components	  as	  advanced	  knowledge	  related	  to	  thoracic	  surgery.	  One	  surgeon	  also	  commented	  that	  “management	  of	  complex	  pleural	  based	  diseases	  and	  post-­‐surgical	  pleural	  spaces”	  was	  advanced	  nursing	  knowledge	  related	  to	  thoracic	  surgery.	  Additionally,	  a	  nurse	  respondent	  commented	  that	  “ELOS”	  (estimated	  length	  of	  stay)	  was	  advanced	  nursing	  knowledge	  related	  to	  the	  thoracic	  surgery	  patient.	  	  	  	  	  	  	  	  	  	  	  	   42	  Table	  3	  Perceptions	  of	  advanced	  nursing	  knowledge	  related	  to	  thoracics,	  by	  role	  	  	   43	  Advanced	  Skills	  Related	  to	  Thoracic	  Surgery	  Responses	  to	  the	  thoracic	  surgery	  specific	  question	  exploring	  perceptions	  of	  advanced	  skills	  related	  to	  thoracic	  surgery	  were	  analyzed	  as	  a	  percentage	  of	  agreement	  (nominal	  level)	  for	  each	  statement,	  and	  the	  results	  are	  given	  in	  Table	  4.	  	  Participants	  were	  asked	  to	  select	  the	  statements	  that	  they	  perceive	  to	  be	  examples	  of	  advanced	  nursing	  skills	  related	  to	  thoracic	  surgery:	  • Auscultation	  of	  chest	  sounds	  • Interpretation	  of	  cardiac	  rhythms	  and	  interventions	  • Assessment	  and	  care	  of	  chest	  tubes	  • Assessment,	  care,	  and	  management	  of	  chest	  drainage	  devices	  (eg.	  Pleur-­‐evac®,	  Thopaz™,	  Pneumostat™)	  	  • Assessment,	  care,	  and	  management	  of	  long-­‐term	  chest	  catheters	  for	  malignant	  pleural	  effusions	  (eg.	  PleurX®)	  • Irrigations/flushing	  of	  chest	  tubes	  • Removal	  of	  chest	  tubes	  • Other:	  __________	  The	  lowest	  scoring	  skill	  perceived	  as	  an	  advanced	  skill	  was	  found	  to	  be	  “auscultation	  of	  chest	  sounds”	  with	  only	  28.1%	  of	  the	  registered	  nurses	  and	  33.3%	  of	  the	  surgeons	  identifying	  this	  as	  an	  advanced	  thoracic	  surgery	  skill.	  This	  would	  seem	  to	  suggest	  that	  both	  nurses	  and	  surgeons	  recognize	  the	  auscultation	  of	  chest	  sounds	  to	  be	  a	  basic	  nursing	  skill.	  However,	  the	  majority	  (81.2%)	  of	  nurses	  felt	  that	  the	  interpretation	  of	  cardiac	  rhythms	  was	  an	  advanced	  nursing	  skill,	  whilst	  only	  66.7%	  of	  surgeons	  were	  in	  agreement.	  	  	   44	  Roughly	  half	  (56.2%)	  of	  the	  nurse	  respondents	  identified	  that	  the	  assessment	  and	  care	  of	  chest	  tubes	  was	  an	  advanced	  thoracic	  nursing	  skill,	  with	  slightly	  more	  (65.6%)	  identifying	  the	  assessment,	  care,	  and	  management	  of	  drainage	  devices	  as	  advanced	  thoracic	  skills.	  	  The	  assessment	  and	  care	  of	  chest	  tubes	  refers	  to	  care	  of	  the	  tube	  itself,	  which	  is	  inserted	  into	  the	  pleural	  space	  for	  drainage	  of	  air	  or	  fluid.	  Assessment	  involves	  inspection	  of	  the	  insertion	  site	  for	  redness,	  swelling,	  drainage,	  subcutaneous	  emphysema	  (air	  under	  the	  skin),	  and	  tube	  placement,	  with	  the	  associated	  care	  being	  cleansing	  and	  dressing	  of	  the	  site.	  Assessment,	  care,	  and	  management	  of	  drainage	  devices	  refers	  to	  the	  equipment	  attached	  to	  the	  chest	  tube,	  which	  collects	  and	  measures	  the	  drainage,	  as	  well	  as	  prevents	  air	  or	  fluid	  from	  returning	  into	  the	  chest,	  thus	  re-­‐establishing	  the	  negative	  pressure	  within	  the	  pleural	  space	  to	  support	  lung	  expansion.	  	  The	  removal	  of	  chest	  tubes	  was	  the	  highest	  scoring	  skill,	  with	  84.4%	  of	  nurses	  perceiving	  it	  to	  be	  an	  advanced	  skill	  related	  to	  thoracic	  surgery.	  All	  of	  the	  surgeon	  respondents	  identified	  all	  of	  the	  skills	  relating	  to	  chest	  tubes	  to	  be	  advanced	  nursing	  skills.	  The	  only	  two	  nursing	  skills	  identified	  as	  advanced	  nursing	  skills	  by	  all	  those	  in	  nursing	  leadership	  roles	  were	  the	  interpretation	  of	  cardiac	  rhythms,	  and	  the	  removal	  of	  chest	  tubes.	  	  One	  of	  the	  nurse	  respondents	  commented,	  “I	  think	  [all	  the]	  examples	  are	  basic	  skills,	  but	  then	  again,	  I	  work	  on	  a	  thoracic	  ward”.	  	  	  	  	   45	  Table	  4	  Perceptions	  of	  advanced	  nursing	  skills	  related	  to	  thoracic	  surgery,	  by	  role	  	  Education	  Requirements	  Participants	  were	  asked	  their	  opinion	  of	  the	  following	  statement	  “Additional	  education	  related	  to	  nursing	  knowledge	  and	  skills	  is	  required	  to	  meet	  the	  care	  needs	  of	  the	  thoracic	  surgery	  patient	  and	  improve	  the	  overall	  nursing	  care	  provided.”	  Answers	  were	  on	  a	  Likert-­‐type	  scale	  with	  respondents	  being	  able	  to	  select	  “strongly	  disagree,”	  “disagree,”	  “agree,”	  “strongly	  agree,”	  or	  identify	  “no	  opinion”	  (Table	  5).	  	  The	  majority	  of	  respondents	  (92.5%)	  either	  agreed	  or	  strongly	  agreed	  with	  this	  statement,	  indicating	  that	  thoracic	  surgery	  nursing	  may	  be	  different	  from	  basic	  	   46	  surgical	  nursing	  or	  entry-­‐to-­‐practice	  standards,	  with	  some	  level	  of	  additional	  nursing	  education	  required.	  The	  three	  respondents	  that	  disagreed	  were	  registered	  nurses,	  with	  the	  remainder	  of	  nurses	  selecting	  “agree”	  or	  “strongly	  agree”.	  Both	  surgeons	  and	  nurse	  leaders	  selected	  only	  “agree”	  or	  “strongly	  agree”.	  Response	  statistics	  by	  role	  is	  presented	  graphically	  in	  Figure	  2.	  	  Table	  5	  Additional	  education	  related	  to	  nursing	  knowledge	  and	  skills	  is	  required	  to	  meet	  the	  care	  needs	  of	  the	  thoracic	  surgery	  patient	  population	  	  	  Figure	  2	  Perception	  of	  additional	  education	  requirements	  for	  thoracic	  nurses,	  response	  breakdown	  by	  role	  	  	  	   47	  Patient	  Outcomes	  Participants	  were	  asked	  their	  opinion	  of	  the	  following	  statement	  “Nursing	  specialty	  recognition	  promotes	  better	  patient	  outcomes.”	  Answers	  were	  on	  a	  Likert-­‐type	  scale	  with	  respondents	  being	  able	  to	  select	  “strongly	  disagree,”	  “disagree,”	  “agree,”	  “strongly	  agree,”	  or	  identify	  “no	  opinion”	  (Table	  6).	  The	  majority	  of	  respondents	  agreed	  (87.5%)	  with	  this	  statement,	  indicating	  the	  perception	  that	  recognition	  of	  nursing	  specialties	  promotes	  better	  outcomes	  for	  patients.	  Response	  statistics	  by	  role	  is	  presented	  graphically	  in	  Figure	  3.	  The	  two	  respondents	  that	  disagreed	  were	  registered	  nurses,	  with	  an	  additional	  three	  not	  responding	  to	  this	  question.	  The	  remaining	  majority	  (84%)	  of	  registered	  nurses	  responded	  with	  either	  “strongly	  agree”	  (50%)	  or	  “agree”	  (34%).	  Two	  surgeons	  answered,	  “strongly	  agree”	  with	  the	  third	  selecting	  “agree”.	  The	  majority	  of	  nurse	  leaders	  responded	  “agree”	  (60%),	  with	  the	  remaining	  selecting	  “strongly	  agree”	  (40%).	  	  Table	  6	  Nursing	  specialty	  recognition	  promotes	  better	  patient	  outcomes	  	  	  	   48	  Figure	  3	  Nursing	  specialty	  recognition	  promotes	  better	  patient	  outcomes,	  response	  breakdown	  by	  role	  	  	  Thoracic	  Surgery	  as	  a	  Nursing	  Specialty	  Participants	  were	  asked	  their	  opinion	  of	  the	  following	  final	  statement	  “Thoracic	  surgery	  should	  be	  formally	  recognized	  as	  a	  certified	  nursing	  specialty.”	  Answers	  were	  on	  a	  Likert-­‐type	  scale	  with	  respondents	  being	  able	  to	  select	  “strongly	  disagree,”	  “disagree,”	  “agree,”	  “strongly	  agree,”	  or	  identify	  “no	  opinion”	  (table	  7).	  The	  majority	  of	  respondents	  (85%)	  responded	  positively,	  either	  agreeing	  or	  strongly	  agreeing	  with	  this	  statement.	  This	  suggests	  that	  thoracic	  nurses	  and	  surgeons	  largely	  feel	  that	  thoracic	  surgery	  should	  be	  formally	  recognized	  as	  a	  certified	  nursing	  specialty.	  Four	  nurses	  did	  not	  respond	  to	  this	  question,	  and	  two	  responded	  with	  “disagree”.	  Response	  statistics	  by	  role	  is	  presented	  graphically	  in	  Figure	  4.	  Additional	  comments	  for	  this	  statement	  included,	  “I	  strongly	  believe	  that	  a	  thoracic	  specialty	  will	  enhance	  patient	  care	  and	  outcomes”,	  and	  “thoracic	  surgical	  	   49	  nursing	  is	  an	  important	  next	  step	  in	  the	  evolution	  of	  the	  management	  of	  thoracic	  surgical	  patients.”	  	  	  Table	  7	  Thoracic	  surgery	  should	  be	  formally	  recognized	  as	  a	  certified	  nursing	  specialty	  	  	  Figure	  4	  Thoracic	  surgery	  should	  be	  formally	  recognized	  as	  a	  certified	  nursing	  specialty,	  response	  breakdown	  by	  role	  	  	  	  	   50	  Summary	  of	  Findings	  Participants	  in	  this	  study	  were	  thoracic	  nurses	  and	  surgeons	  from	  three	  thoracic	  surgery	  centers:	  Surrey	  Memorial	  Hospital,	  Vancouver	  General	  Hospital,	  and	  Victoria	  Royal	  Jubilee	  Hospital.	  The	  typical	  respondent	  was	  female,	  a	  frontline	  registered	  nurse,	  working	  full	  time,	  with	  5	  or	  more	  years	  of	  experience.	  	  The	  most	  agreed	  with	  statement	  in	  the	  Perceive	  Value	  of	  Certification	  tool	  was	  “enhances	  feelings	  of	  personal	  accomplishment,”	  suggesting	  respondents	  identified	  most	  with	  this	  intrinsic	  reward	  of	  certification.	  Other	  statements	  highly	  agreed	  with	  indicated	  respondents	  felt	  that	  certification	  “provided	  a	  professional	  challenge,”	  and	  “validates	  specialized	  knowledge”.	  Overall,	  the	  statements	  most	  agreed	  with	  were	  the	  intrinsic	  rewards,	  suggesting	  that	  internal	  motivators	  may	  be	  more	  important	  to	  respondents	  in	  considering	  certification	  than	  extrinsic	  motivators.	  The	  statement	  with	  the	  highest	  disagreement	  was	  “increases	  salary,”	  indicating	  that	  respondents	  did	  not	  feel	  that	  certification	  resulted	  in	  an	  increase	  in	  salary.	  	  When	  asked	  about	  perceptions	  of	  thoracic	  surgery,	  all	  of	  the	  surgeons	  responded	  that	  all	  knowledge	  statements	  were	  advanced	  thoracic	  surgery	  related	  knowledge.	  While	  the	  majority	  of	  frontline	  nurse	  respondents	  also	  agreed	  that	  all	  the	  knowledge	  statements	  characterized	  thoracic	  surgery,	  the	  highest	  scoring	  statements	  perceived	  by	  nurses	  to	  characterize	  advanced	  knowledge	  were:	  knowledge	  of	  thoracic	  surgical	  procedures,	  knowledge	  and	  understanding	  of	  potential	  complications	  of	  thoracic	  surgical	  procedures	  and	  when	  to	  intervene,	  understanding	  of	  the	  implications	  of	  thoracic	  surgeries	  and	  application	  to	  patient	  	   51	  care	  peri-­‐operatively	  with	  considerations	  to	  pain	  management,	  activity,	  nutrition,	  and	  lifestyle,	  and	  the	  ability	  to	  provide	  patient	  teaching	  of	  thoracic	  surgical	  procedures	  and	  their	  implications.	  In	  terms	  of	  advanced	  skills,	  the	  skill	  with	  the	  lowest	  number	  of	  respondents	  perceiving	  it	  to	  be	  advanced	  was	  found	  to	  be	  “auscultation	  of	  chest	  sounds”.	  The	  majority	  of	  nurses	  and	  surgeons	  felt	  that	  the	  interpretation	  of	  cardiac	  rhythms	  was	  an	  advanced	  nursing	  skill.	  Roughly	  half	  of	  nurse	  respondents	  felt	  that	  the	  assessment	  and	  care	  of	  chest	  tubes	  was	  an	  advanced	  thoracic	  skill,	  while	  the	  removal	  of	  chest	  tubes	  was	  the	  highest	  scoring	  skill,	  with	  the	  majority	  of	  nurses	  perceiving	  it	  to	  be	  an	  advanced	  skill	  related	  to	  thoracic	  surgery.	  Surgeon	  respondents	  perceived	  all	  skills	  related	  to	  chest	  tubes	  to	  be	  advanced	  skills.	  These	  results	  imply	  that	  thoracic	  surgeons	  recognize	  and	  value	  the	  additional	  knowledge	  and	  skill	  of	  thoracic	  nurses.	  The	  majority	  of	  respondents	  either	  agreed	  or	  strongly	  agreed	  with	  that	  additional	  education	  related	  to	  nursing	  knowledge	  and	  skills	  is	  required	  to	  meet	  the	  care	  needs	  of	  the	  thoracic	  surgery	  patient	  and	  improve	  the	  overall	  nursing	  care	  provided	  and	  that	  nursing	  specialty	  recognition	  may	  promote	  better	  patient	  outcomes.	  Finally,	  the	  majority	  of	  respondents	  again	  either	  agreed	  or	  strongly	  agreed	  with	  the	  statement	  that	  thoracic	  surgery	  should	  be	  formally	  recognized	  as	  a	  certified	  nursing	  specialty.	  In	  chapter	  five,	  I	  will	  discuss	  these	  finding,	  suggesting	  explanations	  for	  them	  with	  relation	  to	  existing	  research	  and	  literature.	  	  	  	   52	  CHAPTER	  5:	  DISCUSSION	  	   In	  this	  chapter,	  I	  explore	  the	  implications	  of	  these	  findings,	  discuss	  explanations	  for	  them,	  and	  relate	  the	  findings	  to	  existing	  literature.	  Specialty	  certifications	  have	  been	  shown	  to	  validate	  specific,	  specialized,	  and	  tested	  knowledge	  acquired	  by	  nurses	  (Ferdon,	  2009).	  Research	  is	  essential	  to	  understand	  the	  factors	  affecting	  the	  obtainment	  of	  specialty	  certifications	  for	  growth	  of	  the	  nursing	  profession,	  retention,	  knowledge	  obtainment,	  and	  improved	  patient	  care	  outcomes	  (Ferdon).	  This	  descriptive	  quantitative	  study	  was	  developed	  to	  investigate	  thoracic	  nurses	  and	  surgeons	  perceptions	  of	  specialty	  nursing	  with	  a	  specific	  interest	  in	  whether	  or	  not	  thoracic	  nursing	  should	  be	  considered	  a	  specialty	  and	  why.	  	  Although	  there	  were	  no	  studies	  found	  as	  part	  of	  this	  thesis	  that	  specifically	  examined	  thoracic	  surgery	  as	  a	  nursing	  specialty,	  the	  findings	  of	  this	  study	  support	  results	  of	  studies	  for	  other	  types	  of	  certification,	  indicating	  that	  thoracic	  nurses	  and	  surgeons	  value	  nurse	  certification	  for	  similar	  intrinsic	  and	  extrinsic	  reasons	  as	  nurses	  in	  other	  specialties	  and	  in	  other	  countries	  (Cary,	  2001;	  Niebuhr	  &	  Biel,	  2007).	  This	  chapter	  will	  enhance	  understanding	  of	  the	  perceptions	  of	  thoracic	  surgery	  as	  a	  nursing	  specialty	  in	  order	  to	  help	  make	  recommendations	  for	  future	  research.	  Perceived	  Value	  of	  Certification	  Overall,	  the	  PVCT	  statements	  most	  positively	  validated	  were	  those	  identifying	  the	  intrinsic	  rewards,	  such	  as	  “enhances	  feelings	  of	  personal	  	   53	  accomplishment,”	  “provided	  a	  professional	  challenge,”	  and	  “validates	  specialized	  knowledge,”	  suggesting	  that	  internal	  motivators	  may	  be	  more	  important	  to	  respondents	  when	  considering	  certification,	  than	  extrinsic	  motivators.	  	  Intrinsic	  rewards	  are	  those	  linked	  to	  personal	  development	  and	  self-­‐concept	  values,	  while	  extrinsic	  rewards	  are	  external	  to	  an	  individual	  and	  defined	  by	  others	  (Niebuhr	  &	  Biel,	  2007).	  The	  most	  negatively	  perceived	  statement	  was	  “increases	  salary,”	  suggesting	  that	  most	  respondents	  did	  not	  feel	  that	  certification	  resulted	  in	  an	  increase	  in	  salary.	  This	  result	  is	  consistent	  with	  other	  studies	  (Niebuhr	  &	  Biel,	  2007;	  Ferdon,	  2009;	  Byrne,	  2004).	  Recognition	  of	  the	  value	  of	  specialty	  certification	  in	  this	  study	  is	  consistent	  with	  other	  studies	  that	  identifies	  advantages	  of	  increased	  accountability,	  clinical	  competence,	  confidence	  in	  clinical	  abilities,	  professional	  growth,	  employer	  recognition,	  nursing	  peer	  recognition,	  and	  recognition	  from	  other	  health	  care	  professionals	  (Allen,	  2010;	  Byrne,	  Valentine,	  &	  Cater,	  2004;	  Niebuhr	  &	  Biel,	  2007).	  With	  intrinsic	  and	  extrinsic	  rewards,	  additional	  advantages	  of	  nursing	  specialization	  may	  be	  improved	  nurse	  satisfaction	  and	  retention	  (Miller	  &	  Boyle,	  2008).	  A	  study	  by	  Mallidou,	  Cummings,	  Estabrooks,	  and	  Giovannetti	  (2011)	  suggested	  that	  these	  intrinsic	  and	  extrinsic	  rewards	  can	  also	  be	  influenced	  by	  principles	  and	  values	  associated	  with	  specialization,	  and	  found	  evidence	  of	  the	  existence	  of	  “nurse	  specialty	  subcultures”	  within	  hospitals	  that	  influence	  nurse	  job	  satisfaction	  and	  patient	  outcomes.	  They	  suggested	  that	  communication,	  collaboration,	  and	  teamwork	  improve	  quality	  of	  care	  and	  patient	  outcomes,	  noting	  that	  relationships	  	   54	  between	  nurses	  and	  physicians	  are	  better	  in	  specialty	  areas	  such	  as	  ICU	  or	  Emergency,	  because	  these	  are	  highly	  specialized	  care	  units	  where	  nurses	  are	  experts	  working	  closely	  with	  physicians	  (Mallidou,	  Cummings,	  Estabrooks,	  &	  Giovannetti).	  Perceptions	  of	  Thoracic	  Surgery	  Advanced	  Knowledge	  and	  Skills	  In	  terms	  of	  advanced	  nursing	  knowledge,	  all	  of	  the	  surgeons	  and	  the	  majority	  of	  nurse	  leaders	  identified	  all	  of	  the	  components	  as	  advanced	  thoracic	  surgery	  related	  knowledge,	  indicating	  that	  thoracic	  surgeons	  recognize	  and	  value	  the	  additional	  specialist	  knowledge	  that	  is	  required	  of	  thoracic	  nurses.	  However,	  the	  highest	  scoring	  statements	  identified	  by	  nurses	  were	  those	  relating	  to	  knowledge	  of	  thoracic	  surgical	  procedures,	  potential	  complications	  and	  interventions,	  understanding	  of	  the	  implications	  of	  thoracic	  surgeries	  to	  patient	  care	  peri-­‐operatively	  with	  considerations	  to	  pain	  management,	  activity,	  nutrition,	  and	  lifestyle,	  and	  the	  ability	  to	  provide	  patient	  teaching	  of	  thoracic	  surgical	  procedures	  and	  their	  implications.	  These	  higher	  scoring	  statements	  are	  likely	  more	  often	  associated	  with	  post-­‐operative	  care	  and	  management	  of	  the	  thoracic	  surgical	  patient,	  while	  the	  lower	  scoring	  statements	  about	  the	  knowledge	  of	  lung	  and	  esophageal	  diseases,	  cancers,	  and	  their	  stages	  may	  be	  perceived	  by	  nurses	  as	  more	  applicable	  to	  pre-­‐operative	  decision	  making	  and	  planning.	  In	  terms	  of	  advanced	  nursing	  skills	  related	  to	  thoracic	  surgery,	  the	  lowest	  scoring	  skill	  perceived	  as	  an	  advanced	  skill	  was	  found	  to	  be	  “auscultation	  of	  chest	  	   55	  sounds”	  which	  would	  seem	  to	  suggest	  that	  both	  nurses	  and	  surgeons	  recognize	  the	  auscultation	  of	  chest	  sounds	  to	  be	  a	  basic	  nursing	  skill.	  Roughly	  half	  of	  the	  nurse	  respondents	  identified	  that	  the	  assessment	  and	  care	  of	  chest	  tubes	  was	  an	  advanced	  thoracic	  nursing	  skill,	  with	  slightly	  more	  identifying	  the	  assessment,	  care,	  and	  management	  of	  drainage	  devices	  as	  advanced	  thoracic	  skills.	  A	  larger	  number	  of	  nurses	  identifying	  management	  of	  drainage	  devices	  as	  advanced	  may	  be	  due	  to	  the	  variation	  in	  the	  equipment	  used	  in	  thoracic	  surgery	  compared	  to	  other	  areas.	  For	  example,	  the	  Pleur-­‐evac®	  chest	  drainage	  system	  made	  by	  Teleflex®	  is	  a	  widely	  recognized	  and	  utilized	  device	  in	  many	  units,	  while	  other	  products	  such	  as	  the	  Atrium®	  Pneumonstat™	  and	  the	  Medela®	  Thopaz™	  digital	  drainage	  device	  are	  less	  likely	  to	  be	  seen	  in	  other	  areas	  of	  nursing.	  The	  highest	  scoring	  skills	  perceived	  to	  be	  advanced	  skills	  related	  to	  thoracic	  surgery	  (and	  the	  only	  two	  nursing	  skills	  identified	  as	  advanced	  nursing	  skills	  by	  those	  in	  nursing	  leadership	  roles)	  were	  the	  removal	  of	  chest	  tubes	  the	  interpretation	  of	  cardiac	  rhythms.	  All	  of	  the	  surgeon	  respondents	  identified	  all	  of	  the	  skills	  relating	  to	  chest	  tubes	  to	  be	  advanced	  nursing	  skills.	  It	  may	  be	  that	  the	  nurses	  in	  leadership	  positions	  were	  considering	  which	  skills	  require	  additional	  specific	  formal	  education	  or	  training,	  while	  frontline	  nurses	  considered	  the	  amount	  of	  experience	  or	  expertise	  required	  in	  determining	  which	  were	  “advanced”	  nursing	  skills.	  One	  of	  the	  frontline	  nurse	  respondents	  commented,	  “I	  think	  [all	  the]	  examples	  are	  basic	  skills,	  but	  then	  again,	  I	  work	  on	  a	  thoracic	  ward”.	  This	  comment	  may	  also	  be	  telling	  as	  to	  why	  a	  greater	  number	  of	  nurses	  did	  not	  identify	  the	  examples	  as	  advanced	  skills.	  Since	  nearly	  half	  of	  those	  surveyed	  had	  greater	  than	  5	  years	  of	  	   56	  experience	  in	  a	  thoracic	  surgery	  area,	  skills	  that	  may	  be	  considered	  advanced	  for	  an	  entry-­‐level	  nurse,	  or	  a	  nurse	  working	  on	  a	  medical	  unit	  that	  rarely	  sees	  chest	  tubes,	  often	  becomes	  second	  nature	  to	  a	  nurse	  on	  a	  thoracic	  unit	  where	  nearly	  every	  patient	  will	  have	  one	  or	  more	  chest	  tubes	  and	  many	  will	  be	  cardiac	  monitored.	  Education,	  Patient	  Outcomes,	  and	  Specialty	  Recognition	  During	  a	  conference	  of	  the	  Canadian	  Association	  of	  Thoracic	  Surgeons	  (CATS)	  in	  2001,	  a	  discussion	  was	  facilitated	  by	  an	  expert	  panel	  of	  surgeons,	  of	  which	  the	  goal	  was	  to	  develop	  standards	  of	  practice	  and	  define	  resource	  requirements	  for	  the	  practice	  of	  thoracic	  surgery	  in	  Canada	  (Darling	  et	  al.,	  2004).	  From	  this	  discussion,	  it	  was	  determined	  that	  a	  clinical	  program	  in	  thoracic	  surgery	  should	  include	  one	  thoracic	  surgeon	  for	  every	  300,000	  to	  500,000	  people	  in	  the	  surrounding	  community,	  a	  dedicated	  thoracic	  unit	  with	  5–6	  ward	  beds	  per	  surgeon,	  dedicated	  nurses	  with	  expertise	  in	  thoracic	  surgery,	  a	  dedicated	  physiotherapist	  and	  respiratory	  therapist,	  and	  a	  dedicated	  thoracic	  anesthesiologist	  (Darling	  et	  al.).	  Within	  the	  hospital	  center,	  there	  should	  also	  be	  support	  of	  2	  intensive	  care	  unit	  (ICU)	  beds	  per	  surgeon,	  a	  respirologist,	  general	  and	  interventional	  radiologists,	  and	  pathologist,	  as	  well	  as	  an	  associated	  cancer	  center	  (Darling	  et	  al.).	  These	  recommendations	  were	  made	  to	  promote	  the	  delivery	  of	  optimum	  patient	  care	  in	  the	  practice	  of	  thoracic	  surgery	  in	  Canada.	  	  Study	  findings	  are	  consistent	  with	  other	  research	  which	  similarly	  suggests	  that	  specialized	  thoracic	  surgical	  centers	  demonstrate	  lower	  morbidity	  and	  mortality,	  the	  explanation	  for	  this	  trend	  being	  that	  physicians	  and	  nurses	  become	  	   57	  more	  effective	  in	  providing	  care	  by	  gaining	  experience	  and	  expertise	  as	  patient	  volumes	  increase	  (Farley	  &	  Ozminskowski,	  1992).	  	  The	  majority	  of	  respondents	  in	  this	  study	  agreed	  that,	  “additional	  education	  related	  to	  nursing	  knowledge	  and	  skills	  is	  required	  to	  meet	  the	  care	  needs	  of	  the	  thoracic	  surgery	  patient	  and	  improve	  the	  overall	  nursing	  care	  provided,”	  indicating	  that	  thoracic	  surgery	  nursing	  may	  be	  different	  from	  basic	  surgical	  nursing	  or	  entry-­‐to-­‐practice	  standards,	  with	  some	  level	  of	  additional	  nursing	  education	  required.	  This	  finding	  supports	  the	  definition	  of	  a	  specialty,	  in	  that	  the	  professional	  is	  specifically	  qualified	  to	  practice	  by	  attending	  advanced	  education	  (Boss,	  1989).	  This	  finding	  may	  be	  similar	  to	  findings	  of	  a	  study	  completed	  by	  Coleman	  et	  al.	  (2009)	  which	  suggested	  that	  formal	  certification	  may	  improve	  patient	  care	  quality	  because	  the	  nurses'	  increased	  knowledge	  of	  care	  management	  is	  related	  to	  the	  nurse	  having	  attending	  more	  hours	  of	  continuing	  education.	  The	  majority	  of	  respondents	  also	  agreed	  that,	  “nursing	  specialty	  recognition	  promotes	  better	  patient	  outcomes.”	  This	  finding	  is	  consistent	  with	  multiple	  other	  studies	  (Ferdon,	  2009;	  Coleman	  et	  al.,	  2009;	  Kendall-­‐Gallagher	  et	  al.,	  2011;	  Miller	  &	  Boyle,	  2008).	  The	  Kendall-­‐Gallagher	  (2011)	  study	  in	  particular	  found	  that	  the	  specialty	  certification	  of	  nurses	  was	  associated	  with	  lower	  mortality	  and	  failure	  to	  rescue	  in	  general	  surgery	  patients,	  concluding	  the	  investment	  in	  post-­‐basic	  education	  and	  specialty	  certification	  has	  the	  potential	  to	  improve	  quality	  of	  care.	  	  A	  study	  by	  Dunn	  et	  al.	  (2000),	  looked	  at	  the	  development	  of	  competency	  standards	  for	  specialist	  critical	  care	  nurses,	  suggesting	  that	  while	  both	  entry-­‐to-­‐practice	  nurses	  and	  specialist	  level	  nurses	  should	  be	  effectively	  managing	  the	  care	  	   58	  of	  patients	  for	  whom	  they	  are	  responsible,	  an	  entry-­‐to-­‐practice	  level	  nurse,	  however,	  should	  demonstrate	  the	  effective	  utilization	  of	  resources,	  discharge	  planning	  and	  ongoing	  nursing	  management,	  while	  a	  specialist	  level	  nurse	  with	  additional	  education	  and	  experience	  will	  operate	  at	  a	  higher	  level,	  for	  example,	  providing	  guidance	  in	  patient	  management	  to	  less	  experience	  nurses,	  and	  assisting	  others	  to	  re-­‐evaluate	  priorities	  in	  emergency	  situations.	  The	  results	  of	  this	  study	  indicate	  that	  thoracic	  nurses	  and	  surgeons	  largely	  feel	  that	  there	  is	  benefit	  to	  formally	  recognizing	  thoracic	  surgery	  as	  a	  certified	  nursing	  specialty.	  Limitations	  Although	  these	  study	  findings	  are	  compelling,	  they	  may	  not	  be	  generalizable	  to	  other	  specialist	  nursing	  units	  due	  to	  the	  small	  sample	  size,	  and	  localized	  practices	  of	  thoracic	  centers.	  It	  would	  be	  interesting	  to	  widen	  a	  study	  to	  include	  thoracic	  centers	  in	  western	  Canada,	  or	  nationally,	  since	  the	  study	  was	  only	  completed	  for	  one	  province.	  Additionally,	  this	  study	  only	  included	  part	  of	  the	  thoracic	  surgical	  patient	  trajectory,	  and	  may	  have	  provided	  further	  insight	  if	  pre-­‐admission,	  intra-­‐operative,	  and	  post-­‐anesthetic	  care	  nurses	  were	  included.	  Nor	  did	  the	  study	  determine	  what,	  if	  any,	  additional	  education	  the	  thoracic	  nurse	  respondents	  may	  have	  already	  received.	  Consequently,	  findings	  also	  only	  provided	  a	  professional	  perspective,	  as	  patients	  were	  not	  included	  in	  the	  study.	  	  	  	   59	  As	  a	  limitation	  of	  quantitative	  research,	  this	  study	  did	  not	  allow	  for	  in	  depth	  analysis	  of	  perceptions.	  Although	  some	  good	  comments	  surfaced	  in	  the	  findings,	  they	  could	  have	  been	  further	  analyzed	  through	  qualitative	  study.	  However,	  time,	  workload,	  and	  cost	  constraints	  were	  prohibitive	  for	  this	  depth	  of	  work.	  Summary	  	  With	  the	  Canadian	  Nurses	  Association	  (2014)	  promoting	  nursing	  certification	  as	  a	  “tangible	  distinction”	  that	  indicates	  to	  patients,	  employers,	  and	  the	  public,	  that	  you	  are	  qualified,	  competent,	  and	  current	  in	  a	  specialty	  area	  of	  nursing	  practice,	  and	  the	  increasing	  complexity	  of	  patients	  and	  their	  specific	  needs	  creating	  new	  challenges	  for	  the	  nursing	  profession,	  the	  identification	  and	  development	  of	  nursing	  specialties	  should	  be	  supported.	  Specialty	  areas	  of	  nursing	  practice	  such	  as	  thoracic	  surgery	  may	  benefit	  from	  formal	  recognition	  through	  certification.	  A	  study	  by	  Niebuhr	  and	  Biel	  (2007)	  using	  the	  Perceived	  Value	  of	  Certification	  Tool	  ©,	  that	  included	  a	  sample	  of	  20	  different	  nursing	  specialties,	  determined	  that	  the	  value	  statements	  resonate	  with	  a	  variety	  of	  nurses	  regardless	  of	  specialty	  area,	  work	  role,	  or	  certification	  status.	  This	  supports	  the	  findings	  of	  this	  study,	  indicating	  that	  among	  the	  top	  perceived	  values,	  thoracic	  surgery	  nurses	  perceived	  specialty	  certification	  to	  enhance	  feelings	  of	  personal	  accomplishment,	  provide	  a	  professional	  challenge,	  and	  validate	  specialized	  knowledge.	  	  Several	  examples	  of	  nursing	  knowledge	  was	  found	  to	  characterize	  advanced	  knowledge	  related	  to	  thoracic	  surgery,	  specifically;	  knowledge	  of	  thoracic	  surgical	  procedures,	  knowledge	  and	  understanding	  of	  potential	  complications	  of	  thoracic	  	   60	  surgical	  procedures	  and	  when	  to	  intervene,	  understanding	  of	  the	  implications	  of	  thoracic	  surgeries	  and	  application	  to	  patient	  care	  peri-­‐operatively	  with	  considerations	  to	  pain	  management,	  activity,	  nutrition,	  and	  lifestyle,	  and	  the	  ability	  to	  provide	  patient	  teaching	  of	  thoracic	  surgical	  procedures	  and	  their	  implications.	  Nurses	  and	  surgeons	  also	  identified	  several	  nursing	  skills	  that	  are	  perceived	  as	  advanced	  and	  related	  to	  thoracic	  surgery,	  such	  as	  the	  interpretation	  of	  cardiac	  rhythms,	  the	  assessment	  and	  care	  of	  chest	  tubes,	  and	  the	  removal	  of	  chest	  tubes.	  Overall,	  the	  results	  of	  this	  study	  suggest	  that	  thoracic	  nurses	  and	  surgeons	  largely	  feel	  that	  additional	  education	  related	  to	  nursing	  knowledge	  and	  skills	  is	  required	  to	  meet	  the	  care	  needs	  of	  the	  thoracic	  surgery	  patient	  and	  improve	  the	  overall	  nursing	  care	  provided,	  nursing	  specialty	  recognition	  promotes	  better	  patient	  outcomes,	  and	  thus,	  there	  is	  benefit	  to	  formally	  recognizing	  thoracic	  surgery	  as	  a	  certified	  nursing	  specialty.	  	  In	  chapter	  six,	  I	  will	  summarize	  the	  research	  with	  conclusions	  drawn	  from	  this	  study,	  as	  well	  as	  discuss	  the	  future	  implications,	  with	  regards	  to	  the	  benefits	  of	  recognizing	  and	  supporting	  nursing	  specialization	  and	  certification,	  as	  well	  as	  the	  next	  steps	  in	  recognizing	  thoracic	  surgery	  as	  a	  nursing	  specialty,	  and	  potential	  for	  future	  research.	  	  	  	   61	  CHAPTER	  6:	  CONCLUSIONS	  AND	  IMPLICATIONS	  	  Summary	  	   The	  purpose	  for	  this	  study	  was	  to	  examine	  the	  perceptions	  of	  thoracic	  nurses	  and	  surgeons	  regarding	  nursing	  specialization.	  Using	  multiple-­‐choice	  queries,	  the	  research	  assessed	  what	  elements	  they	  perceive	  characterizes	  a	  nursing	  specialty,	  if	  they	  consider	  thoracic	  surgery	  as	  a	  nursing	  specialty,	  and	  what	  they	  identify	  as	  the	  outcomes	  and	  value	  of	  nursing	  specialization,	  both	  for	  nurses,	  and	  the	  thoracic	  surgery	  patient	  population.	  With	  the	  continual	  advances	  in	  technology	  and	  specialized	  procedures	  in	  health	  care,	  the	  specific	  needs	  and	  complexity	  of	  surgical	  patients	  is	  increasing.	  	  This	  creates	  new	  challenges	  for	  nurses,	  as	  the	  number	  of	  settings	  requiring	  additional	  education	  and	  training	  to	  care	  for	  specific	  patient	  populations	  grows.	  The	  expansion	  of	  specialist	  practice	  in	  the	  last	  50	  years	  is	  an	  indicator	  to	  the	  need	  for	  recognizing	  the	  integral	  role	  of	  applied	  specialist	  knowledge	  in	  facilitating	  optimal	  patient	  outcomes.	  Conclusions	  	  The	  specific	  research	  questions	  for	  this	  study	  included:	  	  (a) How	  do	  experienced	  thoracic	  nurses	  and	  surgeons	  perceive	  nursing	  specialization/certification?	  	  	   62	  (b) Do	  nurses	  and	  surgeons	  perceive	  nursing	  to	  require	  an	  advanced	  level	  of	  knowledge	  and	  skills	  to	  meet	  the	  needs	  of	  the	  thoracic	  surgery	  patient	  population?	  (c) Do	  nurses	  and	  surgeons	  feel	  that	  thoracic	  surgery	  should	  be	  formally	  recognized	  as	  a	  nursing	  specialty?	  Perceptions	  of	  the	  Value	  of	  Specialist	  Certification	  Results	  of	  this	  study	  suggest	  that	  thoracic	  nurses	  and	  surgeons	  value	  nurse	  certification	  for	  similar	  intrinsic	  and	  extrinsic	  reasons	  as	  nurses	  in	  other	  specialties	  and	  in	  other	  countries,	  identifying	  several	  intrinsic	  rewards,	  such	  as	  “enhances	  feelings	  of	  personal	  accomplishment,”	  “provided	  a	  professional	  challenge,”	  and	  “validates	  specialized	  knowledge,”	  as	  motivators	  for	  certification,	  suggesting	  that	  internal	  motivators	  may	  be	  more	  important	  to	  respondents	  when	  considering	  certification,	  than	  extrinsic	  motivators,	  as	  they	  are	  linked	  to	  personal	  development	  and	  self-­‐concept	  values,	  while	  extrinsic	  rewards	  are	  external	  to	  an	  individual	  and	  defined	  by	  others	  (Niebuhr	  &	  Biel,	  2007).	  Level	  of	  Knowledge	  Required	  of	  Thoracic	  Nurses	  This	  study	  found	  that	  nurses	  and	  surgeons	  perceive	  that	  additional	  nursing	  education	  related	  to	  knowledge	  and	  skills	  is	  required	  to	  meet	  the	  care	  needs	  of	  the	  thoracic	  surgery	  patient	  population,	  and	  improve	  the	  overall	  nursing	  care	  provided.	  Dunn	  et	  al.	  (2000)	  suggest	  that	  competency	  is	  the	  overlap	  of	  knowledge	  with	  the	  performance	  components	  of	  psychomotor	  skills	  and	  clinical	  problem	  solving.	  It	  is	  the	  acquisition	  of	  a	  specialized	  body	  of	  knowledge	  and	  its	  application	  to	  clinical	  	   63	  settings	  that	  defines	  competency	  in	  nursing	  care.	  In	  further	  defining	  the	  role	  of	  the	  specialist	  nurse,	  it	  is	  necessary	  to	  challenge	  the	  concept	  of	  nursing	  as	  merely	  a	  combination	  of	  skills	  and	  knowledge.	  Nursing	  must	  be	  demonstrated	  and	  defined	  in	  the	  context	  of	  client	  care	  and	  specific	  populations,	  and	  include	  the	  broader	  concepts	  of	  professional	  development	  and	  competence	  (Dunn	  et	  al.,	  2000).	  Thoracic	  Certification	  Study	  findings	  suggest	  that	  thoracic	  nurses	  and	  surgeons	  believe	  that	  thoracic	  surgery	  should	  be	  formally	  recognized	  as	  a	  certified	  nursing	  specialty.	  While	  nursing	  licensure	  is	  intended	  to	  ensure	  the	  minimum	  competency	  of	  practicing	  nurses,	  “certification	  demonstrates	  nurses'	  achievement	  of	  a	  high	  level	  of	  competence	  or	  expertise	  in	  a	  particular	  area	  or	  specialty”	  (Haskins,	  Hnatiuk,	  &	  Yoder,	  2011,	  p.	  77).	  A	  review	  of	  relevant	  literature	  revealed	  a	  substantial	  body	  of	  evidence	  of	  professional	  recognition	  of	  the	  value	  of	  specialty	  certification,	  that	  identifies	  advantages	  of	  increased	  accountability,	  clinical	  competence,	  confidence	  in	  clinical	  abilities,	  professional	  growth,	  consumer	  confidence,	  employer	  recognition,	  nursing	  peer	  recognition,	  and	  recognition	  from	  other	  health	  care	  professionals	  (Allen,	  2010;	  Byrne,	  Valentine,	  &	  Cater,	  2004;	  Niebuhr	  &	  Biel,	  2007).	  	  Outcomes	  Additionally,	  study	  results	  also	  suggest	  that	  nurses	  and	  surgeons	  feel	  that	  nursing	  specialty	  recognition	  may	  promote	  better	  patient	  outcomes.	  Results	  of	  other	  studies	  also	  support	  the	  sense	  that	  specialty	  nursing	  may	  be	  associated	  with	  patient	  	   64	  satisfaction,	  better	  patient	  outcomes,	  and	  improved	  quality	  of	  care	  (Coleman	  et	  al.,	  2009;	  Kendall-­‐Gallagher	  et	  al.,	  2011;	  Miller	  &	  Boyle,	  2008).	  With	  all	  the	  evidence	  to	  support	  the	  benefit	  of	  nursing	  specialization,	  it	  is	  important	  to	  promote	  formal	  recognition	  of	  specialty	  areas	  of	  nursing	  practice	  through	  the	  process	  of	  nursing	  certification.	  Hopefully	  the	  passion	  and	  commitment	  of	  nurses	  working	  in	  thoracic	  surgery	  areas	  across	  Canada	  will	  help	  advance	  this	  cause,	  and	  we	  will	  one	  day	  see	  thoracic	  surgery	  as	  a	  formally	  recognized	  nursing	  specialty	  area.	  Implications	  This	  study	  provides	  health	  care	  organizations	  insight	  into	  the	  views	  of	  experienced	  thoracic	  nurses	  and	  surgeons	  on	  the	  value	  of	  specialized	  certified	  practice	  in	  this	  area.	  This	  may	  help	  inform	  agencies	  on	  the	  benefits	  of	  recognizing	  and	  supporting	  thoracic	  nursing	  specialization,	  not	  only	  for	  nursing	  satisfaction,	  but	  also	  for	  improvement	  in	  patient	  satisfaction	  and	  outcomes.	  As	  nurses	  and	  surgeons	  have	  identified	  thoracic	  surgery	  as	  a	  prospective	  nursing	  specialty	  through	  this	  study,	  the	  next	  steps	  towards	  establishing	  a	  thoracic	  surgery	  nursing	  specialty	  would	  be	  the	  formation	  of	  a	  national	  nursing	  group	  that	  can	  work	  with	  the	  CNA	  to	  outline	  the	  uniqueness	  of	  thoracic	  nursing	  practice,	  develop	  standards,	  and	  promote	  ongoing	  research	  activities.	  Further	  work	  would	  be	  required	  to	  identify	  the	  competency	  standards	  required	  for	  nurse	  specialists	  in	  this	  area,	  and	  specifically,	  to	  articulate	  the	  differences	  between	  entry-­‐to-­‐practice	  standards	  and	  the	  advanced	  practice	  of	  	   65	  specialist	  nurses	  in	  thoracic	  surgery.	  Additional	  research	  would	  also	  be	  useful	  to	  examine	  the	  roles	  of	  advanced	  practice	  nurses	  (such	  as	  Nurse	  Practitioners	  and	  Clinical	  Nurse	  Specialists)	  who	  work	  in	  thoracic	  settings,	  helping	  meet	  the	  needs	  of	  patients	  and	  staff	  within	  the	  specialty	  area.	  	  Additionally,	  this	  type	  of	  research	  could	  also	  be	  applied	  in	  other	  surgical	  specialties	  such	  as	  general	  surgery,	  head	  and	  neck	  surgery,	  urology,	  or	  gynecology,	  to	  see	  if	  there	  are	  advanced	  nursing	  practices,	  knowledge,	  and	  skills	  specific	  to	  these	  areas.	  Orthopedic	  surgery	  is	  already	  recognized	  as	  a	  nursing	  specialty	  with	  the	  CNA	  through	  a	  certification	  examination,	  as	  well	  as	  several	  medical	  nursing	  specialties	  such	  as	  neuroscience,	  nephrology,	  cardiovascular,	  and	  oncology.	  Further	  study	  into	  the	  extrinsic	  benefits	  of	  supporting	  nursing	  specialization	  could	  also	  be	  examined,	  such	  as	  completing	  patient	  satisfaction	  surveys	  or	  reviewing	  the	  effects	  on	  key	  performance	  indicators	  such	  as	  hospital	  length	  of	  stay	  and	  post-­‐operative	  complication	  rates.	  	  	   66	  REFERENCES	  	  Allan,	  J.	  S.,	  Donahue,	  D.	  M.,	  &	  Garrity,	  J.	  M.	  (2009).	  High-­‐frequency	 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V6T 2B5 Phone: (604) 822-7417  Fax: (604) 822-7466 INVITATION TO PARTICIPATE IN A RESEARCH STUDY             Sunday, November 30, 2014  Dear Nurse/Surgeon,   My name is Angela Wilson and I am a graduate student in the Master of Science in Nursing program at the University of British Columbia.  I am writing to invite you to participate in a study as a nurse/surgeon who has experience with the thoracic surgery patient population. This research is part of my graduate thesis work and is being conducted in partial fulfillment of the requirements for the degree of Master of Science in Nursing.  The Project  This study examines the perceptions of nurses and surgeons with regard to nursing specialization. This study will explore what is perceived to characterize a nursing specialty, if thoracic surgery is considered a nursing specialty, and what the potential outcomes of nursing specialization might be, both for nurses, and the thoracic surgery patient population. Specifically, I wish to explore views on nursing specialization and the appropriate level of education and training surgical nurses are perceived to require in meeting the needs of the thoracic surgery patient population.   What is involved?  You are being asked to participate in this study by completing a simple survey. Your participation in this study will require the following:  • Completion of an online survey (FluidSurvey Canada), using the Perceived Value of Certification Tool© (PVCT), which is an established tool used to explore perceptions of the value of nurse certification. Additionally, several multiple choice questions will be included to collect demographic information, and explore your views on thoracic nursing as a specialty, and level of education/training required. At the end of the survey, you will also have the option of entering additional comments in an open text field.  It is estimated the survey will take approximately 15 minutes to complete.      TITLE:  Thoracic Surgery as a Nursing Specialty:  Perceptions of Senior Nurses and Surgeons of Specialty Nursing Practice 	   75	  	  	  Thoracic Nursing Study Invitation Version #: 3.0    11/30/2014  Page 2/3 Compensation  Unfortunately we cannot offer any compensation for participation in this study. However, all participants will be eligible to enter an optional prize draw for one of three $25 Starbucks Gift Cards. At the end of the survey, there will be an optional field to enter your email address. The email you provide will not be associated with your survey responses, and used only for the purpose of this prize draw.   Consent  Your participation in this project is entirely voluntary and you may refuse to participate in the study or any element of the survey activities listed above at any time without giving a reason and without any negative impact on your employment, professional standing, or any relationship with UBC. For further details, please read the accompanying consent information letter. Completion and submission of the online survey will be taken to imply your consent to participate in the study.  Contact for Information About the Study    If you have any questions related to this project or wish to have further information with respect to the study, you may contact me at (+1) 604-585-5666 ext. 778326 or angela.wilson@fraserhealth.ca, or my primary supervisor and principal investigator for this study, Dr. Bernie Garrett at (+1) 604-875 8203 or bernie.garrett@nursing.ubc.ca.   Contact for Concerns About the Rights of Research Subjects    If you have any concerns about your treatment or rights as a research participant, you may contact the Research Subject information Line in the UBC Office of Research Services at (+1) 604-822-8598 or RSIL@ors.ubc.ca, which is also affiliated with Vancouver Coastal Health. For Fraser Health, please contact the Fraser Health Research Ethics Board co-Chair at (+1) 604-587-4681. For Island Health, please contact the Island Health Research Ethics Office in Victoria at (+1) 250-370-8620 or researchethics@viha.ca. For Interior Health, please contact the Chair of the Interior Health Research Ethics Board at (250) 870-4602 or researchethics@interiorhealth.ca.   Thank you very much for your time in considering this invitation and participating, if you choose to do so.   Yours faithfully,  Angela Wilson, RN - Investigator / Contact Person MSN Student University of British Columbia   Supervisory Committee  Dr. Bernie Garrett - Primary Supervisor / Principal Investigator             Associate Professor               School of Nursing             University of British Columbia  	   76	  	  	  	  	  	  	  Thoracic Nursing Study Invitation Version #: 3.0    11/30/2014  Page 3/3  Dr. Victoria Bungay Associate Professor               School of Nursing             University of British Columbia  Sarah Derman, RN, MSN Clinical Nurse Specialist Fraser Health Authority 	   77	  APPENDIX	  B	  	  	  	  Thoracic Nursing Study Consent Version #: 4.0    11/30/2014   Page 1/3  The University of British Columbia School of Nursing T201-2211, Wesbrook Mall Vancouver, B.C.  V6T 2B5 Phone: (604) 822-7417  Fax: (604) 822-7466 Consent Information           !! !Investigator / Contact Person:  Angela Wilson, Graduate Student (MSN), University of British Columbia, School of Nursing, (+1) 604-585-5666 ext. 778326, angela.wilson@fraserhealth.ca! This research is part of graduate thesis work in my Master’s of Science in Nursing program at the University of British Columbia School of Nursing.   Supervisory Committee Primary Supervisor / Principal Investigator: Dr. Bernie Garrett, School of Nursing, University of British Columbia, (+1) 604-822-7443, bernie.garrett@nursing.ubc.ca Committee Member: Dr. Victoria Bungay, School of Nursing, University of British Columbia, (+1) 604-822-7933, vicky.bungay@nursing.ubc.ca Committee Member: Sarah Derman, Clinical Nurse Specialist, Fraser Health Authority (+1) 604-585-5666 Ext 2771, sarah.derman@fraserhealth.ca   Purpose  This study examines the perceptions of nurses and surgeons with regard to nursing specialization. This study will explore what is perceived to characterize a nursing specialty, if thoracic surgery is considered a nursing specialty, and what the potential outcomes of nursing specialization might be, both for nurses, and the thoracic surgery patient population. Specifically, I wish to explore views on nursing specialization and the appropriate level of education and training surgical nurses are perceived to require in meeting the needs of the thoracic surgery patient population.   Study Procedures  You are being asked to participate in this study by completing a simple survey. Your participation in this study will require the following:  • Completion of an online survey (FluidSurveys), using the Perceived Value of Certification Tool© (PVCT), which is an established tool used to explore perceptions of the value of nurse certification. Additionally, several multiple choice questions will be included to collect demographic information, and explore your views on thoracic nursing as a specialty, and level of education/training required. At the end of the survey, you will also have the option of entering additional comments in an open text field.    TITLE:    !Thoracic Surgery as a Nursing Specialty: Perceptions of Senior Nurses and Surgeons of Specialist Nursing Practice  	   78	  	  	  	  	  Thoracic Nursing Study Consent Version #: 4.0    11/30/2014   Page 2/3 • Meet one of the following inclusion criteria: • Are a Registered Nurse with two or more years of experience in thoracic surgery and have a permanent assignment in the thoracic surgery unit or area,  • Are an Advanced Practice Nurse within the thoracic specialty area,  • Are a Thoracic Surgeon  • Do not meet any exclusion criteria: • Casually employed on multiple units (not permanent in a thoracic surgery area) • Staff with less than two years of experience • Students • Surgical Fellows/Residents/Medical Students  It is estimated the survey will take approximately 15 minutes to complete.   The results of this study will be reported in a graduate thesis and may also be published in journal articles. Results will also be made available to the Clinical Nurse Educator for your area.! Compensation  Unfortunately we cannot offer any compensation for participation in this study. However, all participants will be eligible to enter an optional prize draw for one of three $25 Starbucks Gift Cards. At the end of the survey, there will be an optional field to enter your email address. The email address you provide will not be associated with your survey responses, and used only for the purpose of this prize draw.   Research Use and Confidentiality  By agreeing to participate in this project, you will be allowing the research team to use and analyze the materials you produce. Please note, the survey is anonymous and no biographical information will be required or collected. Any data kept on electronic media (computers) will not include the name or personal details of the individual subject and will be encrypted, kept solely on the computers of the investigator, or primary supervisor Dr. Garrett. As a research participant, you will not be identified by name in any reports of the completed study. There are no known risks to participating in any aspect of this study. As a participant, you will be given the option of providing an email address for entry into a prize draw. If you choose to provide your email address for prize draw entry, it will be kept confidential, will not be associated with study data, and used only for the purpose of the prize draw.  Please note that FluidSurveys is being used to collect survey data, and is a service provided by SurveyMonkey, a US based company. The servers on which FluidSurveys operate are located in Canada, so your information will be hosted in Canada. Additionally, your information may be processed in and transferred or disclosed to countries in which their affiliates are located and in which their service providers are located or have servers. In particular, the US Patriot Act allows authorities access to the records of internet service providers. The survey or questionnaire does not ask for personal identifiers or any information that may be used to identify you. The web survey company servers record incoming IP addresses of the computer that you use to access the survey but no connection is made between your data and your computer’s IP address. If you choose to participate in the survey, you understand that your responses to the survey questions may be accessed in the USA.  The security and privacy policy for the websurvey company can be found at the following link: http://fluidsurveys.com/about/privacy    	   79	  	  	  	  	  Thoracic Nursing Study Consent Version #: 4.0    11/30/2014   Page 3/3 Consent  Your participation in this project is entirely voluntary and you may refuse to participate or any element of the survey activities listed above at any time without giving a reason and without any negative impact on your employment or professional standing, or any relationship with the University of British Columbia. If the online survey is completed and submitted, your consent to participate in this study as outlined above will be assumed to have been given.  Further Information  Contact for information about the study: If you have any questions related to this project or wish to have further information with respect to the study, you may contact me at (+1) 604-585-5666 ext. 778326 or angela.wilson@fraserhealth.ca, or my primary supervisor and principal investigator for this study, Dr. Bernie Garrett at (+1) 604-875 8203 or bernie.garrett@nursing.ubc.ca.  Contact for concerns about the rights of research subjects:  If you have any concerns about your treatment or rights as a research participant, you may contact the Research Subject information Line in the UBC Office of Research Services at (+1) 604-822-8598 or RSIL@ors.ubc.ca, which is also affiliated with Vancouver Coastal Health. For Fraser Health, please contact the Fraser Health Research Ethics Board co-Chair at (+1) 604-587-4681. For Island Health, please contact the Island Health Research Ethics Office in Victoria at (+1) 250-370-8620 or researchethics@viha.ca. For Interior Health, please contact the Chair of the Interior Health Research Ethics Board at (250) 870-4602 or researchethics@interiorhealth.ca.     Thank you very much for your time in considering this invitation.  Yours faithfully,  Angela Wilson, RN – Investigator / Contact Person MSN Student University of British Columbia  Supervisory Committee  Dr. Bernie Garrett – Primary Supervisor / Principal Investigator             Associate Professor               School of Nursing             University of British Columbia  Dr. Victoria Bungay Associate Professor               School of Nursing             University of British Columbia  Sarah Derman, RN, MSN Clinical Nurse Specialist Fraser Health Authority    	   80	  APPENDIX	  C	  	  	  	  	  	  	  	  	   !Are$you$an$RN,$nurse$leader,$or$surgeon,$working$$with$Thoracic$Surgery$patients?$!I!am!conducting!a!research!study!looking!at!perceptions!of!nursing!specialization!related!to!thoracic!surgery!and!would!like!your!opinion!!!Participation!in!this!study!involves!an!online!survey,!which!will!take!approximately!15!minutes!to!complete.!!!You!may!enter!your!name!into!a!draw!to!WIN!one!of!three!$25!Starbucks!cards!!!Survey!information!and!links!will!be!distributed!by!email.!Please!ask!your!CNE!!!THORACIC$SURGERY:$$A$Nursing$Specialty?$! The!University!of!British!Columbia!School of Nursing T20192211,!Wesbrook!Mall!Vancouver,!B.C.!!V6T!2B5!Phone:!(604)!82297417!Investigator,/,Contact,Person:,Angela!Wilson,!RN!Graduate!Student!(MSN)!angela.wilson@fraserhealth.ca!(+1)!604958595666!ext.!778326!!Supervisor,/,Principle,Investigator,Dr.!Bernie!Garrett!Associate!Professor!bernie.garrett@nursing.ubc.ca!(+1)!604987598203!Inclusion$Criteria$for$Study$• Registered!Nurses!with!two!or!more!years!of!experience!in!thoracic!surgery!and!a!permanent!assignment!in!the!thoracic!surgery!unit!or!area!!• Advanced!Practice!Nurses!within!the!thoracic!surgery!area!!• Thoracic!Surgeons!!Exclusion$Criteria$for$Study$• Casually!employed!nurses!on!multiple!units!(and!are!therefore!not!permanent!in!a!thoracic!surgery!unit!or!area)!!• Staff!with!less!than!two!years!of!experience!!• Students!• Surgical!Fellows/Residents/Medical!Students!!	   81	  APPENDIX	  D	  	  	  Thoracic(Nursing(Study(Survey(Version(#:(1.0((((9/13/2014( ( ( Page(1/6(( The University of British Columbia School of Nursing T201A2211,(Wesbrook(Mall(Vancouver,(B.C.((V6T(2B5(Phone:((604)(822A7417((Fax:((604)(822A7466( Survey (( ((((      Dear Nurse/Surgeon, You are invited to complete this survey, which examines the perceptions of nurses and surgeons of nursing specialization.   The American Board of Nursing Specialties defines nursing specialty certification as the “formal recognition of specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty to promote optimal health outcomes” (2005). The Canadian Nurses Association currently offers such certification in 20 specialties of nursing practice, including areas such as cardiovascular nursing, critical care nursing, orthopedic nursing, perioperative nursing, and medical-surgical nursing (CNA, 2014).  This research study looks to explore your perception of nursing certification, whether or not you perceive thoracic surgery nurses to have advanced knowledge and skills that may meet specific needs of the thoracic surgery patient population, and if you perceive value in recognizing thoracic surgery as a nursing specialty.   It is estimated this survey will take approximately 15 minutes to complete.   The first section uses the Perceived Value of Certification Tool© (PVCT), which is an established tool used to explore perceptions of the value of nurse certification. The second section is comprised of multiple choice questions that explore your views on thoracic nursing as a specialty, and level of education/training required. The last section will collect demographic information. At the end of the survey, you will also have the option of entering additional comments in a free text field, as well as your email address for prize draw entry.  Your participation in this project is entirely voluntary and you may refuse to participate in the study or any element of the survey activities listed above at any time without giving a reason and without any negative impact on your employment, professional standing, or any relationship with UBC. Completion and submission of the online survey will be taken to imply your consent to participate in the study.      TITLE:    (Thoracic Surgery as a Nursing Specialty: Perceptions of Senior Nurses and Surgeons of Specialist Nursing Practice  	   82	  Thoracic(Nursing(Study(Survey(Version(#:(1.0((((9/13/2014( ( ( Page(2/6((Perceived Value of Certification   DIRECTIONS: Below are statements that relate to perceived values of certification. Please indicate the degree to which you agree to disagree with the statements by circling SA for strongly agree, A for agree, D for disagree, SD for strongly disagree, and NO for no opinion.  Validates specialized knowledge.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Indicates level of clinical competence.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Indicates attainment of a practice standard.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Enhances professional credibility.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Promotes recognition from peers.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Promotes recognition from other health professionals.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Promotes recognition from employers.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Increases consumer confidence.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Enhances feeling of personal accomplishment.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion  	   83	  	  	  Thoracic(Nursing(Study(Survey(Version(#:(1.0((((9/13/2014( ( ( Page(3/6(( Enhances personal confidence in clinical abilities.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Provides personal satisfaction.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Provides professional challenge.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Enhances professional autonomy.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Indicates professional growth.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Provides evidence of personal commitment.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Provides evidence of accountability.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Increases marketability.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   Increases salary.  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion    Perceived Value of Certification Tool (PVCT) reproduced with permission from Certification Board of Perioperative Nursing (CBPN). Copyright 2002.   	   84	  	  	  Thoracic(Nursing(Study(Survey(Version(#:(1.0((((9/13/2014( ( ( Page(4/6(( Perception of Thoracic Surgery as a Nursing Specialty  1. Please indicate which of the below statements you perceive to be examples of advanced nursing knowledge related to thoracic surgery (select one or more): ! Knowledge of lung-associated diseases, cancers and their stages ! Knowledge of esophageal-associated diseases, cancers and their stages ! Knowledge of thoracic surgical procedures (eg. lobectomy, esophagectomy) ! Knowledge and understanding of potential complications of thoracic surgical procedures and when to intervene ! Understanding of the implications of thoracic surgeries and application to patient care peri-operatively, with considerations to pain management, activity, nutrition, and lifestyle ! Ability to provide patient teaching of thoracic surgical procedures and their implications ! Anticipation of the needs of thoracic surgery patients post-discharge from acute care, with considerations to pain management, activity, nutrition, and lifestyle ! Other: _________  2. Please indicate which of the below statements you perceive to be examples of advanced nursing skills related to thoracic surgery (select one or more): ! Auscultation of chest sounds ! Interpretation of cardiac rhythms and interventions ! Assessment and care of chest tubes ! Assessment, care, and management of chest drainage devices (eg. Pleur-evac, Thopaz, Pneumostat)  ! Assessment, care, and management of long term chest catheters for malignant pleural effusions (eg. PleurX) ! Irrigations/flushing of chest tubes ! Removal of chest tubes ! Other: __________  3. What is your opinion on the following statement? “Additional education related to nursing knowledge and skills is required to meet the care needs of the thoracic surgery patient and improve the overall nursing care provided.”  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   4. What is your opinion on the following statement? “Nursing specialty recognition promotes better patient outcomes.”  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   5. What is your opinion on the following statement? “Thoracic Surgery should be formally recognized as a certified nursing specialty.”  ! Strongly Agree ! Agree ! Disagree ! Strongly Disagree ! No Opinion   	   85	  	  	  	  	  	  	  	  	  	  Thoracic(Nursing(Study(Survey(Version(#:(1.0((((9/13/2014( ( ( Page(5/6((Demographic Information  1. In what hospital are you currently and primarily working? ! Surrey Memorial Hospital ! Vancouver General Hospital ! Victoria Royal Jubilee Hospital ! Kelowna General Hospital  2. In what role do you practice? ! Registered Nurse ! Surgeon ! Advanced Practice Nurse (NP or CNS) ! Nursing Leadership (Manager, PCC, CNE)  3. What is your gender? ! Female  ! Male  4. What is your employment status? ! Full-time ! Part-time ! Casual  5. Overall years of experience: ! Less than 1 year ! 2-3 years ! 3-5 years ! Over 5 years  6. Years of experience working with thoracic surgery patients: ! Less than 1 year ! 2-3 years ! 3-5 years ! Over 5 years   Additional Comments  Please feel free to provide any additional comments:        (	   86	  	  	  	  	  	  Thoracic(Nursing(Study(Survey(Version(#:(1.0((((9/13/2014( ( ( Page(6/6((Prize Draw for $25 Starbucks Card  Thank you for your participation, you are welcome to enter an optional prize draw for one of three $25 Starbucks Gift Cards. Please note, any email address you provide will not be associated with your survey responses, and used only for the purpose of this prize draw.   Email address for entry into prize draw (optional):     Completion and submission of this online survey will be taken to imply your consent to participate in the study.   Thank you for taking the time to complete this survey. If you are interested in the outcome of this study, results will be made available to the Clinical Nurse Educator for your area.   (	   87	  APPENDIX	  E	  	  	  	  	  	       28#JUL#14####Angela,###Thank#you#for#submitting#the#materials#required#to#receive#permission#to#use#the#CCI#Perceived#Value#of#Certification#Tool#(PVCT©).##We#reviewed#the#information#and#are#pleased#to#grant#you#permission#to#use#the#instrument.###As#a#reminder,#this#permission#is#granted#with#following#conditions:## • You#will#use#the#instrument#without#modifications.#• You#will#include#the#necessary#copyright#statement#at#the#bottom#of#all#photocopies.#• You#will#use#the#instrument#only#for#the#purposes#of#the#research#project#you#originally#submitted.#• You#will# provide# CCI#with# any# validity# and# reliability# data# you# derive# from# the# PVCT©#based#on#your#sample.#• If#the#work#is#published#you#will#provide#a#copy#of#the#article#to#CCI.###Thank#you#for#your#interest#in#the#PVCT©,#and#best#of#luck#with#your#work.##We#look#forward#to#hearing#from#you.##Sincerely,#   James#X#Stobinski#PhD#RN#CNOR#Director#of#Credentialing#and#Education#      

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